US · guidance
CMS SOM App. U, Tag R175
§403.738 Condition of Participation: Administration
An RNHCI must have written policies regarding its organization, services, and
administration.
Interpretive Guidelines: §403.738
The RNHCI must have written policies which govern the organization, services provided
to patients, and administration. The policies and procedures should be reviewed on an
ongoing basis by the governing body (see §403.738(b)) who is legally responsible for the
organization.
Survey Procedures:
• Request to see the organizational chart and schedules.
• Does the RNHCI have policies regarding how services are provided to patients?
• Does the RNHCI have administration policies? How is administration handled?
• Interview the facility Administrator to ask them to explain the structure of the
organization and services provided.
History
Rev. 239; Issued: 04-24-26; Effective: 04-24-26; Implementation: 04-24-26
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
82a653fd7c21bcc5ec156d0b43f3583669d5a66b2a3c2960635306475e2cdcb8
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