| 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) |
| J0043 | PHYSICAL PLANT AND ENVIRONMENT The clinic . . . has a preventive maintenance program to ensure that: 491.6(b)(2) Drugs and biologicals are appropriately stored; and This STANDARD is not met as evidenced by: Based on the Rural Health Clinic (RHC)'s policy review and observation, the RHC failed to ensure that the clinic had a preventive maintenance program to ensure that drugs and biologicals were stored and maintained in accordance with the expiration dates. The findings included: Review of the undated RHC's policy, "Emergency Kit Drugs," revealed, "The emergency kit will be checked monthly by on site staff to ensure appropriate types and quantities are maintained in the emergency kit and will remove, properly dispose of any expired drugs/biologicals, and will replace drugs/biologicals as needed." Observations during the tour on 5/13/2026 at 11:30 AM, revealed a vial adrenaline (a medicine used to treat allergic reactions) 1milligram/1milliliter with an expiration date of 12/2025. |