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 883831 (X3) Date Survey Completed 09/28/2020
Name of Provider or Supplier Spring City Family Clinic Pllc Street Address, City, State 126 Lavender Street Ste 2, Spring City, 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)
E0001 Establishment of the Emergency Program (EP)

§403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements:


This CONDITION is not met as evidenced by:
An Emergency Preparedness initial certification survey was conducted on 9/28/2020, at Spring City Family Clinic Pllc. The facility was found to be out of compliance under 42 CFR, 491.12, Conditions for Certification for Rural Health Clinics. The findings include: Interview with the Office Manager on 9/28/2020 at 12:57 P.M., in the owners office, revealed there was no emergency preparedness plan and no emergency preparedness documentation to review related to staff and patient safety. Interview with the clinic consultant on 9/28/2020 at 1:05 P.M., by phone, confirmed there was no emergency preparedness documentation to review in the clinic. Interview confirmed the clinic failed to establish a comprehensive site specific emergency preparedness plan.