Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 883835 (X3) Date Survey Completed 03/31/2026
Name of Provider or Supplier Premier Family Care, Inc Street Address, City, State 9458 Highway 100, Scotts Hill, TN
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
E0000 An Emergency Preparedness (EP) survey was completed on 3/31/2026 during a recertification survey. The Rural Health Clinic (RHC) was found substantially noncompliance at CFR 491.12, Establishment of the Emergency Program (EP).
E0001 Establishment of the Emergency Program (EP)

§403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:


This CONDITION is not met as evidenced by:
Based on the rural health clinic's (rhc's) policies and procedures, document review, observations, and interviews, the RHC failed to develop and implement an Emergency Preparedness (EP) plan that was reviewed and updated at least every 2 years with all the essential elements. The findings included: 1. The RHC failed to maintain an EP plan to be reviewed and updated every two years. Refer to E 0004 2. The RHC failed to maintain and update every two years a documented community and facility-based risk assessment, utilizing an all-hazards approach. Refer to E 0006 3. The RHC failed to review and update their EP plan every two years to address the population and the continuity of operations. Refer to E 0007 4. The RHC failed to maintain an EP plan that was reviewed and updated every two years that included a process for cooperation and collaboration with EP officials' efforts to maintain an integrated response during a disaster or emergency situation. Refer to E 0009 5. The RHC failed to review and update their EP policies and procedures at least every two years based on the emergency plan. Refer to E 0013. 6.The RHC failed to maintain and update every two years emergency preparedness policies and procedures to address safe evacuation from the facility, staff responsibilities, transportation, and alternate means of communication. Refer to E 0020. 7. The RHC failed to maintain and update every two years preparedness policies and procedures to address a means to shelter in place for patients, staff, and volunteers who remain in the facility. Refer to E 0022 8. The RHC failed to maintain and update every two years policies and procedures for maintaining confidentiality of records during an emergency. Refer to E 0023 9. The RHC failed to maintain and update every two years policies and procedures for the use of volunteers and other staffing strategies in case of an emergency or disaster. Refer to E 0024 10. The RHC failed to maintain and update every two years an EP communication plan. Refer to E 0029 11.The RHC failed to maintain and update every 2 years contact information for staff, physicians, volunteers and other health facilities as part of the written communication plan. Refer to E 0030 12. The RHC failed to maintain and update contact information every 2 years for Federal, State, regional and local emergency preparedness officials as part of the written communication plan. Refer to E 0031 13. The RHC failed to maintain and update every 2 years a communication plan that included primary and alternate means for communication with facility staff, Federal, State and local emergency management agencies. Refer to E 0032 14. The RHC failed to maintain and update a communication plan every 2 years for sharing medical information. Refer to E 0033 15. The RHC failed to maintain and update a communication plan every 2 years that provided information about the RHC's occupancy, needs and its ability to provide assistance. Refer to E 0034 16. The RHC failed to maintain and update every 2 years an EP training and testing program. Refer to E 0036 17. The RHC failed to educate all employees on the EP program upon hire and at least every two years. Refer to E 0037 18. The RHC failed to document they had conducted exercises to test the emergency plan annually and participate in a full-scale exercise, facility-based functional exercise or community-based every 2 years. Refer to E 0039
E0004 Develop EP Plan, Review and Update Annually

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. .


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy and interview, the RHC failed to maintain an Emergency Preparedness Plan (EPP) to be reviewed and updated every two years. The findings included: Review of the Rural Health Clinic's (RHC) policy, "Emergency Preparedness Plan (EPP) and Policies and Procedures," reviewed 10/1/2022," revealed that the emergency preparedness manual, "...will be reviewed biennially by the Professional Advisory Group... This page will be updated and signed biennially after the program evaluation, and the policies and procedures have been reviewed and updated." During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated that the EP manual had not been updated, and they were not ready for the survey.
E0006 Plan Based on All Hazards Risk Assessment

