Organizational Structure, Multiple Locations and Lines of Authority
Describes how the Agency keeps a written organizational structure that shows who answers to whom down to the patient's bedside, how any additional location is approved, licensed and supervised as part of the one hospice, and what must happen before the Agency opens or closes a location or a service.
About this policy
- Policy number
- PA-HSP-GOV-02
- Version
- 1.0
- Main rule
- 42 CFR §418.100(f)
- Library
- Pennsylvania hospice · 60 policies
- Category
- Governance
- Sections
- 17
In short
- Know who your supervisor is and who the on-call manager is. The organizational chart is posted in the office.
- Every Agency location uses the same policies. There are no local versions.
- Report complaints, incidents and abuse concerns from any location to the parent office the same day.
- The Agency does not start or stop a service without telling the Department of Health 60 days ahead.
What's inside
17 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §418.100(f))
- 5. The Written Organizational Structure
- 5.1 When the chart is updated
- 5.2 Who sees it
- 6. Opening an Additional Location
- 7. Supervision of Multiple Locations
- 8. Starting or Stopping a Service
- 9. Responsibilities
- 10. Records and Compliance Monitoring
- 11. References
- 12. Related Policies and Forms
- 13. Approval
- 14. Revision History
An inspector may ask
- Show me your organizational chart. Can you trace the line of authority from a hospice aide at a patient's home to the governing body?
- Do you operate any multiple locations? Show me the Medicare approval and how the parent office supervises them.
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