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Governing Body, Administrator and Key Designations

Sets out what the governing body of the Agency does itself, the appointments it makes in writing (Administrator, Alternate Administrator, medical director and leader of the medical staff, director of nursing, quality lead and the other named roles Michigan and Medicare require), what the Administrator is responsible for, how leadership is reachable, and how the governing body meets at least once a year and keeps a written record.

Preview: full text with a package
About this policy
Policy number
MI-HSP-GOV-01
Version
1.0
Main rule
Mich. Admin. Code R 325.45123
Library
Michigan hospice · 59 policies
Category
Governance
Sections
19

In short

  • The governing body of Sample Agency, LLC is responsible for the hospice: how it is run, every service, the money and the quality program.
  • Pat Sample runs the Agency day to day. Jo Sample takes over in writing whenever the Administrator is away.
  • Dr. Morgan Sample leads the medical staff. Robin Sample, RN directs all nursing.
  • State surveyors can arrive without notice. Check their ID, let them in right away and call the Administrator.
  • A surveyor must get the patient's spoken permission before watching care in the home.

What's inside

19 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 (Mich. Admin. Code R 325.45123; 42 CFR §418.100(b))
  • 5. What the Governing Body Does Itself
  • 6. Appointments the Governing Body Makes
  • 7. What the Administrator Does
  • 8. Leadership Availability
  • 8.1 During and outside office hours
  • 8.2 When a Department surveyor arrives
  • 9. Governing Body Meetings 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 show me the written record of its actions from the last year.
  • Show me the written appointment of the Administrator and the written delegation for the person who acts when the Administrator is away.

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