Management & Administrative Services

Policy 381-150  · Volume 1 · Governance & Administration  · Issued: 10/07/2025  · Updated: 10/14/2025
Active
This policy deals with Harbor’s required management and administrative practices for safe, continuous, and compliant home care operations. It covers posted business hours with live office coverage, 24/7 on-call response for urgent issues, the Emergency Operations Plan (including a client priority list and staff contact tree), mandated reporting of abuse/neglect/exploitation, and monthly OIG LEIE exclusion screening for all personnel and contractors.

Harbor Home Healthcare LLC (“Harbor”) shall maintain management and administrative practices that ensure the organization is fully operational during regular posted business hours, maintains 24-hour, 7-day-a-week (24/7) on-call availability for urgent client and personnel needs, operates a written emergency operations plan for inclement weather and disaster situations, complies with mandated reporting obligations for suspected abuse, neglect, or exploitation, and conducts monthly federal exclusion screening of all personnel and contractors. (; ; 42 CFR § 455.436; ; Ref: 4; Ref: 5)

This policy establishes the administrative infrastructure that supports safe, continuous, and compliant home care operations, including availability expectations, escalation pathways, emergency preparedness, and compliance screening controls required by Virginia licensure and Medicaid participation. (; ; Ref: 5; Ref: 6)

Requirements
  • 1.1 Harbor shall maintain regular posted business hours during which the administrative office is fully operational — meaning a qualified person is available to answer telephones, access records, and make operational decisions. (; Ref: 5.1)
  • 1.2 Harbor shall maintain 24/7 on-call availability so clients and personnel can reach a qualified Harbor representative by telephone at all times for urgent issues. (; Ref: 5.2)
  • 1.3 The Administrator or a qualified designee shall be available at all times during operating hours and during emergencies to ensure operational continuity. (; Ref: 5.1)
  • 1.4 Harbor shall maintain a written emergency operations plan (EOP) that addresses inclement weather, natural disasters, power outages, and other emergencies affecting client safety or service delivery, including a client priority list ranking clients by vulnerability and medical need. (; Ref: 5.3)
  • 1.5 All Harbor personnel are mandated reporters under Virginia law and shall immediately report suspected abuse, neglect, or exploitation to the appropriate protective services agency. (; ; ; Ref: 5.4)
  • 1.6 Harbor shall screen all personnel and contractors against the OIG List of Excluded Individuals/Entities () at least monthly and document screening results. (42 CFR § 455.436; DMAS requirements; Ref: 5.5)
  • 1.7 If an individual is found on the federal exclusion list, Harbor shall immediately remove them from any Medicaid-funded service delivery and report the finding to the Governing Body. (42 CFR § 455.436; Ref: 5.5)
1.1 Definitions
  • Operating Hours means the routine business hours when Harbor’s administrative office is open and fully operational. Harbor’s standard operating hours are Monday through Friday, 9:00 AM to 5:00 PM. ()
  • Service Hours means the times when client services may be delivered in the home, which may extend beyond office hours based on the client’s plan of care.
  • On-Call Coverage means the system allowing clients and personnel to reach a designated Harbor representative by telephone 24 hours a day, 7 days a week, for urgent issues outside of posted business hours. ()
  • On-Call Representative means the Administrator, Alternate Administrator, or qualified designee designated to respond to after-hours urgent calls. ( Ref: 5.2)
  • Emergency Operations Plan (EOP) means Harbor’s written plan for continuing, adjusting, or safely suspending services during emergencies, inclement weather, or disasters. ()
  • Client Priority List means a list ranking current clients by vulnerability and medical need so Harbor can prioritize welfare checks and service continuity during emergencies. ()
  • means the Office of Inspector General (OIG) List of Excluded Individuals/Entities, the federal database used to screen personnel and contractors for exclusion from federally funded health care programs. (42 CFR § 455.436)
  • Mandated Reporter means any person required by Virginia law to report suspected abuse, neglect, or exploitation to the appropriate protective services agency. All Harbor personnel are mandated reporters. ()
Implementation Guidance
  • A1 “Fully operational” means more than unlocking the door. A qualified person must be available to answer phones, access client records, and make operational decisions. If the Administrator is at lunch or away, a designee must provide live coverage. VDH surveyors may call the office unannounced during posted hours — if no one answers, they may cite . ()
  • A2 The on-call phone is the lifeline. It must be answered or returned within 20 minutes. It cannot go to an unmonitored voicemail that is not checked until Monday. (; Ref: 5.2)

