381-170 – Administrator – Harbor Home Healthcare

1.Policy Objective

Harbor Home Healthcare LLC (“Harbor”) shall appoint an Administrator who is responsible for the day-to-day management and operation of Harbor’s home care organization and who ensures Harbor maintains operational readiness, regulatory compliance, and effective implementation of Harbor policies and procedures. (; ) This policy establishes Administrator responsibilities and delegation expectations while maintaining Governing Body oversight and accountability for Harbor operations and policy review. (; Ref: 4, 5)

Requirements

1.1 The Governing Body shall appoint an Administrator with authority to manage Harbor’s day-to-day operations and implement Harbor policies and procedures. (; ; Ref: 5.1)
1.2 The Administrator shall organize and direct the day-to-day operation of Harbor and ensure Harbor remains operational and responsive to client and personnel needs consistent with Harbor policies. (; ; Ref: 5.4)
1.3 The Administrator shall ensure Harbor develops, implements, and maintains written policies and procedures and ensures personnel receive orientation and training on applicable policies. (; Ref: 5.5)
1.4 Harbor shall designate an Alternate Administrator (or qualified designee) to provide continuity of Administrator functions when the Administrator is unavailable. (; Ref: 5.2)
1.5 The Administrator may delegate specific tasks in writing to qualified personnel, and the Administrator shall retain accountability for ensuring delegated functions are completed as required. (; Ref: 5.3)
1.6 The Administrator shall ensure required notices to the licensing authority are completed when changes occur that affect Harbor operations or the license. (; Ref: 5.7)
1.7 The Administrator shall support the Governing Body’s annual policy review process by coordinating review materials and ensuring approvals are documented. (; Ref: 5.8)

1.1 Definitions

Administrator means the individual appointed by the Governing Body to manage day-to-day operations with authority to implement policy and ensure compliance. ()
Alternate Administrator means a qualified individual designated to act on behalf of the Administrator when the Administrator is unavailable. (; Ref: 5.2)
Designee means a person authorized in writing by the Administrator to perform defined tasks while the Administrator retains accountability. (; Ref: 5.3)
Delegation means assignment of tasks or functions to a qualified designee without transfer of Administrator accountability for outcomes. ( Ref: 5.3)
On-Call Representative means the Administrator, Alternate Administrator, or qualified designee available after hours to respond to urgent operational or client needs. ( Ref: 5.4)
Personnel means Harbor employees and contracted personnel (as applicable) who represent Harbor and/or provide services under Harbor’s license, including Direct Care Staff (Home Attendants). ()

Implementation Guidance

A1 Delegation assigns tasks and does not transfer accountability; the Administrator remains responsible for ensuring required functions are completed. ( Ref: 5.3)
A2 This policy defines Administrator oversight expectations, and related policies define detailed operational processes for staffing, scheduling, compliance activities, and quality monitoring. ( Ref: 7)

2.Scope & Application

This policy applies to the Administrator, Alternate Administrator, and any designated designees who perform Administrator functions on behalf of Harbor. () This policy also applies to supervisors, intake/admissions personnel, scheduling/operations personnel, billing personnel (as applicable), and all personnel who must know when and how to escalate urgent issues or compliance concerns to the Administrator or On-Call Representative. (; Ref: 5.4, 5.6)

Requirements

2.1 Harbor shall communicate Administrator escalation pathways to applicable personnel so urgent operational issues and compliance concerns are routed to the Administrator or On-Call Representative as appropriate. (; Ref: 5.4, 5.5)
2.2 When the Administrator is unavailable, Harbor shall ensure Alternate Administrator coverage is in place so Administrator functions continue without interruption. (; Ref: 5.2)
2.3 When the Administrator delegates tasks, Harbor shall ensure delegations are in writing and are limited to qualified designees. (; Ref: 5.3)

Implementation Guidance

A3 When one individual is assigned more than one required role, the responsibilities of each role remain in effect and shall be completed and documented for each function performed. ( Ref: 4, 6)

