| 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) |
| J0162 | PROGRAM EVALUATION 491.11(d) The clinic or center staff considers the findings of the evaluation and takes corrective action if necessary. This STANDARD is not met as evidenced by: Based on review of the Rural Health Clinic (RHC) manual and interview, the RHC failed to provide documentation of any actions taken based on completed biennial evaluations. 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. Review of the RHC manual revealed no documentation of completion of biennial evaluations of the total program. 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. |