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 883829 (X3) Date Survey Completed 02/09/2026
Name of Provider or Supplier Humboldt Family Walk-In Clinic Llc Street Address, City, State 1600 Coleman Drive, Humboldt, 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)
E0007 EP Program Patient Population

§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]


This STANDARD is not met as evidenced by:
Based on the facility's policy review, Emergency Preparedness (EP) manual review, training guidelines and interview, the facility failed to review and update their EP plan every two years to address the population and the continuity of operations. The findings included: Review of the facility's policy, "Emergency Preparedness," reviewed 8/7/2019, revealed that "It is the policy of [the named facility] to comply with all Federal, State, and local laws regarding community emergency preparedness and to maintain an emergency preparedness program in compliance with 491.12 Emergency preparedness [regulation]..." Review of the facility's "Required Emergency Preparedness Training" revealed that the facility "must develop and maintain an emergency preparedness plan that is reviewed and updated annually..." There was no documentation the facility updated the EP plan to address the population and continuity of operations since 2020. During an interview, on 2/9/2026, at 9:15 AM, the Advanced Practice Registered Nurse (APRN) reported that the facility did not have updates available for review.