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Governing Body, Administrator and Key Designations

Sets out how the governing body of the Agency holds legal responsibility for the hospice, appoints and oversees the Administrator, and designates in writing the people every Pennsylvania hospice must name: the medical director and physician designee, the QAPI lead, the bereavement supervisor, the volunteer supervisor and the emergency preparedness lead. It also covers the Agency's own back-up roles and how Department of Health surveyors are received.

Preview: full text with a package
About this policy
Policy number
PA-HSP-GOV-01
Version
1.0
Main rule
42 CFR §418.100(b)
Library
Pennsylvania hospice · 60 policies
Category
Governance
Sections
20

In short

  • The governing body of Sample Agency, LLC is legally responsible for all hospice care, money and quality.
  • Pat Sample runs the Agency day to day. Jo Sample takes over when the Administrator is away.
  • The posted list of designations tells you who the medical director, clinical manager, QAPI lead, bereavement and volunteer leads are.
  • If a Department of Health surveyor arrives, ask for identification, let them in right away and call the person in charge.
  • Never change, back-date or remove a record during or after a survey.

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 (42 CFR §418.100(b))
  • 5. What the Governing Body Does Itself
  • 6. Written Designations
  • 7. Administrator Responsibilities
  • 8. Availability of Leadership
  • 8.1 During office hours
  • 8.2 Absences
  • 8.3 Receiving Department of Health surveyors
  • 9. Change of Administrator
  • 10. Governing Body Meetings and Reports
  • 11. Responsibilities
  • 12. Records and Compliance Monitoring
  • 13. References
  • 14. Related Policies and Forms
  • 15. Approval
  • 16. Revision History

An inspector may ask

  • Who is your governing body, and how does it exercise its responsibility for management, services, finances and QAPI?
  • Show me the Administrator's appointment and job description. Is the Administrator a hospice employee?

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