SC Home Health NFP

“Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) Standard: Administrator. The administrator must: (i) Be appointed by and report to the governing body; This Element is not met as evidenced by: Based on staff interview and document review, the facility failed to ensure the administrator was appointed by the governing body. Findings include: 1. A review of the Board of Directors meeting minutes dated June 9, 2025 and March 4, 2025 was completed on 8/27/2025 at approximately 12:00 PM. No documentation was present indicating appointment of E#1 as Administrator of the agency. 2. The Policy titled “Board of Directors”, effective 8/17/2022, states “The Board of Directors is the governing body for Whitestar Home Health Agency (SC Home Health NFP)…The Board of Directors is responsible for…Appointing a qualified Administrator for the Agency.” 3. An interview was conducted on 8/27/2025 at approximately 11:50 AM, with the Director/Administrator, (E#1). During discussion regarding appointment of the administrator, E #1 noted she was promoted to Director/Administrator of the agency in January, 2025. E#1 further noted the Board of Directors had not officially appointed her as Administrator since her promotion to the position.”

“Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This Element is not met as evidenced by: Based on document review and interview, the facility failed to ensure a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, was provided in writing, as authorized by the administrator and governing body. Findings include: 1. A review of the Board of Directors meeting minutes dated June 9, 2025 and March 4, 2025 was completed on 8/27/2025 at approximately 12:00 PM. No documentation was present indicating authorization of a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available. 2. The Policy titled “Board of Directors”, effective 8/17/2022, states “The Board of Directors is the governing body for Whitestar Home Health Agency (SC Home Health NFP).” 3. The Policy titled “Organization and Structure”, effective 8/17/2022, states: -The Administrator of Whitestar Home Health Agency (SC Home Health NFP) has overall administrative responsibility for the Agency’s operations. -In the absence of the Administrator, the Director of Patient Care Services assumes responsibility of administrative and operational activities. -In the absence of the Administrator and the Director of Patient Care Services, the Director of Quality Improvement assumes responsibility of administrative and operational activities. -In the absence of the Administrator and the Director of Patient Care Services, a Clinical Supervisor is designated responsibility for the delivery of patient care and services. 4. An interview was conducted on 8/26/2025 at approximately 1:00 PM, with the Director (E #1). During discussion about who is the Director of Patient Services and Director of Quality Improvement, E #1 noted she serves in those roles. During discussion regarding a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available, E #1 stated the “back-up person when I’m gone” is E #4, the Vice President of Operations and Quality. E #1 also identified E #4 as the Vice President of the Board of Directors. E #1 further noted a pre-designated person who assumes the same responsibilities and obligations as the administrator when the administrator is not available was not provided in writing, as authorized by E #1 as Administrator, nor the Board of Directors, who serve as the governing body for the agency.”