§403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review, and interview, the RHC failed to maintain and update every two years a documented community and facility-based risk assessment, utilizing an all-hazards approach. The findings included: Review of the Rural Health Clinic's (RHC) policy, "Maintain and Biennial Updates", reviewed 10/1/2022, revealed, "The clinic will develop and maintain an emergency preparedness plan that will be reviewed and updated at least biennially. The plan must... be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach." Review of the Rural Health Clinic's (RHC) manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed there was no documented risk assessment for 2021, 2022, 2023, 2024, nor 2025 available for review. During an interview on 3/31/2026, at 9:15 AM, the President of the RHC stated the RHC did not have documentation of updates available for review, and they were not ready for the survey.
E0007 EP Program Patient Population

§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to review and update their Emergency Preparedness (EP) plan every two years to address the population and the continuity of operations. The findings included: Review of the Rural Health Clinic's (RHC) policy, "Emergency Preparedness Process", reviewed 10/1/2022, revealed, "...the RHC would update EP plan at least biennially to address the population and continuity of operations..." Review of the Rural Health Clinic's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed that the RHC had not reviewed and updated an EP plan every two years to address the population and continuity of operations. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0009 Local, State, Tribal Collaboration Process

§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.


This STANDARD is not met as evidenced by:
0009 Based on review of the Rural Health Clinic's (RHC) policy, manual review, and interview, the RHC failed to maintain an Emergency Preparedness (EP) plan that was reviewed and updated every two years in an attempt to maintain an integrated response with EP officials during a disaster or emergency situation. The findings included: Review of the Rural Health Clinic's (RHC) policy, "Emergency Preparedness Process", reviewed 10/1/2022, revealed that the RHC would, "... maintain an Emergency Preparedness (EP) plan that was reviewed and updated every two years in an attempt to maintain an integrated response with EP officials during a disaster or emergency situation..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed that the RHC failed to maintain an Emergency Preparedness (EP) plan that was reviewed and updated every two years in an attempt to maintain an integrated response with EP officials during a disaster or emergency situation. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0013 Development of EP Policies and Procedures

§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy and interview, the RHC failed to review and update their EP policies and procedures at least every two years based on the emergency plan. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the Rural Health Clinic will maintain documentation of Emergency Preparedness policies and procedures that had been updated every 2 years..." During an interview, on 3/31/2026, at 9:15 AM, the President of the RHC stated the RHC did not have documentation of updates available for review, and they were not ready for the survey.
E0020 Policies for Evac. and Primary/Alt. Comm.

§403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review, and interview, the RHC failed to maintain and update every two years emergency preparedness policies and procedures to address safe evacuation from the facility, staff responsibilities, transportation, and alternate means of communication. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "... the RHC would maintain and update every two years emergency preparedness policies and procedures to address safe evacuation from the facility, staff responsibilities, transportation, and alternate means of communication..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed the RHC did not maintain and update every two years emergency preparedness policies and procedures to address safe evacuation from the facility, staff responsibilities, transportation, and alternate means of communication. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated the RHC did not have documentation of updates available for review, and they were not ready for the survey.
E0022 Policies/Procedures for Sheltering in Place

§403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review, and interview, the RHC failed to maintain and update every two years emergency preparedness policies and procedures to address a means to shelter in place for patients, staff, and volunteers who remain in the facility. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the RHC would maintain and update every two years emergency preparedness policies and procedures to address a means to shelter in place for patients, staff, and volunteers who remain in the facility..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed that the RHC did not maintain and update every two years emergency preparedness policies and procedures to address a means to shelter in place for patients, staff, and volunteers who remain in the facility. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated the RHC did not have documentation of updates available for review, and they were not ready for the survey.
E0023 Policies/Procedures for Medical Documentation

