Lee County Health Department

“The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 1 of 4 sampled employees (Staff D) who began serving hospice patients since their last survey, dated 4/21/22. The hospice reported hiring 5 contracted staff since the last survey. Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from staff who had direct patient contact. According to the hospice policy titled Employment, last revised October 2023, offers of employment are based upon having acceptable results from the abuse registries background check. A criminal history check, dependent adult abuse record check and child abuse record check for each prospective employee will be completed within 30 days prior to the hire date of the prospective employee. During an interview on 4/3/25 at 10:40 AM, the Clinical Manager stated Staff D, Hospice Aide lived in Illinois and worked out of the Illinois office. The Criminal Background check ran in Illinois. 1. Staff D, Hospice Aide, had a hire date of 5/4/22. A criminal background check, dated 3/24/22, was completed using the Illinois De[artment of Public Health. The hospice failed to follow through to complete adult abuse and child abuse registry checks with the Iowa department of human services within 30 days prior to the date of hire. Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring. The above findings were reviewed with the Clinical Manager.”

“Based on clinical record review and agency policy review, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements for 1 of 5 sampled patients (Patient #10), with wounds. Failure to complete an initial wound assessment increased the risk patient’s needs would not be identified and/ or addressed appropriately, and the hospice would have an incomplete baseline assessment for comparison in order to determine effectiveness of wound treatments and interventions. Findings Include: According to the undated agency policy titled Homecare and Hospice Wound Care, nurses will use the wound assessment tool in the clinical Electronic Medical Record (EMR), software system on admission and weekly, and at the onset of new wounds or as specified in the plan of care. Documentation will include size of wound including length, width and depth. Patient #10 had a start of care date of 2/27/25 and a death date of 3/4/25, and received hospice services in a long term care facility. a. The Plan of Care (POC), dated 2/27/25 to 5/27/25, included a primary diagnosis of a stroke, and physician orders for skilled nurse to assess and evaluate for admission to hospice services. b. The initial comprehensive assessment completed on 2/27/25, by Staff C, Registered Nurse (RN), identified a stage 2 pressure ulcer (a partial-thickness skin loss characterized by a shallow, open wound) on patients coccyx. Documentation identified wound measurements: length of 2.4 centimeters (cm) and width of 0.3 cm but failed to include a measurement for the depth of the wound. The initial comprehensive assessment lacked documentation of depth to the wound on the coccyx. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure a Registered Nurse provided coordination of care and implementation of the interdisciplinary plan of care for 4 of 14 sampled patients (Patient #3, #4, #8 and #9). Failure of the hospice to ensure a Registered Nurse (RN) participated in each interdisciplinary group meeting and completed interdisciplinary group meeting notes placed hospice patients at risk for not having all of their medical needs identified and met. 3. Patient #3 had a start of care date of 12/30/24 and received services from the hospice while residing in a private home. Clinical record review revealed IDG meeting notes, dated 1/29/25, 2/13/25, 2/26, 3/12/25 and 3/26/25 were written and completed by Staff F, LPN. The IDG failed to ensure an RN completed the IDG meeting notes for the patient. 4. Patient #8 had a start of care date of 04/24/24 and a discharge date of 10/8/24 and received services from the hospice while residing in a private home. Clinical record review revealed IDG meeting note, dated 6/25/24 was written and completed by Staff F, LPN. The IDG failed to ensure an RN completed the IDG meeting notes for the patient. The above findings were reviewed with the Administrator and the Clinical Manager. Findings include: According to the hospice policy, titled Interdisciplinary Group, dated 2/2024, the interdisciplinary group (IDG) includes at a minimum: a doctor of medicine or osteopathy, a registered nurse, a social worker and a pastoral or other counselor. A registered nurse member of the IDG is designated as the RN Case Manager for each patient and is responsible for coordinating care and services provided by the IDG, ensuring continuous assessment of the patient/caregiver needs, and implementing the IDG plan of care. According to the hospice policy, titled Assessment – Updates to the Comprehensive Assessment, dated 4/2019, patient’s progress toward desired outcomes and response to care is reassessed as often as required by the patient’s condition but no less frequently than every 15 days. Information from the updated comprehensive assessment is reviewed by the IDG at the IDG meeting and is used to revise the patient’s plan of care as needed. During an interview on 4/8/25 at 1:05 PM, Clinical Manager reported the Licensed Practical Nurse (LPN) completes IDG meeting notes on weeks opposite the RN for patients seen by the LPN. 1.Pateint #4 had a start of care date of 12/5/24 and received services from the hospice while residing in a private home. Clinical record review revealed IDG meeting notes, dated 12/31/24, 1/15/25 and 3/19/25, were written and completed by Staff F, LPN. The IDG failed to ensure an RN completed the IDG meeting notes for the patient. 2. Patient #9 had a start of care date of 4/10/24, a discharge date of 7/5/24 and received services from the hospice while residing in a private home. Clinical record review revealed IDG meeting note, dated 6/12/24, was written and completed by Staff F, LPN. The IDG failed to ensure an RN complete the IDG meeting note for the patient.”

“Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure care and services were provided in accordance with the plan of care or the Interdisciplinary Group was notified of change in service frequency or missed visits for 2 of 14 sampled patients (Patients #3 and #8). Failure to provide services in accordance with the plan of care and/or to update the Interdisciplinary Group (IDG) of changes in service frequency or missed visits increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include:According to the hospice policy, titled Interdisciplinary Group, dated 2/2024, identified any change in service frequency or missed visits will be documented on the Interdisciplinary Group meeting note by the nurse, social worker, Registered Nurse case manager or designated nurse. 1.Patient #3 had a hospice admission date of 12/30/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 12/30/24 to 3/29/24, included primary diagnosis of lung cancer and included physicians orders for social work visits 2 times per month. b. During an interview on 4/8/25, at 2:30 PM, Staff E, Licensed Social Worker (LSW), acknowledged a missed a visit due to patient refusal on 2/6/25 and failed to complete a missed visit notification. c. The clinical record included a visit note completed by Staff E, LSW, on 2/19/24, but lacked a second visit note for the month of February. d. The IDG meeting notes to update the POC, dated 2/13/25, lacked documentation the IDG was notified LSW missed a visit for the week of 2/2/25. The hospice failed to provide social work visits as ordered per the POC. 2. Patient #8 had a start of care date of 4/12/24, and a discharge date of 10/8/24, and received hospice services in a private home. Clinical record review revealed: a. The POC, dated 7/11/24 to 10/8/24, included a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD), and included physician orders for massage therapy visits 2 times per month. b. The clinical record included a visit note completed by Staff H, Licensed Massage Therapist (LMT), on 7/10/24, but lacked a second visit note for the month of July. c. The clinical record included a visit note completed by Staff H, LMT, on 8/9/24, but lacks a second visit note for the moth of August. d. The IDG meeting notes to update the POC, dated 7/17/24, 7/31/24, 8/21/24 and 9/4/24, lacked documentation IDG team was notified of missed LMT visits. The hospice failed to provide LMT visits as ordered per the POC. The above findings were shared with the Administrator and the Clinical Manager.”

