| 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) |
| J0162 | PROGRAM EVALUATION 491.11(d) The clinic or center staff considers the findings of the evaluation and takes corrective action if necessary. This STANDARD is not met as evidenced by: Based on review of the Rural Health Clinic's (RHC's) manual and interview, the RHC failed to provide documentation of any actions taken based on completed biennial evaluations. The findings included: Review of Rural Health Clinic's (RHC's) manual revealed the RHC will 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. |