FND-030 — Organizational Structure – Harbor Home Healthcare

1.Policy Objective

Harbor Home Healthcare LLC (“Harbor”) shall maintain a clearly defined and documented organizational structure that establishes lines of authority, accountability, and supervision for all agency functions, ensuring that a qualified individual is responsible for day-to-day operations at all times and that clinical supervision is integrated into the reporting structure as required for personal care services. (; ; ; ) The organizational structure supports compliance with applicable laws and regulations by defining how Harbor manages services, supervises staff through both administrative and clinical channels, communicates decisions, and provides continuity of leadership through an Alternate Administrator designation. (; ; Ref: 4; Ref: 5)

Requirements

1.1 Harbor shall maintain an organizational chart that visually identifies all positions, key management roles, reporting relationships, and lines of authority, including the dual administrative and clinical supervisory structure. (; Ref: 5.1)
1.2 The organizational structure shall clearly distinguish between administrative authority (Administrator) and clinical authority (RN Supervisor) over Direct Care Staff. (; ; Ref: 5.3)
1.3 Harbor shall designate in writing an Alternate Administrator (or qualified designee) to perform Administrator functions when the Administrator is unavailable, ensuring continuity of operations without interruption. (; Ref: 5.4)
1.4 The Governing Body shall review and approve the organizational structure at start-up and at least annually thereafter, and document approval in meeting minutes or a written approval record. (; Ref: 5.2)
1.5 Job descriptions shall exist for each position within the organizational structure and shall identify supervisory relationships, duties, and required qualifications. (; Ref: 5.6)
1.6 Harbor shall communicate the organizational structure, including dual reporting lines and escalation pathways, to all personnel during orientation and upon significant changes. (; Ref: 5.6)
1.7 When Harbor provides personal care services, the organizational structure shall reflect an RN Supervisor position with clinical authority over direct care staff as required by regulation. (; Ref: 5.3)

1.1 Definitions

Organizational Structure means the documented framework that defines positions, reporting relationships, lines of authority, and supervisory responsibilities within Harbor. ()
Organizational Chart means the visual diagram showing all positions, key management roles, reporting relationships, and lines of authority maintained as a controlled document with an effective date. ()
Administrator means the individual appointed by the Governing Body to manage day-to-day operations and hold administrative authority as defined by Harbor policy. ()
RN Supervisor means a Registered Nurse responsible for clinical supervision of Direct Care Staff, development of client plans of care, competency assessments, and oversight of personal care service delivery. ()
Alternate Administrator means an individual designated in writing by the Administrator to perform the Administrator’s duties when the Administrator is absent or unavailable, ensuring continuity of operational leadership. ()
Dual Reporting means the supervisory structure in which Direct Care Staff report administratively to the Administrator (hiring, scheduling, payroll, discipline) and clinically to the RN Supervisor (care plans, competency, clinical safety). (; )
Direct Care Staff (Home Attendants) means personnel who provide non-skilled personal care and respite services to clients in their homes under clinical supervision. ()

Implementation Guidance

A1 The organizational chart must visually show the dual reporting relationship. Direct Care Staff have two supervisors: the Administrator for hiring, scheduling, and payroll; and the RN Supervisor for care plans, competency, and clinical oversight. Surveyors expect to see this clinical reporting line documented.
A2 When the Administrator and Owner are the same person, the organizational chart still shows the Governing Body (Owner) as a separate governance layer above the Administrator role to demonstrate the regulatory distinction between governance oversight and operational management. (; )

2.Scope & Application

This policy applies to the Governing Body, Administrator, RN Supervisor(s), Alternate Administrator, and all workforce members including office and field staff, employees, and contracted personnel providing services under Harbor’s license. (; ; ) It applies to all Harbor programs and service lines regardless of payer or funding source when services are provided under Harbor’s home care organization license. (; Ref: 5)

Requirements

2.1 Every individual working for Harbor — whether employee or contractor — shall have a defined reporting line within the organizational structure (or have a defined supervisory relationship) to ensure accountability. (; ; Ref: 5.6)
2.2 All personnel shall know their immediate supervisor (Administrator for administrative matters; RN Supervisor for clinical matters) and the chain of command for reporting concerns, incidents, or urgent issues. (; Ref: 5.6)
2.3 When Harbor uses contracted personnel for service delivery, the organizational structure shall include their supervisory and reporting relationships consistent with Harbor’s contracted services policy. (; Ref: 7)

Implementation Guidance

A3 The contracted RN Supervisor reports to the Administrator regarding operational matters and client care issues. The organizational chart reflects this as a contract relationship (not an employee relationship) while still showing the clinical authority line over Direct Care Staff. (; )

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, written policies and job descriptions, and RN supervision of personal care services. (; ; ; ; ) 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 explicitly requires RN supervision for personal care services. The organizational structure must reflect this clinical reporting line to demonstrate compliance during licensure surveys. If the RN Supervisor position is vacant, Harbor cannot provide personal care services until qualified coverage is arranged. (; ; Ref: 5.3)
A5 VDH surveyors will review the organizational chart during the entrance conference and compare it to actual operations. The chart must match current reality — positions shown should be filled or have designated coverage, and reporting lines should reflect how supervision actually occurs. ()

