| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 883828 | (X3) Date Survey Completed 11/25/2025 |
| Name of Provider or Supplier Anew Family Medical Pllc | Street Address, City, State 111 Front Street, Henderson, 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) |
| 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 facility policy review and interview, the Rural Health Clinic (RHC) failed to establish and maintain a comprehensive emergency preparedness program that meets the requirements. The findings included: 1. The Rural Health Clinic (RHC) failed to maintain an Emergency Preparedness (EP) plan that was reviewed and updated at least every 2 years. Refer to E-004 2. The RHC failed to maintain a documented community and facility-based risk assessment, utilizing an all-hazards approach. Refer to E-006 3. The RHC failed to maintain documentation of any reviews and updates to the Emergency Preparedness (EP) policies and procedures, based on review of the updated emergency plan at least every two years. Refer to E-0013 4. The RHC failed to develop, implement and update Emergency Preparedness (EP) 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 5. The RHC failed to update policies and procedures for maintaining confidentiality of medical records during an emergency. Refer to E-0023 6. The RHC failed to update policies and procedures for the use of volunteers during an emergency or other emergency staffing strategies. Refer to E-0024. 7. The RHC failed to maintain updated contact information for staff, physicians, volunteers and other health facilities as part of a written communication plan. Refer to E-0030 8. The RHC failed to update contact information for Federal, State, regional and local emergency preparedness officials every 2 years as part of a written communication plan. Refer to E-0031 9. The RHC failed to document a plan for an alternate and primary means to communicate with facility staff, Federal, State and local emergency management agencies. Refer to E-0032 10. The RHC failed to update a documented plan for sharing information and medical documentation for patients under the clinic's care, as necessary, with other health providers to maintain the continuity of care. Refer to E-0033 11. The RHC failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in the regulations. The training and testing program must be reviewed and updated at least every 2 years. Refer to E-0036 12. The RHC failed to document initial training in Emergency Preparedness (EP) policies and procedures consistent with their roles in an emergency to all new and existing staff including volunteers, based on the clinic's risk assessment policies and procedures as well as the communication plan. Refer to E-0037 13. The RHC failed to document they had conducted exercises to test the emergency plan by participating in a full-scale exercise, community-based, every 2 years or conducting a facility-based functional exercise every 2 years. Refer to E- 0042 |