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)
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.