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Governing Body, Administrator and Key Designations

Names the governing body as the body legally responsible for the Agency, sets how the Administrator is appointed and what the Administrator does, lists every role the Conditions of Participation and privacy and civil rights rules require a hospice to designate, and explains how leadership is covered during absences, surveys and changes of key personnel. The District does not license hospices, so this policy follows 42 CFR §418.100(b).

Preview: full text with a package
About this policy
Policy number
DC-HSP-GOV-01
Version
1.0
Main rule
42 CFR §418.100(b)
Library
Washington, DC hospice · 60 policies
Category
Governance
Sections
22

In short

  • The governing body is legally responsible for Sample Agency, LLC. Pat Sample runs it day to day.
  • When the Administrator is away, Jo Sample acts with full authority.
  • Every key role (medical director, clinical manager, QAPI lead, privacy official and others) is named in writing.
  • If surveyors arrive, welcome them, check their ID and tell the Administrator or alternate at once.
  • Never change or back-date a record after a surveyor asks for it.

What's inside

22 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. The Administrator
  • 7.1 Qualifications
  • 7.2 Duties
  • 8. Availability of Leadership
  • 8.1 During office hours
  • 8.2 Absences
  • 8.3 Receiving surveyors
  • 9. Change of Administrator or Other Key Person
  • 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 legal authority over the hospice? Show me the minutes of its last meetings.
  • Show me the governing body’s written appointment of the Administrator. Is the Administrator a hospice employee?

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