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)
J0000 An initial certification survey was conducted on 9/28/2020, at Spring City Family Clinic Pllc. The clinic was found to not meet the Conditions of Participation for Rural Health Clinics under 42 CFR 491 Subpart A - Conditions of Participation for Rural Health Clinics. The following Conditions of Participation for Rural Health Clinics were not met.: 1. Condition of Participation: Organizational Structure Policies: Interview with the Office Manger on 9/28/2020 at approximately 12:51 PM, revealed the clinic had no Organizational Structure Policies to review under Spring City Family Clinic Pllc. 2. Condition of Participation: Staffing and Staff Responsibilities Policies: Interview with the Office Manager on 9/28/2020 at approximately 12:53 PM, revealed the clinic had no Staffing and Staff Responsibilities Policies to review under Spring City Family Clinic Pllc. 3. Condition of Participation: Provision of Services Policies: Interview with the Office Manager on 9/28/2020 at approximately 12:55 PM, revealed the clinic had no Provision of Services Policies to review under Spring City Family Clinic Pllc. 4. Condition of Participation: Patient Health Records Policies: Interview with the Office Manger on 9/28/2020 at approximately 12:58 PM, revealed the clinic had no Patient Health Records Policies to review under Spring City Family Clinic Pllc. 5. Condition of Participation: Program Evaluation Policies: Interview with the Office Manager on 9/28/2020 at approximately 1:02 PM, revealed the clinic had no Program Evaluation Policies to review under Spring City Family Clinic Pllc.