Sec. 10.07.21.06. Administration

A. Responsibility of Licensee. A licensee shall ensure that the operation of the hospice care program complies with Health-General Article, Title 19, Subtitle 9, Annotated Code of Maryland, and this chapter.

B. Governing Body.

(1) A licensee shall have a governing body for the hospice care program. The governing body shall:

(a) Determine the hospice care program's mission and purpose;

(b) Conduct a periodic community needs assessment;

(c) Provide outreach programs appropriate to the needs of the communities it serves, including making information about hospice care services readily available and providing appropriate educational activities to the communities it serves;

(d) Make efforts to secure access to hospice care services for the underserved;

(e) Adopt administrative and clinical policies and procedures, and review them annually;

(f) Monitor the hospice's program and establish a process to evaluate the quality of services it is providing;

(g) Have fiscal and fiduciary responsibility for the hospice care program including the review and approval of its budget;

(h) Ensure compliance with all legal requirements;

(i) Adopt bylaws which:

(i) Specify the role and responsibility of the governing body; and

(ii) Define the hospice care program's relationship to any other governing body; and

(j) Develop and implement a written conflict of interest policy which includes guidelines for the resolution of any existing or apparent conflict of interest.

(2) All members of the governing body shall participate in an orientation program and continuing education to enable the members to fulfill their responsibilities to the hospice care program.

C. Administrator.

(1) The governing body or the licensee shall:

(a) Identify an administrator who has full responsibility for the day-to-day operations of the hospice care program; and

(b) Evaluate the administrator's performance on at least an annual basis.

(2) In the absence of the administrator, the program shall remain under the continuous supervision of a designated individual with appropriate experience and training.