“Based on family and staff interviews, clinical record review, and agency policy review, the hospice agency failed to ensure that services were provided based on the assessments of the patient and family needs, including medical equipment and supplies for 1 of 14 (Patient #3) sampled patients. Failure to ensure that services and medical supplies are provided that meet the needs of the patient and family based on comprehensive assessments, puts patients at risk for not having their needs met. Findings include: According to the agency policy titled Durable Medical Equipment, dated 10/2024, the hospice maintains contacts with accredited DME providers for the provision of safe and effective DME or the hospice clients. The DME must be approved by the hospice IDG, ordered by the client’s attending physician, and included in the clients plan of care. The RN Clinical Case Manager requests the ordered DME from the provider and informs the client of the expected delivery and ensures adequate instruction and information related to the equipment is given to the client Patient #3 had a start of care date of 12/30/24, and received hospice services in a private home. During an interview on 4/8/25, at 10:56 AM with a patient family member, he/she indicated that both patient and spouse had requested portable oxygen several different times and stated the agency staff did not provide portable oxygen, stating the patient wasn’t safe walking to the garage with oxygen. The patient had wanted to go out to his/her garage and go on car rides and it would be hard without portable oxygen to go out to the garage. He/she also reported they still did not have portable oxygen in the home, but that he/she wasn’t even sure patient could go out to his garage now as health had declined. During an interview on 4/8/25, at 1:30 PM, Clinical Manager stated the portable oxygen had not been ordered for the home because of safety concerns and the agency felt that the house had to many fall risks for the patient to attempt to get out to the garage and that the agency was concerned it was to cold for the patient to leave the home. The Clinical Manager stated they were going to get the portable oxygen out to the home this week as the weather had warmed up, but acknowledged the safety risks, clutter and fall risk had not changed. The patient had declined physically and may not be able to out of bed. Clinical record review revealed the following. a. The Plan of Care (POC), dated 12/30/24 to 3/29/25, included a primary diagnosis of lung cancer, and included physician orders for skilled nurse visits 1-2 times a week and continuous oxygen at 3-4 liters per nasal cannula. b. The skilled nurse visit note dated 1/7/25 noted the patient spouse requesting portable oxygen so patient could get out of the house, the Registered Nurse (RN) documented safety concerns with patient getting out of the house and that safety education had been completed with the patient and spouse. c. The Interdisciplinary group note (IDG), dated 1/29/25 noted patient needs continuous oxygen at 4 Liters through a nasal cannula, but lacked documentation about family and patient request for portable oxygen. d. The IDG note, dated 2/13/25, noted patient requested portable oxygen and wanted to be able to get out of the house, agency documented continued safety concerns including cold weather for why the agency would not provide the portable oxygen and to continue to remind patient and family of safety concerns. The IDG note included documentation of possibly ordering the portable oxygen when the weather became warmer. e. The IDG note, dated 3/12/25, documented patient was scheduled for an appointment with the attending physician on 3/26/25, but lacked documentation of how patient would be able to go to the physicians office without portable oxygen. The agency failed to provide portable oxygen to enable to patient to leave home. The above findings were reviewed with the Administrator and the Clinical Manager.”

“Based on personnel file review, staff interview and policy review the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed direct observation of a performance aide’s performance of all required hospice aide skills on a hospice patient or pseudo-patient to determine satisfactory competency prior to allowing the hospice aide to provide care independently to hospice patients for 1 of 3 sampled hospice aides (Staff D) hired since the last recertification survey (3/21/22). At the time of the survey, the agency employed 4 hospice aides and provided hospice aide services to 3 patients. Failure to ensure hospice aides successfully complete a competency evaluation in all basic home hospice aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic hospice aide skills placed agency patients at risk to receive inadequate or unsafe hospice aide services. Findings include: The Medicare Conditions of Participation require hospices to ensure all newly hired hospice aides are competent in all of the basic hospice aide skills by successfully demonstrating competency in the performance of all of the “hands on” basic home health aide skills with a home health patient, exactly as these tasks will be performed with an actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently. The list of “hands on” basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tub and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation and range of motion and positioning. Basic hospice aide competencies may be demonstrated using a patient or pseudo-patient. According to the hospice policy titled Homemaker/Home Health Aide/Hospice Aide Training and Competency Evaluation, last revised February 2024, when a Homemaker/Home Health Aide/Hospice Aide is hired and prior to assignment of any client cares the Homemaker/Home Health Aide/Hospice Aide must demonstrate competency and Documentation of competent performance will be recorded in the Homemaker/Home Health Aide/Hospice Aide personnel records. During an interview on 2/25/24 at 3:10 PM The Clinical Manager stated Staff D, Hospice Aide contracted through another agency and already had competency testing completed. 1. Staff D, Hospice Aide, had a hire date of 5/4/22. Staff D’s personnel file included competency documentation on 5/8/19. The competency documentation failed to include competency testing completed by the hiring hospice. Staff D provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills. The above findings were reviewed with the Clinical Manager.”

“Based on personnel file review and staff interview the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed a written competency test to determine satisfactory competency prior to allowing the hospice aide to provide care independently to hospice patients for 1 of 3 sampled hospice aides (Staff D) hired since the last recertification survey (3/21/22). At the time of the survey, the agency employed 4 hospice aides and provided hospice aide services to 3 patients. Failure to ensure hospice aides successfully complete a competency evaluation in all basic home hospice aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic hospice aide skills placed agency patients at risk to receive inadequate or unsafe hospice aide services. Findings include: According to the hospice policy titled Homemaker/Home Health Aide/Hospice Aide Training and Competency Evaluation, last revised February 2024, competency will be evaluated by written examination, oral examination or observation of the Homemaker/Home Health Aide/Hospice Aide performance of the task on a person. During an interview on 2/25/24 at 3:10 PM The Clinical Manager stated Staff D, Hospice Aide contracted through another agency and already had competency testing completed. She further stated unable to locae the written competency test. 1. Staff D, Hospice Aide, had a hire date of 5/4/22. Staff D’s personnel file included competency documentation on 5/8/19. The competency documentation failed to include written competency testing completed by the hiring hospice. Staff D provided care independently to agency patients without successfully completing the written test demonstrating competency in the performance of all required basic skills. The above findings were reviewed with the Clinical Manager.”

