| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 883843 | (X3) Date Survey Completed 05/13/2026 |
| Name of Provider or Supplier Dickson Medical Associates Mathis Pediatrics | Street Address, City, State 110 Mathis Drive, Suite 103, Dickson, 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) |
| E0001 | Establishment of the Emergency Program (EP) §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on review of the Rural Health Clinic's (RHC) policies, Emergency Preparedness (EP) manual, and interview, the cllinic failed to establish and maintain a comprehensive emergency preparedness program that meets the requirements. The findings included: 1. The RHC failed to maintain an EP plan to be reviewed and updated every two years. Refer to E 0004 2. The RHC failed to maintain and update every two years a documented community and facility-based risk assessment, utilizing an all-hazards approach. Refer to E 0006 3. The RHC failed to review and update their EP plan every two years to address the population and the continuity of operations. Refer to E 0007 4. The RHC failed to maintain an EP plan that was reviewed and updated every two years that included a process for cooperation and collaboration with EP officials' efforts to maintain an integrated response during a disaster or emergency situation. Refer to E 0009 5. The RHC failed to review and update their EP policies and procedures at least every two years based on the emergency plan. Refer to E 0013 6. The RHC failed to maintain and update every two years emergency preparedness policies and procedures to address safe evacuation from the facility, staff responsibilities, transportation, and alternate means of communication. Refer to E 0020 7. The RHC failed to maintain and update every two years preparedness policies and procedures to address a means to shelter in place for patients, staff, and volunteers who remain in the facility. Refer to E 0022 8. The RHC failed to maintain and update every two years policies and procedures for maintaining confidentiality of records during an emergency. Refer to E 0023 9. The RHC failed to maintain and update every two years policies and procedures for the use of volunteers and other staffing strategies in case of an emergency or disaster. Refer to E 0024 10. The RHC failed to maintain and update every two years an EP communication plan. Refer to E 0029 11.The RHC failed to maintain and update every 2 years contact information for staff, physicians, volunteers and other health facilities as part of the written communication plan. Refer to E 0030 12. The RHC failed to maintain and update contact information every 2 years for Federal, State, regional and local emergency preparedness officials as part of the written communication plan. Refer to E 0031 13. The RHC failed to maintain and update every 2 years a communication plan that included primary and alternate means for communication with facility staff, Federal, State and local emergency management agencies. Refer to E 0032 14. The RHC failed to maintain and update a communication plan every 2 years for sharing medical information. Refer to E 0033 15. The RHC failed to maintain and update a communication plan every 2 years that provided information about the RHC's occupancy, needs and its ability to provide assistance. Refer to E 0034 16. The RHC failed to maintain and update every 2 years an EP training and testing program. Refer to E 0036 17. The RHC failed to educate all employees on the EP program upon hire and at least every two years. Refer to E 0037 18. The RHC failed to document they had conducted exercises to test the emergency plan annually and participate in a full-scale exercise, facility-based functional exercise or community-based every 2 years. Refer to E 0039 |