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)
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 facility's policy review, Emergency Preparedness (EP) manual review, training guidelines, and and interview, the facility 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: 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 clinic "must develop and maintain an emergency preparedness plan that is reviewed and updated annually..." There was no documentation the clinic 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.