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 883826 (X3) Date Survey Completed 03/03/2026
Name of Provider or Supplier Decaturville Family Practice Street Address, City, State 187 West Main Street, Decaturville, 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)
E0000 An unannounced Emergency Preparedness Survey was initiated at the facility in conjunction with a recertification survey on 03/03/2026 at 9:10 AM. An Entrance Conference was held with the Administrator/Owner on 03/03/2026 at 9:20 AM. The purpose of the survey was explained. Requests were made. An opportunity to ask questions/provide comments was provided. An Exit Conference was held with the Administrator/Owner at the facility on 03/03/2026 at 2:00 PM. The Administrator/Owner was notified of preliminary findings of deficiency under E0001 - Emergency Prepardness.
E0036 EP Training and Testing

§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.


This STANDARD is not met as evidenced by:
Based on the Rural Health Clinic's (RHC) policy review, review of the Emergency Preparedness (EP) manual, and interview, the Rural Health Clinic (RHC) failed to provide initial Emergency Preparedness training for all staff. The findings included: Review of the Rural Health Center's policy, "Emergency Preparedness", revealed, "It is the policy of . . . to comply with all Federal, State, and local law regarding community emergency preparedness and to maintain an emergency preparedness program in compliance with 491.2 Emergency Preparedness . . ." Review of the Rural Health Clinic (RHC) Emergency Preparedness (EP) Manual, revealed that the facility failed to provide initial EP training for all staff. During an interview on 3/3/2026 at 11:00 AM, the Administrator/Owner stated that no initial EP training was provided for the staff.
J0000 An unannounced recertification survey was initiated at the facility on 03/03/2026 at 9:10 AM. An Entrance Conference was held with the Administrator/Owner on 03/03/2026 at 9:20 AM. The purpose of the survey was explained and requests made. An opportunity for questions/comments was provided. An Exit Conference was held at the facility with the Administrator/Owner on 03/03/2026 at 2:00 PM. The Administrator/Owner was notified of preliminary findings of no deficiencies cited under FED - J -10.1.