Failure to Appoint Licensed Administrator for Facility Management
Penalty
Summary
The facility failed to ensure that its governing body appointed a state-licensed administrator to be responsible for the management of the facility, as required by policy and regulation. Record review showed that the previous administrator was terminated in mid-July, and since then, the facility had not had a licensed administrator in place. Interviews with staff, including the Administrator-in-Training (AIT), Interim DON, HRP Director, and Corporate Regional Director, confirmed that the AIT had not passed the licensing exam and was acting in the administrator role without a license. The facility's own policy requires a duly licensed administrator to oversee day-to-day operations, but this requirement was not met for several months. Staff interviews revealed that the absence of a licensed administrator was known to facility leadership, and the AIT was expected to assume the role upon passing the exam. In the interim, there was no full-time licensed administrator overseeing the facility. The lack of a licensed administrator was acknowledged by staff as a potential cause for regulatory citation, and concerns were raised that staff might not follow facility policies or rules in the absence of proper oversight. The deficiency affected all 50 residents in the facility, as there was no licensed administrator to ensure appropriate management and oversight of care.