| 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) |
| J0136 | PROVISION OF SERVICES 491.9(c) Direct services (3) Emergency. The clinic . . . provides medical emergency procedures as a first response to common life-threatening injuries and acute illness and has available the drugs and biologicals commonly used in life saving procedures, such as analgesics, anesthetics (local), antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids This STANDARD is not met as evidenced by: Based on review of the facility's policy, and interview, the facility failed to ensure adherance to procedures and maintained drugs and biologicals to appropriately respond to common life-threatening injuries and acute illnesses. The findings included: Review of the facility's policy, "Emergency Kit Drugs/Biologicals Policy", revealed the facility will maintain the following types of drugs/biologicals in the emergency kit: analgesics, local anesthetics, antibiotics, promethazine, diphenhydramine and epinephine. "The emergency kit will be checked Monthly by [Advancd Practice Registered Nurse] to ensure appropririate types and quantities [of medications] are maintained in the emergency kit ..." Observation during the tour of the facility, on 2/9/2026, at 1:00 PM revealed there was no emergency kit available for use. During an interview on 2/9/2026 at 1:00 PM, the APRN reported she was not aware of where the emergency kit was located. |