This policy applies to the Governing Body, Administrator, RN Supervisor, and all personnel involved in scheduling, on-call coverage, emergency operations, mandated reporting, and compliance screening, including employees and contracted personnel providing services under Harbor’s license. (; ; ) It applies to all services provided by Harbor including Medicaid personal care and respite care, regardless of payer or funding source. (; Ref: 5)

Requirements
  • 2.1 All personnel shall know Harbor’s operating hours, how to contact the on-call representative after hours, and when to direct clients to call 911 for medical emergencies. (; Ref: 5.2)
  • 2.2 All personnel shall know their mandated reporting obligations, including how and when to report suspected abuse, neglect, or exploitation and the applicable hotline numbers. (; ; Ref: 5.4)
  • 2.3 All personnel shall cooperate with /OIG exclusion screening conducted by the Administrator and report promptly if they become aware of any exclusion action against themselves. (42 CFR § 455.436; Ref: 5.5)
Implementation Guidance
  • A3 Personnel receive operating hours, on-call contact instructions, mandated reporting training (including hotline numbers), and exclusion screening expectations during orientation. These topics are reinforced during annual in-service training. (; Ref: 6)

This policy supports Harbor’s compliance with Virginia home care licensure requirements for management and administration (including posted business hours, on-call availability, and emergency preparedness), Administrator availability, mandated reporting under Virginia law, and federal exclusion screening requirements for Medicaid providers. (; ; 42 CFR § 455.436; ; ) 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 This policy consolidates several management and administrative requirements that VDH surveyors commonly review together: operating hours, on-call availability, EOP/disaster planning, and mandated reporting. Having these in one policy simplifies survey preparation. ()
  • A5 DMAS compliance reviews may evaluate whether Harbor’s on-call system, EOP, and exclusion screening practices meet both state licensure and federal Medicaid requirements. (42 CFR § 455.436)
4.1 Governing Body
  • 4.1.1 Approve Harbor’s operating hours and ensure the organization is staffed to support them, including adequate administrative coverage during business hours. (; )
  • 4.1.2 Ensure Harbor maintains compliant 24/7 on-call coverage and an operational emergency operations plan. (; )
  • 4.1.3 Review emergency operations and after-hours reports at least annually as part of governance oversight. (; ; Ref: 5.3)
  • 4.1.4 Ensure mandated reporting training and exclusion screening are maintained as required. (; 42 CFR § 455.436)
4.2 Administrator
  • 4.2.1 Establish, post, and maintain standard operating hours and ensure the office is fully operational during those hours with live telephone coverage. (; Ref: 5.1)
  • 4.2.2 Maintain the 24/7 on-call system, designate the on-call representative, and ensure after-hours calls are responded to within 20 minutes. (; Ref: 5.2)
  • 4.2.3 Maintain the written Emergency Operations Plan including the client priority list and staff contact tree, and review it at least annually. (; Ref: 5.3)
  • 4.2.4 Ensure all personnel receive mandated reporting training during orientation and know the APS and CPS hotline numbers. (; ; Ref: 5.4)
  • 4.2.5 Conduct monthly /OIG exclusion screening for all active personnel and contractors, document results, and take immediate action if an exclusion is identified. (42 CFR § 455.436; Ref: 5.5)
4.3 RN Supervisor
  • 4.3.1 Participate in the on-call system to address urgent clinical questions and client care emergencies when required by Harbor’s on-call rotation. (; )
  • 4.3.2 Provide clinical guidance to staff on appropriate responses to client emergencies, including when to direct clients to call 911. ()
4.4 All Personnel
  • 4.4.1 Know Harbor’s operating hours and how to reach the on-call representative for after-hours urgent issues. ()
  • 4.4.2 Inform clients of the on-call number and when to use it versus calling 911. ()
  • 4.4.3 Report suspected abuse, neglect, or exploitation immediately per mandated reporting requirements and notify the Administrator of all reports made. (; Ref: 5.4)
  • 4.4.4 Promptly report any failure of the on-call system (no answer, delayed response) to the Administrator. ()
Implementation Guidance
  • A6 The Administrator is the on-call representative by default. The RN Supervisor may share on-call rotation for clinical questions. Harbor documents the current on-call schedule and ensures the designated person has access to client records, staff contacts, and emergency procedures. (; Ref: 5.2)