4.Roles & Responsibilities

4.1 Governing Body

4.1.1 Establish Harbor’s overall organizational structure to support the agency’s mission, regulatory compliance, and safe service delivery. ()
4.1.2 Appoint a qualified Administrator and define the Administrator’s authority and reporting relationship to the Governing Body. (; ; Ref: 5.1)
4.1.3 Review and approve the organizational chart at start-up and at least annually thereafter, documenting approval in meeting minutes or a written approval record. (; Ref: 5.2)
4.1.4 Ensure RN supervision is maintained for personal care services, including directing the Administrator to arrange qualified RN coverage if the position becomes vacant. (; ; Ref: 5.3)

4.2 Administrator

4.2.1 Develop and maintain the organizational chart showing all positions, dual reporting lines (administrative and clinical), and the Alternate Administrator designation. (; Ref: 5.1)
4.2.2 Ensure job descriptions exist for each position and identify supervisory relationships, duties, and required qualifications. (; Ref: 5.6)
4.2.3 Designate in writing a qualified individual to serve as Alternate Administrator and ensure the designation identifies the individual, scope of coverage, and effective circumstances. (; Ref: 5.4)
4.2.4 Communicate the organizational structure to personnel during orientation and upon significant changes, including the dual reporting relationship and escalation pathways. (; Ref: 5.6)
4.2.5 If the RN Supervisor position becomes vacant, immediately notify the Governing Body and arrange qualified RN coverage before the next scheduled supervisory visit. (; ; Ref: 5.3)

4.3 RN Supervisor

4.3.1 Provide clinical supervision to Direct Care Staff as required by regulation, including competency assessment, plan of care development, and at least 90-day supervisory visits. (; Ref: 5.3)
4.3.2 Report to the Administrator regarding operational matters, client care issues, and clinical staffing concerns. (; Ref: 5.3)
4.3.3 Collaborate with the Administrator to ensure clinical compliance and address aide performance issues. ()

4.4 Alternate Administrator

4.4.1 Perform assigned Administrator functions during the Administrator’s absence, including operational decisions, personnel matters, and escalation responses. (; Ref: 5.4)
4.4.2 Must be familiar with Harbor’s key policies, emergency procedures, staffing, and escalation pathways to function effectively during coverage periods. ()

4.5 All Personnel

4.5.1 Know their immediate supervisor (Administrator for administrative matters; RN Supervisor for clinical matters) and the chain of command for reporting concerns. (; Ref: 5.6)
4.5.2 Perform duties within the scope of their position and job description. ()

Implementation Guidance

A6 When the Administrator is also the Owner (Governing Body), the organizational chart still shows both roles distinctly. The Owner provides governance oversight; the Administrator executes daily operations. Documentation must distinguish between governance actions (annual approvals, QI review) and operational actions (hiring, scheduling, corrective action). (; )

5.Procedures

5.1 Establishing the Organizational Structure

5.1.1 The Administrator drafts an organizational chart reflecting all required leadership positions (Governing Body, Administrator, RN Supervisor, Alternate Administrator) and direct care positions, including the dual administrative and clinical reporting lines. (; ; Ref: 6)
5.1.2 The organizational chart includes the effective date and is maintained as a controlled document with version control. (; Ref: 6)

5.2 Annual Review and Governing Body Approval

5.2.1 The Governing Body reviews and approves the organizational structure at least annually and documents approval in meeting minutes or a written approval record. (; Ref: 6)
5.2.2 The annual review confirms that: positions shown are filled or have designated coverage; reporting lines match actual supervisory practice; the RN Supervisor position is filled with a qualified individual; and the Alternate Administrator designation is current. (; ; Ref: 6)
5.2.3 Significant changes between annual reviews (new services, leadership departures, structural reorganization) are presented to the Governing Body for approval before implementation. (; Ref: 6)

5.3 RN Supervisor Integration and Clinical Reporting Line

5.3.1 The organizational chart reflects the RN Supervisor’s clinical authority over Direct Care Staff, showing a distinct clinical supervision line separate from the administrative reporting line to the Administrator. (; Ref: 6)
5.3.2 The RN Supervisor reports to the Administrator regarding operational matters and collaborates on clinical compliance, aide performance, and training needs. (; )
5.3.3 If the RN Supervisor position becomes vacant, the Administrator notifies the Governing Body immediately and arranges qualified RN coverage before the next scheduled supervisory visit to ensure uninterrupted clinical supervision. (; ; Ref: 4.2.5)
5.3.4 Harbor shall not provide personal care services without a qualified RN Supervisor in place. If coverage cannot be arranged, Harbor suspends affected services and notifies clients until qualified supervision is restored. ()

