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 883837 (X3) Date Survey Completed 02/03/2021
Name of Provider or Supplier Crossville Medical Clinic Rhc Street Address, City, State 229 Interstate Drive Suite 105, Crossville, 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 Emergency Preparedness survey was conducted at Crossville Medical Clinic Rhc on 2/3/21. No deficiencies were cited under 42 CFR 491, Subpart A, Conditions for Certification for Rural Health Clinics.
J0000 An initial Certification survey was conducted on 2/3/21, at Crossville Medical Clinic Rhc. Deficiencies were cited under 42 CFR 491 Subpart A - Conditions of Participation for Rural Health Clinics.
J0041 PHYSICAL PLANT AND ENVIRONMENT

491.6(a) Construction: The clinic and the center is constructed, arranged, and maintained to insure access to and safety of patients, and provides adequate space for the provision of direct services.


This STANDARD is not met as evidenced by:
Based on interview the center failed to ensure local fire department inspections were completed annually to insure local codes were met and the inspections were available for review. The findings include: Interview with the clinic Manager on 2/4/21 at 10:51 A.M., by phone, confirmed the clinic had no inspections from the local fire department available for review.
J0042 PHYSICAL PLANT AND ENVIRONMENT

491.6(b) Maintenance: The clinic . . . has a preventive maintenance program to ensure that: (1) All essential mechanical, electrical and patient-care equipment is maintained in safe operating condition;


This STANDARD is not met as evidenced by:
Based on observation and interview the clinic failed to ensure all electrical equipment was inspected annually. The findings include: Observation on 2/3/21 at 10:02 AM, revealed a 12 lead electrocardiography and a bladder scan machine the clinic failed to have an annual inspection on. Interview with the clinic Manager on 2/4/21 at 10:55 AM, by phone, confirmed the equipment was not inspected annually.