#5: Governing Body and Administrator : 42 CFR 418.100(b) Tag 0651

The hospice failed to ensure a governing body (or designated persons functioning as the governing body) assumes full legal authority and responsibility for the management of the hospice and the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. The hospice failed to ensure a qualified administrator appointed by and reporting to the governing body was responsible for the day-to-day operation of the hospice. The hospice failed to ensure that the administrator is a hospice employee with the education and experience required by the hospice's governing body.

The hospice administrator failed to ensure the hospice physician took part in physical assessments to update the clinical diagnoses, medical plan of care, and prognosis for 4 of 5 patients.