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)
E0022 Policies/Procedures for Sheltering in Place

§403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (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:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice.


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 maintain and update every two years emergency preparedness policies and procedures to address a means to shelter in place for patients, staff, and volunteers who remain in the facility. 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 RHC "must develop and maintain an emergency preparedness plan that is reviewed and updated annually... including procedures to shelter in place patients and staff..." There was no documentation the facility updated its EP policies and procedures every 2 years. 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.