Fkc Temple Germantown

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 49513 Based on review of facility policy, observation, staff, and an interview conducted with the Facility Administrator and Regional Director of Operations the agency failed to ensure prepared filled syringes were separated from patient access areas and were not on medication carts and trays. Findings included: A review of facility policy titled “Medication Preparation and Administration” conducted on June 5, 2025 at approximately 12:45 PM states, “Medications shall be prepared in a clean work area away from dialysis patient stations and delivered separately to each patient. Common medication carts and trays shall not be used to deliver medications from patient station to patient station. “ Observation on June 4, 2025 at 10:15 a.m. revealed two (2) heparin filled syringes sitting on top of a supply cart in front of station 3 in a patient access area. Observation on June 4, 2025 at 10:25 a.m. revealed three (3) heparin filled syringes sitting on top of a supply cart in front of the weight station in a patient access area. Observation on the treatment floor on June 4, 2025 at 10:26 a.m. revealed seven (7) heparin filled syringes sitting on top of a supply cart in an aisle between Pod 4 and Pod 5 in a patient access area. An interview conducted with the Facility Administrator and Regional Director of Operations on June 5, 2025, at approximately 1:00 PM confirmed the above findings.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49513 Based on review of facility policy, observation, and staff interview, the facility failed to provide a sage and functional enviroment. Findings include: Review of facility policy “Acid Concentrate Storage and Handling”, on June 5, 2025, showed, “1 Gallon Acid Concentrate Container prior to treatment: .....NOTE: Do not set the want on the table or on the machine. The cap and the wand assembly must remain clean.” Observation on June 4, 2025, at 9:40 a.m. : a dialysate jug lid at station 2 was not secure, open to air, and the lid was leaning on jug. Observation on June 4, 2025 at 9:40 a.m. : a dialysate jug lid at station 10 was not secure, open to air, and the lid was leaning on jug. An interview conducted with the Facility Administrator and Regional Director of Operations on June 5, 2025, at approximately 1:00 PM confirmed the above findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 49513 Based on a review of facility policy, medical records (MR), and an interview with the Facility Administrator and the Regional Director of Operations, the facility did not follow its policy for patient assessment and monitoring for five (5) of ten (10) MRs reviewed, (MR # 2, 3, 4, 8, and 10). Findings include: A review of facility policy titled “Patient Assessment and Monitoring” conducted on June 5, 2025 at approximately 12:45 PM states, “If the PCT/LPN (patient care technician/licensed practical nurse) note any changes or abnormal findings in the patient’s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. The nurse will notify the patient’s physician of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The registered nurse ill assess/re-assess any findings addressed pre or during treatment as needed...During treatment: Blood Pressure: Recheck blood pressures after a drop that requires interventions...Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings, Report to the nurse: Systolic blood pressures greater than 180 mm/Hg; Diastolic blood pressures greater than 100 mm/Hg; Blood Pressure less than or equal to 100 mm/Hg systolic...Reported by patient: Report to the nurse any complaints by the patient during treatment...Document any findings and interventions in the medical record...Safety/Machine checks: Verify dialysate lines are attached and in correct position and DFR (dialysate flow rate) BFR (blood flow rate) and UFR (ultra filtration rate) is set and functioning per treating physician order...” A review of MRs was conducted on 6/4/2025 from approximately 1:20 PM to 2:00 PM and on 6/5/2025 from approximately 8:45 AM to 10:30 AM. Note: BPs within normal range at post treatment. MR #2, Start of Care: 11/1/22. Review of treatments sheets for 5/22/2025 through 6/3/2025 revealed the following: 5/16/2025: PCT documented at 12:05 PM, B/P 132/113. PCT documented at 12:35 PM, B/P 153/110. There is no documentation of a recheck of the blood pressure and no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences. MR #3, Start of Care: 4/29/25. Review of treatment sheets 5/22/2025 through 6/3/2025 revealed the following: 5/27/2025: PCT recorded at 6:44 AM, B/P 159/109. PCT recorded at 6:53 AM, B/P 165/108. PCT recorded at 7:03 AM, B/P 197/173. PCT recorded at 7:29 AM, B/P 170/115. PCT recorded at 8:05 AM, B/P 180/120. PCT recorded at 8:30 AM, B/P 182/112. PCT recorded at 9:12 AM, B/P 181/121. PCT recorded at 9:34 AM, B/P 194/109. PCT recorded at 10:04 AM, B/P 169/113. PCT recorded at 10:32 AM, B/P 179/109. There is no documentation of a recheck of the blood pressure and no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences. 5/29/2025: PCT recorded at 6:34 AM, B/P 176/106. PCT recorded at 6:57 AM, B/P 176/106. PCT recorded at 6:58 AM, B/P 170/113. PCT recorded at 7:25 AM, B/P 171/106. PCT recorded at 7:31 AM, B/P 178/107. PCT recorded at 7:59 AM, B/P 175/107. PCT recorded at 8:36 AM, B/P 174/108. PCT recorded at 9:01 AM, B/P 163/140. PCT recorded at 9:30 AM, B/P 193/106. PCT recorded at 10:01 AM, B/P 166/117. PCT recorded at 10:45 AM, B/P 181/116. There is no documentation of a recheck of the blood pressure and/or no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences. 