Administrator License Expired and Not Renewed
Penalty
Summary
The facility failed to ensure that the Administrator (ADM) held a current and active license as required by federal and state regulations. During an observation, it was noted that the ADM's license, posted in the facility's lobby, had expired. The expiration date on the license was confirmed, and during an interview, the ADM acknowledged that the license had expired and that the renewal application had not yet been submitted. The ADM also stated that the renewal application should have been submitted 60 days prior to the expiration date. A review of the facility's policy and procedure for the Administrator position indicated that the governing board is responsible for appointing an administrator who is duly licensed in accordance with current federal and state requirements. The failure to maintain a current and active license for the ADM resulted in the facility operating without a licensed administrator, which is not in compliance with regulatory requirements.
Plan Of Correction
What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not reoccur: Senior Director of Operations will do random rounds to the facility and check/monitor communication board to ensure that Administrator license is posted and up to date. How the facility plans to monitor performance to make sure solutions are sustained: Findings from monitoring reports will be reviewed and presented to QA monthly for further resolutions and recommendations. Any issues of non-compliance shall be reviewed by the QA Committee for additional actions and recommendations until no negative trends noted and/or 100% compliance has been achieved consistently x 3 months. Administrator and/or Director of Nursing will monitor this corrective action for continued compliance.