---
kind: "section"
citation: "42 C.F.R. § 403.738"
title: "42"
number: "403.738"
heading: "Condition of participation: Administration."
url: "https://uscodex.org/cfr/42/403.738"
---

# §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](/cfr/45/part80.md), [84](/cfr/45/part84.md), 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](/cfr/42/420.206.md) and [455.104](/cfr/42/455.104.md) 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](/cfr/42/420.201.md) and [455.101](/cfr/42/455.101.md) 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.**

## Notes

### Amendments

[64 FR 67047, Nov. 30, 1999, as amended at 68 FR 66720, Nov. 28, 2003]

### Source

Source: 64 FR 67047, Nov. 30, 1999, unless otherwise noted.

### Authority

Authority: 42 U.S.C. 1302 and 1395hh.

### Amendments

[64 FR 67047, Nov. 30, 1999, as amended at 68 FR 66720, Nov. 28, 2003]