CMS SOM App. G, Tag J-0162

and takes corrective action if necessary.

Interpretative Guidelines § 491.11(d)

The RHC’s leadership must consider the evaluation findings and recommendations for

change, if any. It must take corrective actions as necessary, such as changes in policies

or, with respect to clinical personnel, provision of additional training, changes in level of

supervision, or even limiting or terminating clinical privileges. The RHC must document

where and when the evaluation findings and recommendations were considered, and by

whom they were considered. It must also document what corrective actions, if any, were

taken and by whom they were recommended. If the RHC leadership does not take

corrective actions recommended as part of the evaluation, or if it takes corrective actions

different from those recommended, it must document the rationale for its decision.

Survey Procedures § 491.11(d)

• Does the RHC have documentation of leadership review of the evaluation findings

each year?

• Is there evidence of the RHC taking corrective actions?

• If the RHC did not take recommended corrective actions or took corrective actions

different from those recommended, did it document an appropriate rationale

supporting its decision?

Transmittals Issued for this Appendix

Rev # Issue Date Subject Impl Date CR#

R223SOMA 06/07/2024 Revisions to the State Operations Manual

(SOM) Appendix G - RHC

06/07/2024 N/A

R200SOMA

02/21/2020 Revisions to the State Operations Manual

(SOM) Appendix A -

Hospitals, Appendix AA – Psychiatric

Hospitals, Appendix B – Home Health

Agency, Appendix D - Portable X-Ray,

Appendix G - Rural Health

Clinics/Federally Qualified Health Centers,

Appendix H- End Stage Renal Disease

Facilities (ESRD), Appendix K –

Comprehensive Outpatient Rehabilitation

Facility, Appendix L - Ambulatory Surgical

Centers, Appendix M – Hospice, Appendix

U - Religious Nonmedical Healthcare

Institutions, Appendix W - Critical Access

Hospitals (CAHs), Appendix X-Organ

Transplant Program and Appendix Z -

Emergency Preparedness

02/21/2020 N/A

R194SOM 10/25/2019 Revisions to State Operations Manual

(SOM) Appendix G, Guidance for

Surveyors: Rural Health Clinics

10/25/2019 N/A

R177SOM 01/26/2018 Revisions to State Operations Manual

(SOM) Appendix G, Guidance for

Surveyors: Rural Health Clinics

01/26/2018 N/A

R137SOM 04/01/2015 Revisions to State Operations Manual

(SOM) Appendices A, G, L and T related to

Hospitals, Rural Health Clinics, Ambulatory

Surgical Centers and Swing Beds

03/27/2015 N/A

R01SOM 05/21/2004 Initial Release of Pub 100-07 N/A N/A