“Based on agency interviews, clinical record review, and agency policy review, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 2 of 7 sampled patients receiving hospice aide services. (Patients #3 and #9). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient’s physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient’s needs. 2. Patient #9 had a start of care date of 4/10/24, a discharge date of 7/5/24 and received services from the hospice while residing in a private home. Clinical record review revealed: a. The undated hospice aide care plan included Registered Nurse (RN) instructions to the hospice aide to perform the task of Vital Signs – weight prn (as needed), with a start date of 4/10/24 and a resolved date of 7/5/24. b. The hospice aide visit notes, dated 4/30/24, 5/9/24, 5/23/24, 5/28/24 and 6/11/24, included documentation the task of Vital Signs – weight prn was not applicable. The aide care plan failed to provide specific instructions to the hospice aide on when the weight was to be obtained or when to not obtain a weight for the patient. During an interview on 4/8/25 at 1:05 PM, Clinical Manager reported the care plan was not specific with the instructions to the aide on when to obtain or not obtain a weight on patient. The above findings were reviewed with the Administrator and Clinical Manager. Findings include: According to the agency policy titled Hospice Aide Assignments and Duties, dated 2/2024, hospice aides are assigned to specific clients and follow written client care instructions in providing care to assigned clients. A hospice aide provides services that are approved by the IDT group and included in the patient plan of care. During an interview on 4/8/25 at 1PM, the Clinical Manager stated the Registered Nurse (RN) case manager creates and updates the aide care plan. 1. Patient #3 had a hospice admission date of 12/30/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care (POC), dated 12/30/24 to 3/29/24, included primary diagnosis of lung cancer and included physicians orders for hospice aide services two times per week. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task of a complete bath. c. The hospice aide visit notes dated 2/4/24, 2/25/24, and 3/4/24 documented complete bath performed as a bed bath. d. The hospice aide visit notes dated 1/3/24 and 2/14/24 documented complete bath performed as a shower. e. The hospice aide visit note dated 2/28/24 documented complete bath performed as a partial bed bath. f. The hospice aide visit notes dated 2/18/24, 2/21/24, 3/7/24, 3/11/24 and 3/14/24 did not specify the type of complete bath was performed. The hospice aide care plan failed to identify what kind of complete bath the aide should perform, bed bath, shower, or tub bath.”

“Based on review of written hospice agreements for services under arrangements, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 2 of 2 sampled services (Medical equipment/supply provider and Pharmacy provider). Failure to include this provision within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: 1.Review of the contract between the hospice and sampled medical equipment/supply provider, dated 7/29/2011, identified the contract lacked the following required components: a. The hospice retains administrative and financial management, b. The hospice retains oversight of staff and services and c. All services are delivered in accordance with the patient’s plan of care. 2. Review of the contract between the hospice and sampled pharmacy provider, dated 12/19/2014, identified the contract lacked the following required components: a. The hospice retains administrative and financial management, b. The hospice retains oversight of staff and services and c. All services are delivered in accordance with the patient’s plan of care. The hospice failed to include all required contract components in written agreements between the hospice agency and agencies providing services under arrangement. The above findings were reviewed with the Clinical Manager.”

