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)
E0034 Information on Occupancy/Needs

§403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.


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 a communication plan every 2 years that provided information about the RHC's occupancy, needs and its ability to provide assistance. 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.