GOVERNING AUTHORITY for PUBLIC HEALTH And

S2AY Network Administrative Manual Revised March 23, 2016

GOVERNING AUTHORITY FOR PUBLIC HEALTH and LICENSED HOME CARE SERVICES AGENCY (LHCSA)

POLICY: The Governing Authority oversees all aspects of the Public Health Department and the Licensed Home Care Services Agency operations.

PURPOSE: To outline and delineate the governing authority’s specific responsibilities for managing the LHCSA operation.

REFERENCES: NYCRR 10 section, 766.9

General Information:

The governing authority for the County is the Board of Supervisors/Legislators.

The governing authority may not delegate its responsibility to another organization, except when a management contract has been approved.

The governing authority is responsible for the management, operation and evaluation of the Agency as specified below.

New members of the governing authority of the LHCSA and Public Health Department will receive an orientation to their roles and responsibilities (see attached sample checklist and county-specific process for governing authority orientation) within three months of appointment/swearing in and annually thereafter.

Regulatory Compliance The governing authority will ensure compliance of the Agency with the applicable federal, state and local statutes, rules and regulations.

Overseeing Daily Operations Key supervisory staff is designated by the Director/Commissioner to oversee the daily Public Health and LHCSA operations. These designees facilitate the governing authority’s directives.

 The Administrator/Health Department Director will assign a qualified person to act in the Administrator/Health Department Director’s absence.  At least one licensed and currently registered professional nurse with appropriate education and experience will be employed to be responsible for the direction and supervision of all patient care services and other health care activities of the agency.  Only those patients that can be safely cared for by the agency will be accepted and retained for service.

Policies The governing authority shall adopt and approve amendments to written policies regarding the management and operation of the LHCSA and Public Health Department and the provision of health care services.

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Conducting Periodic Evaluations The governing authority evaluates each program’s effectiveness. Results are reported through approved statistical methods, quality improvement initiatives, peer and supervisory review. The governing authority oversees the evaluation processes and provides directives relevant to changes to improve care/services.

Adopting Compliance Initiatives Initiatives have been adopted by the governing authority to facilitate compliance. The Agency will adhere to the corporate compliance program as outlined in the S2AY Network Corporate Compliance Policy and Procedure.

Maintaining Personnel Resources The governing authority assures that personnel resources are adequate to conduct all administrative functions, and to provide care in the home. This is accomplished through case and work load assessments and assignment analysis.

Adopting a Budget, and Implementing Asset and Funds Controls The governing authority assigns designees the responsibility for timely completion of all necessary financial paperwork as required by the State of New York and including the following:

 Ensures that agency personnel and contracted workforce are made aware of and are prohibited from being paid directly by the client for services provided by the agency. This is accomplished through staff in-service training and outlined in workforce member’s contractual agreements.

 Contracted vendors, individuals, or affiliated agencies retained by the Agency for services/care are prohibited from splitting or sharing of fees as outlined in agency contracts or affiliation agreements.

 Retention of all financial transactions directly related to patient care for 3 years.

Overseeing Agreements and Contracts The governing authority oversees the development and adherence to any/all agreements and contracts making sure that applicable program regulatory requirements, standards of practice, quality and continuity of care are upheld.

Addressing Patient Complaints The governing authority implements and oversees an acceptable patient complaint process.

Providing a Facility The governing authority provides an adequate office facility for workforce members to conduct their business, care/services in a safe, hygienic environment.

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Emergency Planning The governing authority oversees the preparation, evaluation and modification, as needed, of a written emergency plan.

Implementing Quality Improvement The governing authority oversees the implementation and monitoring of Performance Management / Quality Improvement Plan.

Professional Advisory Committee The governing authority oversees/appoints a quality improvement committee to establish and oversee standards of care. The quality improvement committee shall:  Review policies pertaining to the delivery of the health care services provided by the agency and recommend changes in such policies to the governing authority for adoption;  Conduct a clinical record review of the safety, adequacy, type and quality of services provided which includes:  Random selection of records of patients currently receiving services and patients discharged from the agency within the past three months; and  All cases with identified patient complaints.  Prepare and submit a written summary of review findings to the governing authority for necessary action; and  Assist the agency in maintaining liaison with other health care providers in the community.

The committee will include a consumer and appropriate health professionals including a physician if professional healthcare services are provided.

Reporting The governing authority oversees an overall evaluation of the agency's program annually. An annual program summary is shared with the appropriate committees and board of legislatures.

Health Commerce System (HCS) The governing authority delegates the responsibility for obtaining an HCS account for the LHCSA and Public Health Department to the Director of Public Health who ensures that sufficient, knowledgeable staff will be available to maintain and keep current such accounts.

Governing Authority Meeting Minutes Minutes of governing authority meeting will be retained for 3 years.

3 Steuben County Public Health 3 East Pulteney Square, Bath, NY 14810 607-664-2438 or 1-800-724-0471 Fax: 607-664-2166

Orientation Process for New Legislators

Each year, Public Health staff will update the Presentation to the Human Services, Health and Education Committee of the Legislature PowerPoint located in O:\HSH&E Committee\Presentations. This PowerPoint orients new legislators to Public Health programs and processes and to the responsibilities of the Public Health department and the governing entity.

The PowerPoint will be sent to the Clerk of the Legislature by January 10 each year to be provided to new legislators.

4 Governing Authority Orientation Checklist

Orientation of the Governing Authority may include:

Responsibilities of the LHD

 Article 6 – Core Public Health Services  10 Essential Health Services  Special Children’s Services  NYSDOH Prevention Agenda  Community Health Assessment  Community Health Improvement Plan  Strategic Plan  Emerging issues

Responsibilities of the Governing Entity

 Establish public health policies  Review public health regulations  Propose public health regulations  Collaborate with health department for strategic plan  Approve Public Health Department Budget  Ensure implementation of the Performance Management / Quality Improvement Plan  Approve Grant Applications  Identify Sources of Funding