Governing Body, Administrator and Key Designations
Sets out what the governing body of the Agency must do itself under Louisiana’s hospice licensing rules, the written designations it makes (Administrator, Alternate Administrator, director of nurses, medical director and others), what the Administrator is responsible for, how leadership stays reachable during operating hours and surveys, and how the governing body keeps minutes and receives reports.
About this policy
- Policy number
- LA-HSP-GOV-01
- Version
- 1.0
- Main rule
- LAC 48:I §8217.F
- Library
- Louisiana hospice · 60 policies
- Category
- Governance
- Sections
- 19
In short
- The governing body of Sample Agency, LLC is legally responsible for the whole hospice and approves all policies at least once a year.
- Pat Sample runs the Agency day to day. Jo Sample takes charge whenever the Administrator is unavailable.
- Robin Sample, RN, the director of nurses, supervises all patient care. When the director is away, Casey Sample, RN is responsible.
- If a state surveyor arrives, check their ID, let them in right away and call the Administrator or the Alternate Administrator.
- Surveyors may see any area and any file and may talk to any staff member or patient. Never refuse or delay them.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (LAC 48:I §8217.F)
- 5. What the Governing Body Does Itself
- 6. Written Designations
- 7. What the Administrator Does
- 8. Leadership Availability
- 8.1 During business hours
- 8.2 When a Department surveyor arrives
- 9. Governing Body Meetings, Minutes and Reports
- 10. Responsibilities
- 11. Records and Compliance Monitoring
- 12. Staff Training
- 13. References
- 14. Related Policies and Forms
- 15. Approval
- 16. Revision History
An inspector may ask
- Who is your governing body, and where are its written minutes and attendance records?
- Show me the written designations of the Administrator, the director of nurses and the person who assumes authority when the Administrator is unavailable.
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