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)
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 facility's policy review, Emergency Preparedness (EP) manual review and interview, the facility failed to maintain and update a communication plan every 2 years that provided information about the clinic's occupancy, needs and its ability to provide assistance. The findings included: Review of the facility's policy, "Emergency Preparedness," reviewed 8/7/2019, revealed "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 the facility "must develop and maintain an emergency preparedness plan that is reviewed and updated annually ..." There was no documentation the facility updated it's communication plan every 2 years that provided information about the clinic's occupancy, needs and its ability to provide assistance. During an interview, on 2/9/2026, at 9:15 AM, the Advanced Practice Registered Nurse (APRN) reported that the clinic did not have updates available for review.