| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 883837 | (X3) Date Survey Completed 02/03/2021 |
| Name of Provider or Supplier Crossville Medical Clinic Rhc | Street Address, City, State 229 Interstate Drive Suite 105, Crossville, 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) |
| J0042 | PHYSICAL PLANT AND ENVIRONMENT 491.6(b) Maintenance: The clinic . . . has a preventive maintenance program to ensure that: (1) All essential mechanical, electrical and patient-care equipment is maintained in safe operating condition; This STANDARD is not met as evidenced by: Based on observation and interview the clinic failed to ensure all electrical equipment was inspected annually. The findings include: Observation on 2/3/21 at 10:02 AM, revealed a 12 lead electrocardiography and a bladder scan machine the clinic failed to have an annual inspection on. Interview with the clinic Manager on 2/4/21 at 10:55 AM, by phone, confirmed the equipment was not inspected annually. |