“Based on staff interview, clinical record review and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 4 of 14 sampled patients (Patients #1,#6, #8 and #14). Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: 4. Patient #14 had a hospice admission date of 5/14/24, a revocation date of 5/31/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 5/14/24 to 8/11/24, identified the patient had a diagnosis of Congestive Heart Failure and included orders for skilled nurse, social worker, hospice aide and music therapy. b. The skilled nurse visit note, dated 5/20/24, completed and signed 6/5/24, 11 working days after the visit and 6 days late. The agency failed to ensure timely completion of routine visit documentation. The above findings were reviewed with the Administrator and Clinical Manager. 2. Patient #6 had a hospice admission date of 7/17/24, a death date of 8/5/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 7/17/24 to 10/14/24, identified the patient had a diagnosis of bladder cancer and included orders for skilled nurse, social worker, hospice aide, massage therapy and music therapy. b. The skilled nurse visit note, dated 7/22/24, completed by Staff C, RN, signed 8/1/24 (3 days late). c. The skilled nurse visit note, dated 7/31/24, completed by Staff C, RN, signed 8/7/24 ( 1 day late). The agency failed to ensure timely completion of routine visit documentation. 3. Patient #8 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 7/11/24 to 10/8/24, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social worker, and massage therapy. b. The skilled nurse visit note, dated 8/7/24, completed by Staff C, RN, signed 8/17/24 (3 days late). c. The skilled nurse visit note, dated 9/11/24, completed by Staff C, RN, signed 9/25/24 (10 days late). d. The skilled nurse visit note, dated 9/17/24, completed by Staff C, RN singed 9/25/24 (1 day late). e. The skilled nurse visit note, dated 9/24/24, completed by Staff C, RN signed 10/4/24 (3 days late). f. The skilled nurse visit note, dated 10/1/24, completed by Staff C, RN signed 10/21/24 ( 9 days late). The agency failed to ensure timely completion of routine visit documentation. According to the hospice policy titled Clinical Records, revised in January 2024, required documentation for each service of care provided by the hospice agency must be completed (confirmed with e-signature for computerized charting) and available to file in the clinical record within five working days for nursing notes, social worker notes and bereavement notes for hospice patients. During an interview on 4/1/25 at 11:15 AM, Staff B, Clinical Manager stated agency staff have five working days to complete routine visit notes. 1.Patient #1 had a hospice admission date of 3/6/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/6/25 to 6/3/25, identified the patient had a diagnosis of Lung Cancer and included orders for skilled nurse, social worker, chaplain, massage therapy and music therapy. b. The skilled nurse visit note, dated 3/12/25, completed by Staff C, Registered Nurse (RN), signed 3/26/25 (5 days late). The agency failed to ensure timely completion of routine visit documentation.”

“Based on review of the written agreements between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreement identified the hospital would send a copy of the hospice patient’s discharge summary to the hospice at the time of discharge from the hospital for 1 of 2 sampled written agreements reviewed (Hospital A). Failure to ensure the hospital provided the hospice with a discharge summary upon hospital discharge of a hospice patient decreased the possibility of continuity of care when the patient returned home. Findings include: The hospice had a contractual agreement with Hospital A, dated 1/23/23. The contractual agreement failed to specify the hospital would provide the hospice agency with a copy of the discharge summary at the time of discharge and failed to specify a copy of the inpatient clinical record is available to the hospice at the time of discharge. The above findings were reviewed with the Clinical Manager.”

“Based on review of the written agreement between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreement identified the hospice’s responsibility to maintain a description of the training and documentation of the names of those giving the training for 1 of 2 sampled written agreements (Hospital A). Failure to ensure the written agreements with hospitals specified the hospice’s responsibility to ensure hospital staff caring for hospice patients received training and the hospice maintained appropriate documentation of the training placed hospice patients at risk for receiving inpatient care in conflict with the hospice philosophy. Findings include: The hospice agency had a contractual agreement with Hospital A, dated 1/23/23. The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators. The above findings were reviewed with the Clinical Manager.”

“The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal background check for 1 of 4 sampled employees (Staff D) who began serving hospice patients since their last survey, dated 4/21/22. The hospice reported hiring 5 contracted staff since the last survey. Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice employees who had direct patient contact. According to the hospice policy titled Employment, last revised October 2023, offers of employment are based upon having acceptable results from the abuse registries background check. A criminal history check, dependent adult abuse record check and child abuse record check for each prospective employee will be completed within 30 days prior to the hire date of the prospective employee. During an interview on 4/3/25 at 10:40 AM, the Clinical Manager stated Staff D, Hospice Aide lived in Illinois and worked out of the Illinois office. The Criminal Background check ran in Illinois. 1. Staff D, Hospice Aide, had a hire date of 5/4/22. A criminal background check was completed using Illinois Department of Public Health and dated 3/24/22. The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients. The above findings were reviewed with the Clinical Manager.”