CMS SOM App. M, Tag L651

A governing body (or designated persons so functioning) assumes full legal

authority and responsibility for the management of the hospice, the provision of all

hospice services, its fiscal operations, and continuous quality assessment and

performance improvement. A qualified administrator appointed by and reporting

to the governing body is responsible for the day-to-day operation of the hospice.

The administrator must be a hospice employee and possess education and

experience required by the hospice's governing body.

Interpretive Guidelines §418.100(b)

If the hospice is part of a larger organization (e.g., HHA, hospital) and the governing

body is the same, there must be documented evidence that the governing body is

assuming full authority and responsibility for the management of the hospice and reviews

and addresses the functioning of specific hospice operations, services and QAPI program.

If the administrator is not available to fulfill his or her assigned duties and

responsibilities, the hospice must identify another individual to assume those assigned

duties and responsibilities in accordance with the hospice’s established policies and

procedures. The governing body must assume responsibility for ensuring that the hospice

is managed by the administrator and any managers that the administrator appoints.