5.4 Alternate Administrator Designation and Coverage

5.4.1 The Administrator designates a qualified individual in writing to serve as Alternate Administrator, specifying the individual’s name, effective date, scope of coverage, and circumstances of activation. (; Ref: 6)
5.4.2 The designation letter is signed by both the Administrator and the Alternate Administrator and retained in the governance file. (; Ref: 6)
5.4.3 Personnel are informed of who is in charge when the Administrator is unavailable so escalation pathways remain functional. (; Ref: 5.6)
5.4.4 If the Administrator position becomes permanently vacant (resignation, termination), the Governing Body must immediately appoint an Acting Administrator and notify VDH OLC. Harbor cannot operate without an identified Administrator. (; )

5.5 Updating the Organizational Chart

5.5.1 The Administrator reviews the organizational chart annually or when significant changes occur, including changes to leadership positions, service lines, or staffing structure. (; Ref: 5.2)
5.5.2 Updates include revising the chart, updating affected job descriptions, and communicating changes to personnel. (; Ref: 5.6)

5.6 Personnel Communication and Orientation

5.6.1 The organizational structure, including the dual reporting relationship and chain of command, is communicated to all personnel during orientation. (; Ref: 6)
5.6.2 Personnel are informed that they report administratively to the Administrator (hiring, scheduling, payroll, discipline) and clinically to the RN Supervisor (care plans, competency, clinical safety). (; )
5.6.3 When significant structural changes occur, the Administrator communicates updates to affected personnel and documents the communication method and date. (; Ref: 6)

Implementation Guidance

A7 Harbor’s current organizational chart shows: Owner/Governing Body → Administrator (Operations, HR, Business, Compliance) → two branches: Clinical (RN Supervisor, contract clinical supervision) and Administrative (Direct Care Staff, PCAs/CNAs), with Alternate Administrator designated as backup for all Administrator functions in absence. Effective date: January 7, 2026. (; )
A8 Harbor uses written coverage documentation (Alternate Administrator designation letter) and communicates the coverage plan to personnel so Administrator functions continue consistently during absences. ( Ref: 5.4; Ref: 6)

6.Documentation Requirements

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

Current approved organizational chart with effective date showing all positions, reporting relationships, and dual supervisory lines. (; Ref: 5.1)
Governing Body minutes or approval record documenting review and approval of the organizational structure. (; Ref: 5.2)
Job descriptions for each position identifying supervisory relationships, duties, and required qualifications. (; Ref: 5.6)
Alternate Administrator designation letter signed by both parties, specifying scope and circumstances of coverage. (; Ref: 5.4)
RN Supervisor contract or employment documentation establishing clinical oversight scope and authority. (; Ref: 5.3)
Orientation records documenting personnel received organizational structure and dual reporting information. (; Ref: 5.6)

Organizational structure 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
Maintain current organizational chart.	Organizational Chart (dated, showing all positions, dual reporting lines, and Alternate Administrator). (; Ref: 5.1)
Document Governing Body approval of structure.	Governing Body meeting minutes or annual approval record with date and approval noted. (; Ref: 5.2)
Maintain job descriptions for each position.	Job description for each position with supervisory relationships, duties, and qualifications identified. (; Ref: 5.6)
Document Alternate Administrator designation.	Alternate Administrator Designation Letter signed by both parties with scope and effective circumstances. (; Ref: 5.4)
Document RN Supervisor arrangement.	RN Supervisor contract or employment agreement with clinical oversight scope defined. (; Ref: 5.3)
Document orientation communication.	Orientation checklist/record noting organizational structure and dual reporting review. (; Ref: 5.6)

Implementation Guidance

A9 Harbor may maintain the organizational chart, designation letter, RN contract, and Governing Body approval record in one Governance File (electronic or paper) for consolidated survey readiness. (; 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 requirements; compliance with regulations and own policies.	Organizational structure supports compliant operations; chart maintenance and version control. Sec 1; Sec 1.1; Sec 2; Sec 5.1; Sec 5.5; Sec 6
	Governing Body responsibilities for management, operation, fiscal affairs; adequate staffing; annual review.	GB approves structure; ensures RN staffing; annual chart review and approval. Sec 1.4; Sec 4.1; Sec 5.2; Sec 6
	Governing Body ensures organization is staffed and equipped to provide services.	GB ensures RN supervision is maintained; directs coverage for vacancies. Sec 1.7; Sec 4.1.4; Sec 5.3.3
	Administrator appointment, day-to-day management, and designee requirement.	Administrator role in structure; Alternate Administrator designation and coverage. Sec 1.3; Sec 4.2; Sec 5.4; Sec 6
	Written policies and procedures; job descriptions; lines of authority.	Job descriptions, personnel communication, orientation on structure. Sec 1.5; Sec 1.6; Sec 4.2.2; Sec 5.6; Sec 6
	Personal care services requiring RN supervision; competency and ongoing training.	RN Supervisor position in structure; clinical reporting line; vacancy response. Sec 1.2; Sec 1.7; Sec 4.3; Sec 5.3; 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)