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 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)
E0007 EP Program Patient Population

§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]


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 review and update their Emergency Preparedness (EP) plan every two years to address the population and the continuity of operations. The findings included: Review of the RHC's policy, "Emergency Preparedness", dated 3/15/2021, revealed the RHC will develop and maintain an emergency preparedness plan that will address patient be reviewed and updated at least every 2 years. The plan must address patient population, including, but not limited to, the type of services the clinic has the ability to provide in an emergency. 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 5/13/2026 at 11:45 AM, the Director of Clinical and Regulatory Compliance (DCRC) stated the RHC did not have documentation of updates available for review.