Welcome to 2019 and the first installment of CMS Compliance Group’s “Ftag of the Week” blog series. This week we are looking at F837 Governing Body, which is part of the Administration regulatory group. The governing body is the group of people who are legally responsible for establishing and implementing policies related to the operations/management of the facility. The Governing Body also has responsibility for appointing the Administrator, who is licensed if required by the State, has responsibility for managing the facility as well as being responsible for reporting and accountability to the Governing Body.
The purpose of this regulation is to ensure that the Governing Body is active, engaged and involved in establishing the policies noted above. The facility needs to have determined the frequency that the administrator reports to the Governing Body, how this communication will be done, how the Governing Body is to respond, as well as what kind of information is to be reported. Think about what your owners would like to know – survey results, of course, but does Administration advise them of other areas of concern that they should be aware of related to management and operational issues regarding such areas as compliance audits, staffing or budgetary concerns?
If your facility has ever been in an Immediate Jeopardy situation, you know that the Governing Body may be cited with a deficiency if there are operational and/or management concerns identified.
The requirements for the Governing Body are relatively straightforward, but the regulation sets out the Governing Body’s role related to two key regulatory requirements as well – the Facility Assessment and Quality Assurance and Performance Improvement (QAPI). The facility is required to determine how the Administration and Governing Body are involved in the Facility Assessment (F838). In Phase 3, effective November 28 of this year, the regulation at F837 also states that the governing body “is responsible and accountable for the QAPI program.”
Lastly, surveyors are to request the names and contact information of the members of the Governing Body during the Entrance Conference. When concerns are identified, surveyors are instructed to interview the Administrator and if possible one or more members of the Governing Body. The facility needs to ensure that members of the Governing Body are well informed regarding the management and operations of the facility.
