This F-Tag requires nursing facilities (long-term care) to maintain an active governing body legally responsible for establishing and implementing facility management policies, appointing a licensed administrator who reports to that body, and overseeing the facility's QAPI program. Surveyors are directed to verify governance structures, administrator accountability mechanisms, and governing body engagement with facility-wide assessments. This regulation applies to Medicare/Medicaid-certified nursing facilities under 42 CFR §483.70.
View official sourceF837 (Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24) §483.70(d) Governing body. §483.70(d)(1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and §483.70(d)(2) The governing body appoints the administrator who is— (i) Licensed by the State, where licensing is required; (ii) Responsible for management of the facility; and (iii) Reports to and is accountable to the governing body. §483.70(d)(3) The governing body is responsible and accountable for the QAPI program, in accordance with §483.75(f). INTENT §483.70(d) This regulation is intended to ensure that the facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility. DEFINITIONS §483.70(d) “Governing body” refers to individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility. GUIDANCE §483.70(d) The facility must determine: • A process and frequency by which the administrator reports to the governing body, the method of communication between the administrator and the governing body including, how the governing body responds back to the administrator and what specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) are reported or not reported directly to the governing body; • How the administrator is held accountable and reports information about the facility’s management and operation (i.e., audits, budgets, staffing, supplies, etc.).; and • How the administrator and the governing body are involved with the facility wide assessment in §483.71 Facility assessment at F838. PROCEDURES §483.70(d) Request the names and contact information of the members of the governing body at the Entrance Conference. If there are concerns, conduct an interview with the administrator and if possible with one or more members of the governing body or designated person(s) functioning as the governing body.