| 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) |
| J0161 | PROGRAM EVALUATION ยง 491.11 Program evaluation. (a) The clinic or center carries out, or arranges for, a biennial evaluation of its total program. (b) The evaluation includes review of: (1) The utilization of clinic or center services, including at least the number of patients served and the volume of services; (2) A representative sample of both active and closed clinical records; and (3) The clinic's or center's health care policies. (c) The purpose of the evaluation is to determine whether: (1) The utilization of services was appropriate; (2) The established policies were followed; and (3) Any changes are needed. This STANDARD is not met as evidenced by: Based on review of Rural Health Clinic's (RHC's) manual and interview, the RHC 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. The findings included: Review of Rural Health Clinic's (RHC's) manual revealed the RHC should carry out or arrange for a biennial evaluation of its total program, consider the findings of the evaluation and take corrective action if necessary. Review of the RHC's manual revealed no documentation of completion of biennial evaluations of the total program. During an interview on 5/11/2026 at 1:30 PM, the Administrator stated the RHC did not have documentation of an annual/biennial evaluation available for review. |