Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 883831	(X3) Date Survey Completed 09/28/2020
Name of Provider or Supplier Spring City Family Clinic Pllc	Street Address, City, State 126 Lavender Street Ste 2, Spring City, 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)
E0001	Establishment of the Emergency Program (EP) §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) [For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: [For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: An Emergency Preparedness initial certification survey was conducted on 9/28/2020, at Spring City Family Clinic Pllc. The facility was found to be out of compliance under 42 CFR, 491.12, Conditions for Certification for Rural Health Clinics. The findings include: Interview with the Office Manager on 9/28/2020 at 12:57 P.M., in the owners office, revealed there was no emergency preparedness plan and no emergency preparedness documentation to review related to staff and patient safety. Interview with the clinic consultant on 9/28/2020 at 1:05 P.M., by phone, confirmed there was no emergency preparedness documentation to review in the clinic. Interview confirmed the clinic failed to establish a comprehensive site specific emergency preparedness plan.
J0000	An initial certification survey was conducted on 9/28/2020, at Spring City Family Clinic Pllc. The clinic was found to not meet the Conditions of Participation for Rural Health Clinics under 42 CFR 491 Subpart A - Conditions of Participation for Rural Health Clinics. The following Conditions of Participation for Rural Health Clinics were not met.: 1. Condition of Participation: Organizational Structure Policies: Interview with the Office Manger on 9/28/2020 at approximately 12:51 PM, revealed the clinic had no Organizational Structure Policies to review under Spring City Family Clinic Pllc. 2. Condition of Participation: Staffing and Staff Responsibilities Policies: Interview with the Office Manager on 9/28/2020 at approximately 12:53 PM, revealed the clinic had no Staffing and Staff Responsibilities Policies to review under Spring City Family Clinic Pllc. 3. Condition of Participation: Provision of Services Policies: Interview with the Office Manager on 9/28/2020 at approximately 12:55 PM, revealed the clinic had no Provision of Services Policies to review under Spring City Family Clinic Pllc. 4. Condition of Participation: Patient Health Records Policies: Interview with the Office Manger on 9/28/2020 at approximately 12:58 PM, revealed the clinic had no Patient Health Records Policies to review under Spring City Family Clinic Pllc. 5. Condition of Participation: Program Evaluation Policies: Interview with the Office Manager on 9/28/2020 at approximately 1:02 PM, revealed the clinic had no Program Evaluation Policies to review under Spring City Family Clinic Pllc.
J0060	ORGANIZATIONAL STRUCTURE 491.7 Organizational structure. This CONDITION is not met as evidenced by: Based on clinic documentation review and interview the clinic failed to have organizational structure polices specific to include administrative, patient care policies, and maintenance of building and equipment policies. The findings include: Review of a policy and procedure book last dated 2018 provided by the Office Manager, revealed the policy and procedure book was for another facility and not for Spring City Family Medical Clinic Pllc. Further review revealed the the facility did not have organizational structure policies. Interview with the clinic current owner on 9/28/2020 at 12:46 P.M., by phone, revealed the current owner was selling the clinic to her brother. Interview with the clinic consultant on 9/28/2020 at 1:05 P.M., by phone, confirmed the clinic failed to develop and establish organizational structure policies.
J0080	STAFFING AND STAFF RESPONSIBILITIES 491.8 Staffing and Staff Responsibilities. This CONDITION is not met as evidenced by: Based on clinic documentation review and interview the clinic failed to have staffing and staff responsibilities policies. The findings include: Review of a policy and procedure book last dated 2018 provided by the Office Manger, revealed the policy and procedure book was for another RHC facility and not for Spring City Family Medical Clinic Pllc. Further review revealed the clinic did not have staffing and staff responsibilities policies. Interview with the center consultant on 9/28/2020 at 1:05 PM., by phone, confirmed the clinic failed to develop and establish specific staffing and staff responsibilities policies.
J0120	PROVISION OF SERVICES 491.9 Provision of services. This CONDITION is not met as evidenced by: Based on clinic documentation review and interview the clinic failed to have provision of services policies. The findings include: Review of a policy and procedure book last dated 2018 provided by the Office Manger, revealed the policy and procedure book was for another RHC facility and not for Spring City Family Medical Clinic Pllc. Further review revealed the clinic did not have provision of services policies for the clinic. Interview with the clinic consultant on 9/28/2020 at 1:05 PM., by phone, confirmed the clinic failed to develop and establish provision of services policies.
J0150	PATIENT HEALTH RECORDS 491.10 Patient health records This CONDITION is not met as evidenced by: Based on clinic documentation review and interview the clinic failed to have current clinic patient health records policies. The findings include: Review of a policy and procedure book last dated 2018 provided by the Office Manger, revealed the policy and procedure book was for another RHC facility and not for Spring City Family Medical Clinic Pllc. Further review revealed the clinic did not have patient health record policies. Interview with the clinic consultant on 9/28/2020 at 1:05 PM., by phone, confirmed the clinic failed to develop and establish patient health records policies.
J0160	PROGRAM EVALUATION §491.11 Program evaluation. This CONDITION is not met as evidenced by: Based on clinic documentation review and interview the clinic failed to have program evaluation policies. The findings include: Review of a policy and procedure book last dated 2018 provided by the Office Manger, revealed the policy and the procedure book was for another RHC facility and not Spring City Family Medical Clinic Pllc. Further review revealed the clinic did not have a program to evaluate policies for the clinic. Interview with the clinic consultant on 9/28/2020 at 1:05 PM., by phone, confirmed the clinic failed to develop and establish program evaluation policies.