Assistant Administrator Not Duly Appointed by Governing Board
Penalty
Summary
The facility failed to ensure that the assistant administrator was duly appointed by the governing board, as required by regulation. Review of the assistant administrator's personnel file showed a job description signed by the individual but lacking CEO approval, and a handwritten HR approval signed by the same individual. The resume did not document any licenses or certifications, and the staff list, business card, and facility documentation all identified the individual as the assistant administrator. A letter designated the assistant administrator as the responsible party in the administrator's absence, but there was no evidence of a formal appointment by the governing board. The administrator confirmed there was no policy for assistant administrator appointment and was unaware of the requirement for board appointment. Interviews with staff revealed that incidents of abuse were reported to the assistant administrator, who, along with the ADON, instructed staff to let the incident go and not escalate it, particularly as it involved residents in the behavioral unit. Despite continued reports of verbal abuse and intimidation, there was no evidence of a thorough investigation or reporting to the state agency. Staff interviews confirmed the assistant administrator's role in handling such incidents, but the lack of proper appointment and oversight contributed to the deficient practice.