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 883825 (X3) Date Survey Completed 02/23/2026
Name of Provider or Supplier Healthy Kids Llc Street Address, City, State 220 West Cedar Street, Shelbyville, 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)
E0024 Policies/Procedures-Volunteers and Staffing

§403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.


This STANDARD is not met as evidenced by:
Based on Rural Health Clinic's (RHC) policy review and interview, the RHC failed to maintain and update every two years policies and procedures for the use of volunteers and other staffing strategies in case of an emergency or disaster. The findings included: 1. Review of the RHC's policy, "Emergency Preparedness" dated 5/1/2022, revealed, "It is the policy of [Named RHC]...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 ..." 2. During an interview on 02/23/2026 at 12:00 PM, the Office Manager stated that she had no signed documentation that the RHC's Emergency Preparedness plan was updated since 2022.