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(a) A full-service hospice agency shall maintain administrative control over the services provided by the agency. The agency may not delegate administrative and supervisory functions to another agency, individual, or organization. The hospice agency shall describe in writing

(1) the services provided by the agency;

(2) the services provided by contract or another arrangement; and

(3) the lines of authority for the delegation of responsibility to the client care level. (b) A full-service or volunteer hospice agency shall have a program director who is responsible for the daily management of the hospice program. The administrator of the agency may act as program director. The program director must have education, experience, and knowledge related to hospice care or related home health program care appropriate to the fulfillment of the responsibilities described in (c) and (d) of this section, as applicable. The agency shall develop written documentation setting out the responsibilities and authority of the program director. If the program director’s position becomes vacant, the agency shall notify the department within 48 hours and provide, if available, the name of the replacement. The agency shall designate, in writing, a qualified individual to act in the capacity described in this subsection in the program director’s absence. (c) The program director for a full-service or volunteer hospice agency shall

(1) have authority to manage, and responsibility for managing, the business affairs and overall operation of the agency;

(2) organize and direct the agency’s ongoing functions;

(3) implement and regularly evaluate policies and procedures for the management and operation of the hospice and evaluation of the overall program performance of the agency;

(4) establish an organizational structure appropriate for directing the work of hospice employees, contractors, and volunteers in accordance with the agency’s policies and procedures;

(5) ensure that employees and ancillary staff receive orientation to their responsibilities and to the hospice program;

(6) evaluate the functions and activities of employees and ancillary staff to assure conformance with applicable state and federal laws, agency policies and procedures, and applicable professional standards;

(7) maintain a liaison between the governing body, any professional committee, and the employees and volunteers;

(8) report to the governing body at least annually regarding agency operation;

(9) ensure adequate continuing education and evaluation of staff; and

(10) evaluate the recommendations of agency committees and consultants.