CMS SOM App. U, Tag R237

The committee is responsible for evaluating each admission and ensuring that the

admission is necessary and appropriate. The utilization review plan must be carried

out by the utilization review committee, consisting of the governing body,

administrator or other individual responsible for the overall administration of the

RNHCI, the supervisor of nursing staff, and other staff as appropriate.

Interpretive Guidelines: §403.746(b)

In addition to the RNHCI’s written evaluation procedures of the processes related to

admissions, duration of care, continuing care, and items and services furnished to

patients; the RNHCI must also have a utilization review committee, which takes part in

the evaluations. The committee must evaluate each admission and ensure that it is

necessary and appropriate. The committee consists of the governing body, administrator

or other individual responsible for the overall administration of the RNHCI, the

supervisor of nursing staff, and other staff as appropriate. These individuals should

provide feedback related to the processes and ensure corrective actions are carried out

to systematically improve the organization’s care provided, especially the admissions

process.

Survey Procedures:

• Review the Utilization Review plan and the determinations involving all

admissions or extended stays.

• Verify that the composition of the UR committee is appropriate.

REFER TO E-TAGS (Appendix Z)

§ 403.748. Condition of Participation. Emergency Preparedness

The Religious Nonmedical Health Care Institution (RNHCI) must comply with all

applicable Federal, State, and local emergency preparedness requirements. The

RNHCI must establish and maintain an emergency preparedness program that meets

the requirements of this section. The emergency preparedness program must include,

but not be limited to, the following elements:

Interpretive Guidelines §403.748

The organization must comply with all Emergency Preparedness requirements under this

condition. This condition consists of multiple standards. Please refer to State Operations

Manual Appendix Z – Emergency Preparedness for All Providers and Suppliers.

Transmittals Issued for this Appendix

Rev # Issue Date Subject Impl Date CR#

R239SOMA

04/24/2026 Revisions to the State Operations Manual

(SOM) Appendix U - Religious

Nonmedical Healthcare Institutions

04/24/2026 N/A

R200SOMA 02/21/2020 Revisions to the State Operations Manual

(SOM) Appendix A -

Hospitals, Appendix AA – Psychiatric

Hospitals, Appendix B – Home Health

Agency, Appendix D - Portable X-Ray,

Appendix G - Rural Health

Clinics/Federally Qualified Health

Centers, Appendix H- End Stage Renal

Disease Facilities (ESRD), Appendix K –

Comprehensive Outpatient Rehabilitation

Facility, Appendix L - Ambulatory

Surgical Centers, Appendix M – Hospice,

Appendix U - Religious Nonmedical

Healthcare Institutions, Appendix W -

Critical Access Hospitals (CAHs),

Appendix X-Organ Transplant Program

and Appendix Z - Emergency

Preparedness

02/21/2020 N/A

R171SOMA.pdf 11/17/2017 Revisions to State Operations Manual

(SOM), Appendix U - Survey Procedures

and Interpretive Guidelines for

Responsibilities of Medicare Participating

Religious Nonmedical Healthcare

Institutions

11/20/2017 N/A

R01SOM 05/21/2004 Initial Release of Pub 100-07 N/A N/A