§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update every two years policies and procedures for maintaining confidentiality of records during an emergency. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the RHC would maintain and update every two years policies and procedures for maintaining confidentiality of records during an emergency...." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed the RHC failed to maintain and update every two years policies and procedures for maintaining confidentiality of records during an emergency. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated the RHC did not have documentation of updates available for review, and they were not ready for the survey.
E0024 Policies/Procedures-Volunteers and Staffing

§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update every two years policies and procedures for the use of volunteers and other staffing strategies in case of an emergency or disaster. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "... the RHC did not have documentation of updates available for review..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC would maintain and update every two years policies and procedures for the use of volunteers and other staffing strategies in case of an emergency or disaster. During an interview, on 3/31/2026, at 9:15 AM, the President of the RHC stated the RHC did not have documentation of updates available for review, and they were not ready for the survey.
E0029 Development of Communication Plan

§403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities].


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update every two years EP communication plan. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "... the RHC would maintain and update every two years EP communication plan..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to maintain and update every two years EP communication plan. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated the RHC did not have documentation of updates available for review, and they were not ready for the survey.
E0030 Names and Contact Information

§403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA).


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update every 2 years contact information for staff, physicians, volunteers and other health facilities as part of the written communication plan. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the RHC would maintain and update every 2 years contact information for staff, physicians, volunteers and other health facilities as part of the written communication plan..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to maintain and update every 2 years contact information for staff, physicians, volunteers and other health facilities as part of the written communication plan. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0031 Emergency Officials Contact Information

§403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update every 2 years contact information for Federal, State, regional and local emergency preparedness officials as part of the written communication plan. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the RHC would update every 2 years contact information for Federal, State, regional and local emergency preparedness officials as part of the written communication plan..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to maintain and update every 2 years contact information for Federal, State, regional and local emergency preparedness officials as part of the written communication plan. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0032 Primary/Alternate Means for Communication

§403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies.


This STANDARD is not met as evidenced by:
0032 Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update every 2 years a communication plan that included primary and alternate means for communication with facility staff, Federal, State and local emergency management agencies. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "... the RHC would update every 2 years a communication plan that included primary and alternate means for communication with facility staff, Federal, State and local emergency management agencies..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC did not update every 2 years a communication plan that included primary and alternate means for communication with facility staff, Federal, State and local emergency management agencies. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0033 Methods for Sharing Information

§403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4).


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update a communication plan every 2 years for sharing medical information. The findings included: Review of the RHC's policy, "Emergency Preparedness" reviewed 10/1/1022, revealed, "... the RHC would maintain and update a communication plan every 2 years for sharing medical information..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to maintain and update a communication plan every 2 years for sharing medical information. During an interview, on 3/31/2026 at 9:15 AM the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0034 Information on Occupancy/Needs

§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update a communication plan every 2 years that provided information about the RHC's occupancy, needs and its ability to provide assistance. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the RHC would maintain and update a communication plan every 2 years that provided information about the RHC's occupancy, needs and its ability to provide assistance..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to maintain and update a communication plan every 2 years that provided information about the RHC's occupancy, needs and its ability to provide assistance. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0036 EP Training and Testing

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to maintain and update every 2 years an EP training and testing program. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the RHC would maintain and update every 2 years an EP training and testing program..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to maintain and update every 2 years an EP training and testing program. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
E0037 EP Training Program

§403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to educate all employees on the EP program upon hire and at least every two years. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "...the RHC would provide initial training in emergency preparedness and update every 2 years an EP training and testing program..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to educate all employees on the EP program upon hire and at least every two years. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of training, nor updates available for review, and they were not ready for the survey.
E0039 EP Testing Requirements

