| 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) |
| J0123 | STAFFING AND STAFF RESPONSIBILITIES 491.8(b) Physician responsibilities. The physician performs the following: (2) In conjunction with the physician assistant and/or nurse practitioner member(s), participates in developing, executing, and periodically reviewing the clinic's . . . written policies and the services provided to Federal program patients. 491.8(c) Physician assistant and nurse practitioner responsibilities. (1) The physician assistant and the nurse practitioner members of the clinic's . . . staff: (i) Participate in the development, execution and periodic review of the written policies governing the services the clinic . . . furnishes; § 491.9(b) Patient care policies . . . (1) The clinic's … health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law. (2) The policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic . . . staff. (4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (b)(2) of this section and reviewed as necessary by the clinic... This STANDARD is not met as evidenced by: Based on review of the Rural Health Clinic (RHC) manual and interview, the physician failed to, in conjunction with the nurse practitioner, participate in developing and executing and periodically reviewing at least biennially the clinic's written policies and the services provided to Federal program patients. The findings included: Review of the RHC 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. 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 an annual/biennial evaluation available for review. |