Every finding on record at Hospice of Morrow County, Inc

Based on document review and staff interview, the governing body failed to appoint a qualified administrator and a back up administrator, in the absence of the administrator. This had the potential to affect all patients receiving services from the agency. The agency census is 19. Findings include: In an interview on 12/14/21 at 8:47 AM, Staff A and B stated the previous Executive Director resigned on 10/01/20. The Board appointed a leadership team to cover the administrative duties instead of hiring a new Executive Director. Staff A, B, and C split the administrative duties. Review of an email dated 10/01/20 at 2:18 PM from the President of the Board revealed the Executive Committee of the Board selected a management team of three people to replace the Executive Director/Administrator who resigned. Review of the Board meeting minutes dated 09/29/20 revealed the Executive Director/Administrator resigned. The Board Meeting minutes dated 12/01/20 established a management team of Staff A, B, and C to assume responsibility of the administrative duties. The Board chose to not replace the Executive Director/Administrator position at this time. Review of the "Appointment of Executive Director/Administrator" policy, revised April 2021, revealed the Governing Body will appoint an Executive Director/Administrator. The Executive Director/Administrator will be responsible for the day to day operations, have at least two years health related experience, be knowledgeable of applicable law and regulation, ensure personnel are qualified, and take reasonable steps to assure the organization complies with applicable law and regulation. Review of the "Designation of Individual in Absence of Executive Director/Administrator" policy, revised April 2021, revealed an Executive Director/Administrator or designee will be available at all times. In the event the Executive Director/Administrator is absent, the Clinical Director will assume the operational duties and responsibilities. In the event both are absent, an appropriately qualified nurse will assume the responsibilities. "These individuals have been identified as qualified to act on behalf of the Executive Director/Administrator in his/her absence. Clinical Director: ________________ Qualified Nurse: __________________" The names of the Clinical Director and Qualified Nurse were blank. Review of the "Job Title/Position: Executive Director/Administrator", revised April 2021, revealed the job description and position qualifications for the Executive Director/Administrator. The position qualifications included a Bachelor's degree in business administration, master's degree in health care or related field preferred, two to five years experience in health care management, an ability to supervise and direct professional and administrative personnel, knowledge of corporate business management, an ability to deal tactfully with the community, intimate knowledge of medicare hospice certification, and understanding of hospice care and services provided through an interdisciplinary group. Review of the personnel file for Staff A revealed a hire date of 11/27/17 and a current license as a registered nurse. Review of the personnel file for Staff B revealed a hire date of 04/17/19 and no previous experience in health care. Review of the personnel file for Staff C revealed a hire date of 08/29/16, a current license as a social worker, and a master's degree.