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)
J0160 PROGRAM EVALUATION

ยง491.11 Program evaluation.


This CONDITION is not met as evidenced by:
Based on clinic documentation review and interview the clinic failed to have program evaluation policies. The findings include: Review of a policy and procedure book last dated 2018 provided by the Office Manger, revealed the policy and the procedure book was for another RHC facility and not Spring City Family Medical Clinic Pllc. Further review revealed the clinic did not have a program to evaluate policies for the clinic. Interview with the clinic consultant on 9/28/2020 at 1:05 PM., by phone, confirmed the clinic failed to develop and establish program evaluation policies.