Hospices Overcoming Challenges in Vetting Staff

Issues such as criminal background checks and credentialing and privileging are significant drivers of regulatory deficiencies among hospice providers, leading hospices to seek strategies to improve compliance.

Inadequate vetting of staff was one of the most commonly occurring regulatory survey deficiencies discussed in recent reports from the U.S. Department of Health and Human Services Office of the Inspector General (OIG). The other top deficiencies in the report were related to care planning and comprehensive patient assessments.

“Some hospices did not complete criminal background checks of staff, while other hospices did not update employee credentials,” OIG said in the first of the two reports. “When hospices fail to ensure that staff are qualified, they put the safety of beneficiaries at risk.”


OIG released the reports in July, indicating that more than 87% of the 4,563 hospices operating in the United States between 2012 and 2016 had at least one deficiency identified during a regulatory or accreditor survey. The office examined state agency and accreditor survey findings as well as complaint data from 2012 through 2016, focusing on a sample of 50 types of serious deficiencies. The reports called upon regulators to step up their enforcement strategies for hospices.

One hospice discussed in the report did not perform criminal background checks on six employees who provided direct patient care or had access to patient records. A second hospice failed to ensure that 34 of its 35 employees who provided care had updated credentials. In another hospice, 18 employees were not screened for abuse and neglect prior to working at the facility and three did not have required professional licensure.

A significant contributing factor to these deficiencies is the complexity of the credentialing and privileging process.


In addition to criminal background checks, work history and education history, hospices and other health care providers must take the extra step of completing primary source verification of their staff’s licenses and credentials.

“The proper vetting of staff is a very comprehensive process. Though I think that some hospices don’t spend the money and the time to properly vet out their employees, the majority of providers are very good at vetting staff,” Sarah McSpadden, president and CEO of Elizabeth Hospice told Hospice News. “It’s an extensive list of ongoing background screenings, and we do a lot of screenings monthly for our staff. So you need to have a process in place and making sure that process captures every single individual on your staff on a regular basis.”

Many organizations use an outside vendor to perform some of these processes, sometimes for a nominal fee and sometimes for a substantial fee, depending on the vendor. The vendor may have their own requirements for information they must receive from hospices.

“I think that’s one of the biggest pitfalls,” McSpadden said. “I used to do audits of other providers and what often happened is that they didn’t realize that copies of licenses are not enough as they had been in the past. We are expected to go to the source and verify their license that way.”

The hospice can also work with other health care organizations they contract with to ensure staff have the credentials and clinical privileges necessary to provide care in those settings, such as a hospital hospice unit or a skilled nursing facility.

“When we are audited or surveyed the surveyors look at randomly selected staff personnel files to spot check and make sure we are doing everything that we are required to do,” McSpadden said. “Sometimes there will find something is missing and it may be an oversight of the person in terms of their licenses. There are all kinds of reasons why it might not be where it needs to be at that particular time. Some of the challenges that hospices have in that process certainly could be the extent of the background screenings.”

Among those screenings is the OIG exclusion process, which 100% of staff, including volunteers, leaders and board members must undergo. The process verifies that an individual is not barred from participating in any state or federally funded program, including Medicare and Medicaid.

Elizabeth Hospice maintains a dashboard to ensure they are on point with necessary vetting processes, including the OIG exclusion list and credentialing and privileging. The dashboard indicates whose credentials are up to date and whose are close to expiring.

“We review the dashboard on a monthly basis to make sure that all staff have been through the OIG screening and that we have run all their licenses through the required processes. We notify staff in the field that they must update their credentials usually two months before they are set to expire,” McSpadden told Hospice News. “Having a dashboard and a real process around fulfilling the requirements within the right time frames makes a real difference, as does a clear understanding of what you need to do with the answers that come out of that.”

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