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)
E0031 Emergency Officials Contact Information

§403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency.


This STANDARD is not met as evidenced by:
Based on the Rural Health Clinic's (RHC) policy review and interview, the RHC failed to maintain and update every 2 years contact information for Federal, State, regional and local emergency preparedness officials as part of the written communication plan. 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.