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy, manual review and interview, the RHC failed to document they had conducted exercises to test the emergency plan annually and participate in a full-scale exercise, facility-based functional exercise or community-based every 2 years. The findings included: Review of the RHC's policy, "Emergency Preparedness", reviewed 10/1/1022, revealed, "... the RHC would maintain and update every 2 years an EP training and testing program. The RHC will analyze the clinic's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the RHC s emergency plan, as needed..." Review of the RHC's manual, "Emergency Preparedness Plan (EPP) and Policies and Procedures," revealed RHC failed to document they had conducted exercises to test the emergency plan annually and participate in a full-scale exercise, facility-based functional exercise or community-based every 2 years. During an interview on 3/31/2026 at 9:15 AM, the President of the RHC stated there was no documentation of updates available for review, and they were not ready for the survey.
J0000 A Rural Health Clinic Recertification survey was completed on 3/31/2026. The Rural Health Clinic (RHC) was found to be in substantial noncompliance with CFR: 491.11, Program Evaluation.
J0011 COMPLIANCE WITH FED., STATE & LOCAL LAWS

Standard-level Tag 491.4 Compliance with Federal, State and local laws The rural health clinic . . . and its staff are in compliance with applicable Federal, State and local laws and regulations.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) personnel records and interview, the RHC failed to ensure 7 of 7 (Medical Director (MD), Advanced Practice Registered Nurse (APRN) #1, #2, #3; Registered Nurse (RN) #1; Medical Office Assistant (MOA) #1, and #2) patient care personnel were in compliance with applicable Federal, State and local laws and regulations. The findings included: Review of the RHC's personnel records revealed there was no documentation the MD, APRN #1, APRN #2, APRN #3, RN #1, MOA #1 and MOA #2 had received training and certification in Basic Life Support (BLS), nor Advanced Cardiac Life Support (ACLS) certification. During an interview on 3/31/2026 at 12:30 PM, the President of the RHC stated the documentation was not available for review.
J0043 PHYSICAL PLANT AND ENVIRONMENT

The clinic . . . has a preventive maintenance program to ensure that: 491.6(b)(2) Drugs and biologicals are appropriately stored; and


This STANDARD is not met as evidenced by:
Based on review of Rural Health Clinic's (RHC ) policy, observations, and interview, the RHC failed to ensure the appropriate storage of drugs and biologicals which are used in the clinic. The findings included: 1. Review of the RHC's policy,"Drugs and Biologicals Plan" revealed, "...Expired drugs will be searched for on a monthly basis and that examination will be documented monthly. Expired drugs will be disposed of in compliance with State regulations... In order to assure that drugs and biologicals are properly care for... To insure against deterioration... expiration dates are checked on old stock, and those expired drugs and biologicals are disposed of in the appropriate manner." 2. Observations on 3/31/2026 at 12:15 PM revealed the following medications stored in the refrigerator in the medication room past the expiration date: MIC-Super (a lipotropic vitamin supplement) Lot number 363012003- an opened vial with a beyond use date of 12/29/2025. A box of medication for Patient #1- expiration date12/20/2024 A box of medication for Patient #2- expiration date 3/20/2026 3. During an interview on 3/31/2026 at 12:15 PM, APRN #1 stated the MIC is a medication given with vitamin B, and the expired medications belonged to patients that were no longer receiving the medications; however, each of the medications was too expensive to discard. The medications remained in the refrigerator and were not discarded during the onsite visit.
J0100 STAFFING AND STAFF RESPONSIBILITIES

491.8(b) Physician responsibilities. The physician performs the following: (1) . . . provides medical direction for the clinic's . . . health care activities and consultation for, and medical supervision of, the health care staff. (3) . . . provides medical orders, and provides medical care services to the patients of the clinic or center.


This STANDARD is not met as evidenced by:
Based on interview, the Rural Health Clinic (RHC) failed to ensure the physician provided collaboration and supervision for the non-physician practitioner. The findings included: During an interview on 3/31/2026 at 12:30 PM, the President of the RHC stated there was no documentation of supervision and collaboration for the non-physician practitioner.
J0123 STAFFING AND STAFF RESPONSIBILITIES

491.8(b) Physician responsibilities. The physician performs the following: (2) In conjunction with the physician assistant and/or nurse practitioner member(s), participates in developing, executing, and periodically reviewing the clinic's . . . written policies and the services provided to Federal program patients. 491.8(c) Physician assistant and nurse practitioner responsibilities. (1) The physician assistant and the nurse practitioner members of the clinic's . . . staff: (i) Participate in the development, execution and periodic review of the written policies governing the services the clinic . . . furnishes; § 491.9(b) Patient care policies . . . (1) The clinic's … health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law. (2) The policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic . . . staff. (4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (b)(2) of this section and reviewed as necessary by the clinic...


