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Administration42 CFR §483.70(d)
F0835 — Governing Body
F0835 requires the facility to have a governing body (or designated persons functioning as one) legally responsible for management and operation, with authority and accountability for facility-wide compliance and quality outcomes.
Common Deficiency Examples
- Governing body unable to demonstrate oversight of facility operations or compliance
- Administrator/governing body relationship or reporting structure unclear or undocumented
- Governing body not adequately informed of significant compliance issues (e.g., repeat deficiencies)
- No documented governing body engagement with QAPI outcomes
What Your Plan of Correction Needs
F0835 is often a downstream citation reflecting gaps found elsewhere — PoCs should connect governance oversight to the underlying issues:
Gap identifiedspecific oversight or accountability gap noted
Immediate actiongoverning body briefing on the finding
Systemic fixreporting structure or meeting cadence between administration and governing body
Monitoring plandocumented governing body review of compliance/QAPI data at a defined frequency
Frequently Asked Questions
Does a small independent facility need a formal governing board?+
The specific structure required varies by ownership type — the requirement is that some legally responsible party fulfill the governing body function, not necessarily a formal board in every case.
Related tags in Administration
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