CMS SOM App. K, Tag I-505

Administration

The facility must have a governing body that assumes full legal responsibility for

establishing and implementing policies regarding the management and operation of the

facility.

A - General

The CORF must have a governing body which is responsible for its policies and operation,

and which appoints an individual to act as the facility administrator. A group of professional

personnel must develop and review policies that govern the CORF services.

The governing body is the Board of Directors or Trustees of a corporation or the owner(s), in

the case of a proprietary agency, or others who assume legal responsibility for the facility.

While there are no requirements that the governing body follow a prescribed meeting

schedule, there should be evidence that the governing body takes an active role in the overall

operation of the CORF. This includes the development and review of the institutional budget

plan, and knowledge of and concurrence with all patient care and major operational policies,

utilization review and quality improvement activities.

B - Major Sources of Information

• Articles of incorporation, bylaws, policy statements, etc.

• Minutes of governing body, staff and patient care policy meetings.

• Organization chart showing administrative framework

• Personnel records -- job descriptions and personnel qualifications

• Institutional budget plan

• Management contracts

• Patient care policies

• Clinical records

• Utilization Review/Quality Improvement Reports

Assess the effectiveness and adequacy of the governing body's management and operation of

the facility by reviewing documentation of the governing body's activities. This

documentation should include minutes of the governing body, policy statements, bylaws and

delegations of authority.