5.1 Operating Hours and Office Availability
  • 5.1.1 Standard operating hours are posted visibly at the office entrance, included in client admission materials and the staff handbook, and published on Harbor’s website when applicable. (; Ref: 6)
  • 5.1.2 Telephones are answered live or monitored continuously during posted business hours. ()
  • 5.1.3 The Administrator or a qualified designee is physically accessible or immediately available by phone during all operating hours to resolve operational issues. ()
  • 5.1.4 Any permanent change in operating hours is communicated to clients and personnel in writing before the change takes effect. (; Ref: 6)
5.2 On-Call Coverage (24/7)
  • 5.2.1 Clients are provided a specific telephone number for after-hours urgent needs during admission and at each service change. (; Ref: 6)
  • 5.2.2 The on-call representative must respond to calls within 20 minutes of receipt. ()
  • 5.2.3 The on-call representative triages each call and takes appropriate action based on the nature of the issue: Emergency — directs client to call 911 immediately; Urgent Clinical — contacts the RN Supervisor immediately for clinical guidance; Urgent Staffing — arranges replacement staff if a scheduled shift is missed or cancelled; Routine — documents for follow-up on the next business day. (; Ref: 6)
  • 5.2.4 All after-hours calls are logged, including the date, time, caller, nature of the call, action taken, and resolution. (; Ref: 6)
  • 5.2.5 The Administrator maintains a current on-call schedule identifying the designated on-call representative for each coverage period. (; Ref: 6)
5.3 Emergency Operations Plan (EOP)
  • 5.3.1 Harbor maintains a written EOP addressing inclement weather, natural disasters, power outages, pandemic conditions, and other emergencies that may affect client safety or service delivery. (; Ref: 6)
  • 5.3.2 The EOP includes a client priority list that ranks all current clients by vulnerability and medical need so Harbor can prioritize welfare checks and service continuity during emergencies. (; Ref: 6)
  • 5.3.3 The EOP includes a staff contact tree for rapid communication with all personnel during emergency events. ()
  • 5.3.4 The EOP is reviewed at least annually by the Administrator and updated when client census, staffing, or service area changes warrant revision. Annual review is documented. (; Ref: 6)
  • 5.3.5 When an emergency event occurs, the Administrator activates the EOP, documents actions taken, and reports outcomes to the Governing Body. (; Ref: 6)
5.4 Mandated Reporting
  • 5.4.1 All Harbor personnel are mandated reporters under Virginia law and shall immediately report suspected abuse, neglect, or exploitation. (; )
  • 5.4.2 Suspected abuse, neglect, or exploitation of adults shall be reported immediately to Adult Protective Services (APS) at 1-888-832-3858. ()
  • 5.4.3 Suspected abuse or neglect of children shall be reported immediately to Child Protective Services (CPS) at 1-800-552-7096. ()
  • 5.4.4 The person making the report shall also notify the Administrator immediately. The Administrator documents the report, the date and time it was made, the agency contacted, and any follow-up actions or instructions received. (; Ref: 6)
  • 5.4.5 Personnel receive mandated reporting training during orientation, including how to recognize signs of abuse, neglect, and exploitation and how to report. Mandated reporting is included in annual in-service training. (; Ref: 6)
5.5 Federal Exclusion Screening (/OIG)
  • 5.5.1 The Administrator screens all active personnel and contractors against the at least monthly. (42 CFR § 455.436; Ref: 6)
  • 5.5.2 Screening results are documented on the screening log, including the date, names screened, and results. “No exclusions found” is the expected result and must still be documented monthly. (42 CFR § 455.436; Ref: 6)
  • 5.5.3 New personnel and contractors are screened against the before their first day of service delivery. (42 CFR § 455.436)
  • 5.5.4 If an individual is found on the exclusion list, Harbor immediately removes them from any Medicaid-funded service delivery, notifies the Governing Body, and documents the action taken. (42 CFR § 455.436; Ref: 6)
Implementation Guidance
  • A7 Harbor maintains the screening log as a standing monthly compliance task. Even when no exclusions are found, the log entry with date and “no exclusions found” demonstrates ongoing compliance during DMAS audits. (42 CFR § 455.436; Ref: 6)
  • A8 When Harbor participates in DMAS Medicaid programs, the EOP, mandated reporting compliance, and exclusion screening are all subject to DMAS audit review. Having these documented in one operations compliance file simplifies audit preparation. ( Ref: 6)

