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 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)
J0161 PROGRAM EVALUATION

ยง 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 the Rural Health Clinic (RHC)'s Policy and Procedures and interview, the rural health clinic (RHC) failed to compete or arrange for, a biennial evaluation of its total program that included a review of policies and procedures, utilization of clinic or center services, including at least the number of patients served and the volume of services and a sample review of active and closed clinical records. The clinic was unable to provide documentation that the utilization of services was appropriate, the established policies were followed and any changes that were made or needed as a result of the evaluation. The findings included: Review of the Rural Health Clinic (RHC)'s Policy and Procedures revealed, "...Introduction to the Program Evaluation... In consideration of the above regulations a program evaluation committee was formed to evaluate the total rural health clinic program. This report reflects the proposed format of the program evaluation reports that will be performed biennially in the future. . ." Review of the Rural Health Clinic (RHC)'s Policy and Procedures and Evidence manuals revealed there was no documentation of program evaluation reports available for review. During an interview on 9/23/2025 at 1:00 PM, the Office Manager reported that evaluations were available for review.