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)
E0009 Local, State, Tribal Collaboration Process

§403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency.


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 that was reviewed and updated every two years in an attempt to maintain an integrated response with EP officials during a disaster or emergency situation. 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. The plan must include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation." 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 RHC did not have documentation of updates available for review.