CFR > Title 42 - Public Health > CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES > SUBCHAPTER A—GENERAL PROVISIONS (parts 400 to 403) > PART 403—SPECIAL PROGRAMS AND PROJECTS > SUBPART G—Religious Nonmedical Health Care Institutions—Benefits, Conditions of Participation, and Payment (§403.700 to §403.770) > 403.738—Condition of participation: Administration.

403.738—Condition of participation: Administration.

An RNHCI must have written policies regarding its organization, services, and administration.
(a) Standard: Compliance with Federal, State, and local laws. 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:
(1) Protection against discrimination on the basis of race, color, national origin, age, or handicap ( 45 CFR parts 80, 84, and 91 ).
(2) Protection of human research subjects ( 45 CFR part 46 ).
(3) Application of all safeguards to protect against the possibility of fraud and abuse ( 42 CFR part 455 ).
(4) Privacy of individually identifiable health information ( 45 CFR part 164 ).
(b) Standard: Governing body. (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.
(2) The governing body must appoint the administrator responsible for the management of the RNHCI.
(c) Standard: Affiliations and disclosure. (1) An affiliation is permissible if it is between one of the following:
(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.
(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.
(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.
(2) The RNHCI complies with the disclosure requirements of §§ 420.206 and 455.104 of this chapter.
(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:
(i) Persons with an ownership or control interest, as defined in §§ 420.201 and 455.101 of this chapter.
(ii) The officers, directors, agents, or managing employees.
(iii) The religious entity, corporation, association, or other company responsible for the management of the RNHCI.
(iv) The RNHCI's administrator or director of nonmedical nursing services.
[64 FR 67047, Nov. 30, 1999, as amended at 68 FR 66720, Nov. 28, 2003]