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)
E0022 Policies/Procedures for Sheltering in Place

§403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice.


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 maintain and update every two years emergency preparedness policies and procedures to address a means to shelter in place for patients, staff, and volunteers who remain in the facility. The findings included: Review of the RHC's policy, "Emergency Preparedness," dated 3/15/2021, revealed the RHC will develop and implement emergency preparedness policies and procedures, based on the emergency plan and address a means to shelter in place for patients, staff and volunteers who remain in the facility. The policies and procedures will be reviewed and updated at least every 2 years. Review of the Emergency Preparedness manual revealed the RHC did not have documentation of updates available for review. 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.