3.Regulatory Basis

This policy supports Harbor’s compliance with Virginia home care licensure requirements related to management and administration, Governing Body oversight, Administrator responsibilities, and maintaining written policies and procedures. (; ; ; ) Detailed citation mapping, policy traceability, and internal cross-references are maintained in Section 8: References & Regulatory Citations (authoritative citation index for this policy). ( Ref: 8)

Implementation Guidance

A4 Administrator duties are demonstrated through consistent operational management, timely escalation pathways, documented coverage and delegation, and completion of required notices when applicable. (; ; Ref: 5, 6)

4.Roles & Responsibilities

4.1 Governing Body

4.1.1 The Governing Body shall appoint the Administrator and ensure the Administrator meets applicable qualifications and has authority to manage day-to-day operations. (; ; Ref: 5.1)
4.1.2 The Governing Body shall receive reports from the Administrator and provide governance oversight, including annual policy review and quality oversight as applicable. (; Ref: 5.8)

4.2 Administrator

4.2.1 The Administrator shall manage Harbor’s day-to-day operations and ensure Harbor remains operational during posted business hours and maintains on-call responsiveness when applicable. (; ; Ref: 5.4)
4.2.2 The Administrator shall ensure Harbor develops, implements, and maintains written policies and procedures and ensures personnel receive training on applicable policies. (; Ref: 5.5)
4.2.3 The Administrator shall ensure staffing and supervision structures support compliant service delivery and address service interruptions and urgent operational issues. (; Ref: 5.4, 5.6)
4.2.4 The Administrator shall ensure required notices to the licensing authority are completed when changes occur that affect the organization or license. (; Ref: 5.7)

4.3 Alternate Administrator / Designee

4.3.1 The Alternate Administrator or designee shall perform assigned Administrator functions when the Administrator is unavailable and document actions taken consistent with delegation parameters. ( Ref: 5.2, 5.3)

4.4 Managers/Supervisors (as applicable)

4.4.1 Managers and supervisors shall escalate incidents, complaints, service failures, and compliance concerns to the Administrator promptly and support corrective actions as assigned. ( Ref: 5.5, 5.6)

Implementation Guidance

A5 Administrator reports may be brief, and governance records capture decisions, action items, and approvals when required by policy or governance processes. ( Ref: 6)

5.Procedures

5.1 Appointment and Authority

5.1.1 The Governing Body appoints the Administrator and documents the appointment and authority to manage Harbor’s licensed operations. (; ; Ref: 6)

5.2 Alternate Administrator Coverage

5.2.1 Harbor designates an Alternate Administrator (or qualified designee) to ensure continuity of Administrator functions when the Administrator is unavailable. (; Ref: 6)
5.2.2 The designation identifies the individual, effective date, and scope of coverage and is communicated to applicable personnel. (; Ref: 6)

5.3 Delegation of Tasks

5.3.1 The Administrator may delegate specific tasks to qualified personnel in writing, and the delegation identifies the task, designee, effective date, limits, and reporting expectations. (; Ref: 6)
5.3.2 The Administrator reviews delegated tasks as needed to ensure delegated functions are completed according to Harbor policy and applicable requirements. (; Ref: 6)

5.4 Operational Readiness and On-Call Escalation

5.4.1 The Administrator ensures Harbor is operational during posted business hours and maintains an after-hours escalation pathway so urgent client or staffing issues are addressed outside business hours when required by Harbor operations. (; Ref: 7)
5.4.2 Harbor maintains and communicates on-call or escalation contact instructions as applicable to Harbor operations and documents the current method used. (; Ref: 6)

5.5 Policy Implementation and Personnel Communication

5.5.1 The Administrator ensures policies are implemented consistently and ensures orientation and training materials reflect current policies. (; Ref: 6)
5.5.2 The Administrator ensures personnel know escalation pathways for urgent issues, complaints, incidents, and compliance concerns and updates communication when pathways change. (; Ref: 6)

5.6 Compliance and Corrective Actions

5.6.1 The Administrator ensures documentation is organized, issues are corrected promptly, and corrective actions are tracked when problems are identified through operations, complaints, incidents, or quality monitoring. (; ; Ref: 6)

