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)
J0160 PROGRAM EVALUATION

ยง491.11 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