US · guidance
CMS SOM App. U, Tag R181
§403.738(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.
Interpretive Guidelines: §403.738(c)(1)
Policies and procedures within the RNHCI should also include written documentation
related to personnel disclosing affiliations as outlined within this standard. The
organization should have disclosure agreements for staff working or providing services
in the RNHCI.
Survey Procedures:
• Interview the individuals responsible for personnel records (HR).
• Ask them to provide a copy of any disclosure agreements which may exist.
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
7d54ee35c6990cdc5b93c77581b1a87d24f06a7850d63bc6bebac0806f3e2da4
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