5.7 Notifications of Changes Affecting the License

5.7.1 When a change occurs that requires notice to the licensing authority, the Administrator prepares and submits timely notice and retains copies of notice and responses in Harbor records. (; Ref: 6)

5.8 Annual Policy Review Support

5.8.1 The Administrator coordinates annual policy review materials and presents recommendations to the Governing Body for approval and documentation. (; Ref: 6)

Implementation Guidance

A6 Harbor uses written coverage and delegation documentation so Administrator functions continue consistently when the Administrator is unavailable or when tasks are assigned to designees. ( Ref: 5.2, 5.3)

6.Documentation Requirements

Documentation related to this policy shall include, at a minimum, when applicable:

Administrator appointment documentation and role description or authority statement. (; Ref: 5.1)
Alternate Administrator designation and coverage documentation when applicable. (; Ref: 5.2)
Written delegation documentation identifying delegated task(s), designee, effective date, and limits when applicable. (; Ref: 5.3)
On-call or escalation coverage documentation when Harbor maintains after-hours coverage. (; Ref: 5.4)
Evidence of annual policy review coordination and Governing Body approvals (minutes or approval record). (; Ref: 5.8)
Copies of notifications and correspondence related to changes affecting the license when applicable. (; Ref: 5.7) Administrator governance, coverage, and delegation records are maintained securely and retained in accordance with Harbor record management and retention standards. (; Ref: 6.1, 7)

6.1 Forms & Tools

The tools below map each documentation requirement to the form/tool used; Harbor may adjust names and formats as long as required content is maintained.

Section 6 Requirement	Form(s) / Tool(s) Used
Document Administrator appointment and authority.	Administrator appointment record and role description/authority statement filed in governance records. (; Ref: 5.1)
Document Alternate Administrator coverage.	Alternate Administrator designation record and coverage note or roster when applicable. (; Ref: 5.2)
Document written delegations when used.	Administrator delegation log or memo identifying task, designee, limits, and effective date. (; Ref: 5.3)
Document on-call or escalation coverage when used.	On-call coverage schedule or escalation contact list; telephone greeting instructions when applicable. (; Ref: 5.4)
Document annual policy review support and approvals.	Annual policy review checklist and Governing Body minutes or approval record. (; Ref: 5.8)
Maintain required notifications for changes affecting the license.	Licensure notification packet (submitted notice and any agency response) retained in governance/compliance file. (; Ref: 5.7)

Implementation Guidance

A7 Documentation demonstrates continuity of authority (appointment), continuity of coverage (alternate/on-call), and controlled delegation (written delegations) as applicable to Harbor operations. ( Ref: 6.1)

8.References & Regulatory Citations

This section serves as the authoritative regulatory citation index for this policy and supports compliance with applicable Virginia home care licensure requirements, including:

Regulation	Regulatory Requirement (Summary)	How Used in This Policy / Internal Cross-References
	Management and administration expectations for home care organizations.	Operational readiness and required notifications when changes affect the organization. Refs: 1, 2, 4.2, 5.4, 5.6, 5.7, 6
	Governing Body responsibilities and annual policy review expectations.	Administrator appointment oversight and annual policy review coordination. Refs: 1, 4.1, 5.1, 5.8, 6
	Administrator responsibilities for day-to-day management and operation of the organization.	Administrator appointment, coverage planning, and delegation expectations. Refs: 1, 2, 5.1, 5.2, 5.3, 6
	Written policies and procedures requirements, including maintenance of current controlled policies.	Policy implementation, training expectations, and controlled documentation. Refs: 1, 5.5, 6

Harbor shall maintain current versions of this policy as a controlled document within the policy and procedure manual and make them available as required for oversight, audit, payer review, or licensing survey activities. (; Ref: 6)

Implementation Guidance

A9 Harbor reviews citations at least annually to ensure the referenced regulation sections remain current and updates this section when regulations are revised or renumbered. (; Ref: 6)
A10 Section 8 serves as the citation index for this policy, and the operational requirements and procedures in Sections 1 through 6 reflect how Harbor applies those citations in practice. (; Ref: 1, 5, 6)