Governing Body

Policy 381-160  · Volume 1 · Governance & Administration  · Issued: 10/07/2025  · Updated: 10/14/2025
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This policy deals with Harbor Home Healthcare LLC's governance structure and the Governing Body's overall responsibilities for managing and overseeing the agency. Specifically, it defines the LLC legal framework, clarifies authority and delegation to the Administrator, and describes oversight of services, staffing, compliance, fiscal affairs, and quality improvement, including required annual policy and QI review.

Harbor Home Healthcare LLC (“Harbor”) shall maintain a Governing Body with authority and responsibility for the management, operation, and compliance of the organization. The Governing Body ensures Harbor operates in accordance with applicable laws and regulations, appoints qualified leadership, and maintains oversight of policies, services, and organizational performance. ()

Requirements
  • 1.1 Harbor shall maintain a Governing Body with legal authority over the organization. ()
  • 1.2 The Governing Body shall ensure Harbor operates in compliance with applicable federal, state, and local laws. ()
  • 1.3 The Governing Body shall appoint a qualified Administrator responsible for daily operations. (; Ref: 5.2)
  • 1.4 The Governing Body shall approve and periodically review Harbor’s policies and procedures. (; )
  • 1.5 The Governing Body shall maintain documentation sufficient to demonstrate oversight activities and decisions. ()
1.1 Definitions
  • Governing Body means the individual(s) or group legally responsible for the management and operation of Harbor. ()
  • Administrator means the individual appointed by the Governing Body to manage day-to-day operations. ()
Implementation Guidance
  • A1 In a small agency, the owner may serve as the Governing Body; however, all required responsibilities must still be carried out and documented. ( Ref: 6)

This policy applies to the Governing Body, Administrator, and any individual(s) performing governance or oversight functions within Harbor. This policy governs authority, accountability, policy approval, and oversight of Harbor’s operations. ()

Requirements
  • 2.1 The Governing Body shall exercise ultimate authority over Harbor’s operations and compliance. ()
  • 2.2 The Administrator shall implement policies and report to the Governing Body. ()
Implementation Guidance
  • A2 Governance oversight may be performed through formal meetings or documented owner review activities appropriate to agency size. ( Ref: 5.4)

Harbor maintains this policy to comply with Virginia Administrative Code requirements for Governing Body authority, responsibility, and oversight of licensed home care organizations. This policy is maintained as a controlled document within Harbor’s policy system. (; )

Implementation Guidance
  • A3 Detailed regulatory citation mapping is maintained in Section 8: References & Regulatory Citations. ( Ref: 8)
4.1 Governing Body
  • 4.1.1 The Governing Body shall be responsible for the overall operation and compliance of Harbor. ()
  • 4.1.2 The Governing Body shall appoint and oversee the Administrator. ()
  • 4.1.3 The Governing Body shall approve policies and review them periodically. (; )
  • 4.1.4 The Governing Body shall review organizational performance and quality activities. (; Ref: 5.4)
4.2 Administrator
  • 4.2.1 The Administrator shall implement policies approved by the Governing Body. ()
  • 4.2.2 The Administrator shall report operational and compliance matters to the Governing Body. ()
Implementation Guidance
  • A4 When one individual serves in multiple roles, all responsibilities for each role shall still be fulfilled and documented. ( Ref: 6)
5.1 Governing Body Structure
  • 5.1.1 Harbor shall maintain documentation identifying its Governing Body structure (e.g., owner or governing group). ()
5.2 Appointment of Administrator
  • 5.2.1 The Governing Body shall appoint a qualified Administrator and document the appointment. ()
5.3 Policy Approval and Review
  • 5.3.1 The Governing Body shall approve policies prior to implementation. (; )
  • 5.3.2 The Governing Body shall review policies at least annually and update as needed. ()
5.4 Oversight Activities
  • 5.4.1 The Governing Body shall review information related to operations, compliance, and quality improvement. (; Ref: 381-250)
  • 5.4.2 Harbor shall document oversight activities in minutes, summaries, or written approvals sufficient to demonstrate review and follow-up. ()
Implementation Guidance
  • A5 For small agencies, oversight may be documented through owner notes, signed approvals, or brief meeting summaries rather than formal board meetings. ( Ref: 6)

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

  • Documentation identifying the Governing Body structure. ()
  • Administrator appointment record. ()
  • Policy approval and review documentation. (; )
  • Records of oversight activities (minutes, summaries, or written approvals). ()
6.1 Forms & Tools
Section Requirement Form(s) / Tool(s) Used
Document Governing Body structure Ownership or organizational structure record
Document Administrator appointment Administrator Appointment Record
Document policy approval Policy approval log or signed policy
Document oversight activity Meeting minutes, summary notes, or written approvals
Implementation Guidance
  • A6 Harbor may maintain minimal documentation as long as it clearly demonstrates required oversight and decision-making activities. ()

This section serves as the authoritative regulatory citation index for this policy.

Regulation Regulatory Requirement (Summary) How Used in This Policy
Governing Body authority and responsibilities Primary governance requirements (Sections 1–5)
Administrator responsibilities Administrator appointment and reporting
Written policies and documentation Policy approval and record retention

Harbor shall maintain this policy as a controlled document and update it as regulations change. ()

Implementation Guidance
  • A8 Section 8 serves as the citation index, while Sections 1–6 reflect operational implementation.
Controlled document if viewed online. Uncontrolled if printed.