Every finding on record at St. Charles Health System Inc.

Based on documents reviewed, it was determined the hospice failed to produce a policy and procedure that identifies another individual to assume administrator duties and responsibilities when the administrator is not available. The hospice also failed to provide documentation that identifies an individual, approved by the governing body, to assume administrator responsibilities when the administrator is not available. --- Findings: On 11/12/2024 at 1:40 PM, a list of documents to be reviewed was presented to the Hospice Director. Included on this list was a request for documentation with identity of, and governing body authorization for, the person who is authorized to act on behalf of the administrator during the administrator's absence. On 11/13/2024, a second request was made to the Director for documentation of the person who is authorized to act on behalf of the administrator during the administrator's absence. The documentation was not provided. On 11/18/2024, Director emailed Surveyor for clarification on this standard of the CoPs. The Director stated, "We are having a tough time locating this information." The documentation was not provided. During an interview with the Director on 11/26/2024 at 2:45 PM, the above document was discussed. The Director acknowledged they did not have the document stating, "We have searched through the policies and procedures and could not find a document with this information."