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Governing Body, Administrator and Hospice Management Personnel

Sets out who governs the Agency, the six management positions California requires and who appoints each in writing, what the governing body decides itself, what the Administrator does day to day, how leadership stays reachable, and how the Agency receives a CDPH inspector.

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About this policy
Policy number
CA-HSP-GOV-01
Version
1.0
Main rule
22 CCR §74876(a)
Library
California hospice · 60 policies
Category
Governance
Sections
20

In short

  • The governing body of Sample Agency, LLC appoints the Administrator, the Director of Patient Care Services and the Medical Director in writing. The Administrator appoints a designee for each.
  • Pat Sample runs the Agency day to day. When the Administrator is not available, Jo Sample has the same authority.
  • If a state inspector arrives, check their ID, let them in right away and call the Administrator. Inspections can happen at any time without notice.
  • Give inspectors the records, files and computer access they ask for. Personnel records must be produced within 24 hours.
  • After hours, on-call nurses can always reach the Director of Patient Care Services or Medical Director, or their designees.

What's inside

20 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (22 CCR §§74852(a), 74856(a), 74876(a); 42 CFR §418.100(b))
  • 5. Who Appoints Whom
  • 6. What the Governing Body Does Itself
  • 7. What the Administrator Does
  • 8. Designees and Leadership Availability
  • 8.1 Administrator and Administrator Designee
  • 8.2 Clinical and medical leadership after hours
  • 9. When a CDPH Representative Arrives
  • 10. Governing Body Meetings and Reports
  • 11. Responsibilities
  • 12. Records and Compliance Monitoring
  • 13. Staff Training
  • 14. References
  • 15. Related Policies and Forms
  • 16. Approval
  • 17. Revision History

An inspector may ask

  • Who is your governing body, and where are the written appointments of your Administrator, Director of Patient Care Services and Medical Director?
  • Show me the Administrator's written appointments of the Administrator Designee, the DPCS Designee and the Medical Director Designee.

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