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

  • Current posted operating hours (office posting and admission materials). (; Ref: 5.1)
  • On-call coverage schedule identifying the designated on-call representative for each coverage period. (; Ref: 5.2)
  • After-hours call log documenting each call, action taken, and resolution. (; ; Ref: 5.2)
  • Written Emergency Operations Plan with client priority list and staff contact tree, with annual review documented. (; Ref: 5.3)
  • Mandated reporting training records (orientation and annual in-service). (; ; Ref: 5.4)
  • Mandated report incident documentation including date, time, agency contacted, and follow-up actions. (; Ref: 5.4)
  • Monthly /OIG exclusion screening log with date, names screened, and results. (42 CFR § 455.436; Ref: 5.5)

Operations, compliance, and screening records are maintained securely and retained in accordance with Harbor record management and retention standards. (; Ref: 6.1; Ref: 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 posted operating hours. Office posting at entrance; website hours page; admission materials. (; Ref: 5.1)
Document on-call coverage and designee. On-call coverage schedule and after-hours call log (date, time, caller, nature, action, resolution). (; Ref: 5.2)
Document emergency operations plan. Written EOP with client priority list and staff contact tree; annual review notation with date. (; Ref: 5.3)
Document mandated reporting training. Orientation checklist and annual in-service training log noting mandated reporting training completion. (; Ref: 5.4)
Document mandated report incidents. Incident report documenting date, time, suspected concern, agency contacted, and follow-up actions. (; Ref: 5.4)
Document monthly exclusion screening. screening log with date, names screened, and results (“no exclusions found” or action taken). (42 CFR § 455.436; Ref: 5.5)
Implementation Guidance
  • A9 Harbor may maintain on-call logs, EOP, mandated reporting records, and screening logs in one operations compliance file (electronic or paper) for consolidated survey and DMAS audit readiness. (; Ref: 6.1)

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
Regular posted business hours and 24/7 on-call availability for home care organizations. Operating hours, telephone coverage, on-call system, and 20-minute response standard. Sec 1.1; Sec 1.2; Sec 5.1; Sec 5.2; Sec 6
Emergency operations plan for inclement weather and disasters. Written EOP with client priority list, staff contact tree, and annual review. Sec 1.4; Sec 5.3; Sec 6
Administrator or designee available at all times during operating hours and emergencies. Administrator availability and designee coverage during business hours. Sec 1.3; Sec 4.2; Sec 5.1
Mandated reporting of suspected abuse, neglect, or exploitation of adults. All personnel as mandated reporters; APS hotline 1-888-832-3858. Sec 1.5; Sec 5.4.1; Sec 5.4.2
Mandated reporting of suspected abuse or neglect of children. CPS hotline 1-800-552-7096. Sec 1.5; Sec 5.4.3
42 CFR § 455.436 Federal exclusion screening requirements for Medicaid providers — monthly /OIG screening. Monthly screening, documentation, and immediate removal upon exclusion finding. Sec 1.6; Sec 1.7; Sec 5.5; Sec 6
Written policies and procedures requirements, including training and documentation. Orientation training, policy documentation, and record retention. Sec 5.4.5; Sec 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
  • A11 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)
  • A12 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; Ref: 5; Ref: 6)
Controlled document if viewed online. Uncontrolled if printed.