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)
J0135 PROVISION OF SERVICES

491.9(a) Basic requirements: (3) The laboratory requirements in paragraph (c)(2) of this section apply to RHCs, . . . 491.9(c) Direct services (2) Laboratory. These requirements apply to RHCs . . . . The RHC provides laboratory services in accordance with part 493 of this chapter, which implements the provisions of section 353 of the Public Health Service Act. The RHC provides basic laboratory services essential to the immediate diagnosis and treatment of the patient, including: (i) Chemical examinations of urine by stick or tablet method or both (including urine ketones); (ii) Hemoglobin or hematocrit; (iii) Blood glucose; (iv) Examination of stool specimens for occult blood; (v) Pregnancy tests; and (vi) Primary culturing for transmittal to a certified laboratory.


This STANDARD is not met as evidenced by:
Based on policy review, facility document review, observation and interview, the facility failed to adequately store laboratory (lab) testing items and maintain temperature logs for 1 of 1 (Refrigerator #1) refrigerators observed. The findings included: The facility provided no policy for storing and recording temperatures for lab items. The facility did not provide temperature monitoring logs for Refrigerator #1. Observations on 05/13/2026 at 11:32 AM of Refrigerator #1 revealed the following: (a) 1 box of 4 bottles and 4 individual bottles of glucose testing microcuvettes (hard plastic testing strips) with instructions to store at 15- 30 degrees Celsius (C). (b) 2 boxes of high and low hemoglobin controls (liquid used to test accuracy of hemoglobin machine measurements) with instructions to store at 2-8 degrees C. Refrigerator #1 did not contain a thermometer to adequately measure the refrigerator temperature. During an interview on 05/13/2026 at 11:42 AM, the Director of Clinical and Regulatory Compliance stated that they did not maintain temperature logs on Refrigerator #1 because it was used for lab specimens.