This STANDARD is not met as evidenced by:
Based on the Rural Health Clinic's (RHC's) policy and interview, the physician in conjunction with the nurse practitioner failed to participate in developing and executing and periodically reviewing at least biennially the clinic's written policies and the services provided to Federal program patients. The findings included: Review of the RHC's policy,"Job Descriptions and Performance Evaluations- Medical" revealed "... the Medical Director's responsibility was to review the Policy and Procedure manual on a biennial basis and sign the signature page indicating the review took place... participate in and review the program evaluation and sign the signature page indicating participation biennially..." During an interview on 3/31/2026 at 12:30 PM, the President of the RHC stated there was no documentation of an annual/biennial evaluation available for review.
J0160 PROGRAM EVALUATION

§491.11 Program evaluation.


This CONDITION is not met as evidenced by:
Based on review of Rural Health Clinic's (RHC) policy and interview, the RHC failed to perform a program evaluation, at least biennially. The findings included: 1.The Rural Health Clinic failed to complete or arrange for a biennial evaluation of the total program that included a review of policies and procedures and a sample review of active and closed clinical records. Refer to J-0161 2. The Rural Health Clinic failed to provide documentation of any action taken based on a completed biennial evaluation. Refer to J-0162
J0161 PROGRAM EVALUATION

§ 491.11 Program evaluation. (a) The clinic or center carries out, or arranges for, a biennial evaluation of its total program. (b) The evaluation includes review of: (1) The utilization of clinic or center services, including at least the number of patients served and the volume of services; (2) A representative sample of both active and closed clinical records; and (3) The clinic's or center's health care policies. (c) The purpose of the evaluation is to determine whether: (1) The utilization of services was appropriate; (2) The established policies were followed; and (3) Any changes are needed.


This STANDARD is not met as evidenced by:
Based on review of Rural Health Clinic's (RHC) policy and interview, the RHC failed to complete or arrange for a biennial evaluation of the total program that included a review of policies and procedures and a sample review of active and closed clinical records. The findings included: Review of Rural Health Clinic's (RHC) policy, "Biennial Program Evaluation," reviewed 10/1/2021, revealed the RHC "...carries out a biennial program evaluation of its total program drawing upon any technical assistance resources that may be available ..." There was no documentation of biennial evaluations of the total program completed by the RHC. During an interview on 3/31/2026 at 12:30 PM, the President of the RHC stated there were no biennial evaluations available for review.
J0162 PROGRAM EVALUATION

491.11(d) The clinic or center staff considers the findings of the evaluation and takes corrective action if necessary.


This STANDARD is not met as evidenced by:
Based on review of the Rural Health Clinic's (RHC) policy and interview, the RHC failed to provide documentation of any actions taken based on completed biennial evaluations. The findings included: Review of Rural Health Clinic's (RHC) policy, "Biennial Program Evaluation," reviewed 10/1/2021, revealed the RHC "...carries out a biennial program evaluation of its total program drawing upon any technical assistance resources that may be available... The responsibility and purpose of the Biennial Program Evaluation Elements are to evaluate the utilization of clinic services, including at least the number of patients served and the volume of services to determine appropriateness of utilization; Evaluate all polices with regards to appropriateness and whether or not the policies were followed..." There was no documentation of any corrective action taken, if needed from the biennial evaluations of the total program. During an interview on 3/31/2026 at 12:30 PM, the President of the RHC stated the RHC did not have documentation of an annual/biennial evaluation available for review.