| 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) |
| J0160 | PROGRAM EVALUATION ยง491.11 Program evaluation. This CONDITION is not met as evidenced by: Based on review of Rural Health Clinic's (RHC's) manual and interview, the RHC failed to perform a program evaluation, at least biennially. The findings included: The Administrator/Medical Director failed to complete or arrange for a biennial evaluation of the total program that included a review of policies and procedures and a sample review of active and closed clinical records. Refer to J 0161. The Rural Health Clinic was unable to provide documentation of any action taken based on a completed biennial evaluation. Refer to J 0162. |