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 883842 (X3) Date Survey Completed 05/11/2026
Name of Provider or Supplier Dickson Medical Associate White Bluff Street Address, City, State 2004 Highway 47 N, White Bluff, 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)
E0004 Develop EP Plan, Review and Update Annually

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. .


This STANDARD is not met as evidenced by:
Based on the Rural Health Clinic's (RHC's) policy review, manual review, and interview, the RHC failed to maintain an Emergency Preparedness (EP) plan to be reviewed and updated every two years. The findings included: Review of the RHC's policy "Emergency Preparedness", dated 03/15/2021, revealed the RHC will develop and maintain an emergency preparedness plan that will be reviewed and updated at least every 2 years. Review of the RHC's EP manual revealed that the RHC did not have an EP plan that was reviewed and updated every two years. During an interview on 05/11/2026 at 1:30 PM, the Administrator stated the EP manual had not been updated.