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  <FDSYS>
    <CFRTITLE>42</CFRTITLE>
    <CFRTITLETEXT>Public Health</CFRTITLETEXT>
    <VOL>2</VOL>
    <DATE>2007-10-01</DATE>
    <ORIGINALDATE>2007-10-01</ORIGINALDATE>
    <COVERONLY>false</COVERONLY>
    <TITLE>Condition of participation: Administration.</TITLE>
    <GRANULENUM>403.738</GRANULENUM>
    <HEADING>Section 403.738</HEADING>
    <ANCESTORS>
      <PARENT HEADING="Title 42" SEQ="4">Public Health</PARENT>
      <PARENT HEADING="CHAPTER IV" SEQ="3">CENTERS FOR MEDICARE&amp; MEDICAID SERVICES,DEPARTMENT OF HEALTH ANDHUMAN SERVICES</PARENT>
      <PARENT HEADING="SUBCHAPTER A" SEQ="2">GENERAL PROVISIONS</PARENT>
      <PARENT HEADING="PART 403" SEQ="1">SPECIAL PROGRAMS AND PROJECTS</PARENT>
      <PARENT HEADING="Subpart G" SEQ="0">Religious Nonmedical Health Care Institutions-Benefits, Conditions of Participation, and Payment</PARENT>
    </ANCESTORS>
  </FDSYS>
  <SECTION>
    <SECTNO>§ 403.738</SECTNO>
    <SUBJECT>Condition of participation: Administration.</SUBJECT>
    <P>An RNHCI must have written policies regarding its organization, services, and administration.</P>
    <P>(a) <E T="03">Standard: Compliance with Federal, State, and local laws.</E> The RNHCI must operate in compliance with all applicable Federal, State, and local laws, regulations, and codes including, but not limited to, those pertaining to the following:</P>
    <P>(1) Protection against discrimination on the basis of race, color, national origin, age, or handicap (45 CFR parts 80, 84, and 91).</P>
    <P>(2) Protection of human research subjects (45 CFR part 46).</P>
    <P>(3) Application of all safeguards to protect against the possibility of fraud and abuse (42 CFR part 455).</P>
    <P>(4) Privacy of individually identifiable health information (45 CFR part 164).</P>
    <P>(b) <E T="03">Standard: Governing body.</E> (1) The RNHCI must have a governing body, or a person designated to function as a governing body, that is legally responsible for establishing and implementing all policies regarding the RNHCI's management and operation.</P>
    <P>(2) The governing body must appoint the administrator responsible for the management of the RNHCI.</P>
    <P>(c) <E T="03">Standard: Affiliations and disclosure.</E> (1) An affiliation is permissible if it is between one of the following:</P>
    <P>(i) An individual serving as an uncompensated director, trustee, officer, or other member of the governing body of an RNHCI and a provider of medical treatment or services.</P>
    <P>(ii) An individual who is a director, trustee, officer, employee, or staff member of an RNHCI and another individual, with whom he or she has a family relationship, who is affiliated with (or has an ownership interest in) a provider of medical treatment or services.</P>
    <P>(iii) The RNHCI and an individual or entity furnishing goods or services as a vendor to both providers of medical treatment or services and RNHCIs.</P>
    <P>(2) The RNHCI complies with the disclosure requirements of §§ 420.206 and 455.104 of this chapter.</P>
    <P>(3) The RNHCI furnishes written notice, including the identity of each new individual or company, to CMS at the time of a change, if a change occurs in any of the following:</P>
    <P>(i) Persons with an ownership or control interest, as defined in §§ 420.201 and 455.101 of this chapter.</P>
    <P>(ii) The officers, directors, agents, or managing employees.</P>
    <P>(iii) The religious entity, corporation, association, or other company responsible for the management of the RNHCI.</P>
    <P>(iv) The RNHCI's administrator or director of nonmedical nursing services.</P>
    <CITA>[64 FR 67047, Nov. 30, 1999, as amended at 68 FR 66720, Nov. 28, 2003]</CITA>
  </SECTION>
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