5/31/2025: PCT recorded at 6:40 AM, B/P 185/119. PCT recorded at 6:56 AM, B/P 178/109. PCT recorded at 7:30 AM, B/P 172/112. PCT recorded at 8:02 AM, B/P 167/105. PCT recorded at 8:30 AM, B/P 178/114. PCT recorded at 9:01 AM, B/P 177/104. PCT recorded at 9:30 AM, B/P 163/100. PCT recorded at 10:30 AM, B/P 171/100. PCT recorded at 10:51 AM, B/P 180/100. There is no documentation of a recheck of the blood pressure and/or no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences. 6/3/2024: PCT recorded at 6:32 AM, B/P 152/108. PCT recorded at 6:44 AM, B/P 152/104. PCT recorded at 7:04 AM, B/P 168/108. PCT recorded at 7:33 AM, B/P 169/112. PCT recorded at 8:11 AM, B/P 155/104. PCT recorded at 9:11 AM, B/P 154/100. PCT recorded at 10:35 AM, B/P 158/130. PCT recorded at 10:38 AM, B/P 161/104. PCT recorded at 10:40 AM, B/P 166/112. There is no documentation of a recheck of the blood pressure and/or no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences. MR #4, Start of Care: 5/1/2025 (transferred to this facility). Review of treatment sheets 5/22/2025 through 6/3/2025 revealed the following: 5/22/2025: PCT recorded at 7:16 AM, B/P 209/104. PCT recorded at 8:05 AM, B/P 233/110. PCT recorded at 8:32 AM, B/P 203/186. PCT recorded at 9:02 AM, B/P 214/128. PCT recorded at 9:30 AM, B/P 225/108. PCT recorded at 10:00 AM, B/P 176/119. PCT recorded at 10:13 AM, B/P 176/119. PCT recorded at 10:38 AM, B/P 161/104. PCT recorded at 10:40 AM, B/P 166/112. There is no documentation of a recheck of the blood pressure and/or no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences. 5/29/2025: PCT documented at 8:32 AM, B/P 126/110. PCT documented at 9:31 AM, B/P 140/104. There is no documentation of blood pressure recheck or that the PCT notified the RN of the above findings and therefore, no RN patient assessment performed at the time of occurrences. MR #8, Start of Care: 1/17/13. Review of treatment sheets 5/21/2025 through 6/2/2025 revealed the following: 5/21/2025: PCT recorded at 6:10 AM, B/P 145/122. There is no documentation of a recheck of the blood pressure and/or no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrence. 5/28/2025: PCT recorded at 8:06 AM, B/P 93/29. There is no documentation of a recheck of the blood pressure and/or no documentation of RN notification of the low blood pressure and therefore, no RN patient assessment performed at the time of occurrences. MR #10, Start of Care: 11/2/2022. Review of treatment sheets 5/23/2025 through 6/4/2025 revealed the following: 5/22/2025: PCT recorded at 2:05 PM, B/P 189/102. PCT recorded at 3:32 PM, B/P 137/110. PCT recorded at 4:01 PM, B/P 182/160. There is no documentation of a recheck of the blood pressure and/or no documentation of RN notification of the high blood pressure and therefore, no RN patient assessment performed at the time of occurrences. An interview conducted with the Facility Administrator and Regional Director of Operations on June 5, 2025, at approximately 1:00 PM confirmed the above findings.”

“POC-PT/FAMILY EDUCATION & TRAINING CFR(s): 494.90(d) The patient care plan must include, as applicable, education and training for patients and family members or caregivers or both, in aspects of the dialysis experience, dialysis management, infection prevention and personal care, home dialysis and self-care, quality of life, rehabilitation, transplantation, and the benefits and risks of various vascular access types. This Standard is not met as evidenced by: 49513 Based on a review of facility policy, medical records (MR), and an interview with the Facility Administrator and the Regional Director of Operations, the facility did not have all quarterly fire drills compeleted per policy for for ten (10) of ten (10) MRs reviewed, (MR # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). Findings include: A review of facility policy titled “ Fire Drill “ conducted on June 5, 2025, at approximately 12:50pm states, “ Fire Drills: Quarterly, all FKV facilities shall perform a fire drill for each shift of patients and staff including Home Therapies patients present in the facility and Nocturnal shifts. “ A review of MRs was conducted on 6/4/2025 from approximately 1:20 PM to 2:00 PM and on 6/5/2025 from approximately 8:45 AM to 10:30 AM. MR # 1 Start of Care: 06/17/23, review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 4th quarter of 2024 quarterly fire drill. MR #2, Start of Care: 11/1/22, review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 4th quarter of 2024 quarterly fire drill. MR#3, Start of Care: 4/29/25, review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 2nd quarter of 2025 quarterly fire drill. MR #4, Start of Care: 5/1/25 (transferred to this facility), review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 2nd quarter of 2025 quarterly fire drill. MR #5 Start of Care: 10/24/2011 review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 4th quarter of 2024 quarterly fire drill. MR #6 Start of Care: 03/26/24 review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 4th quarter of 2024 quarterly fire drill. MR# 7 Start of Care: 05/25/20 review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 4th quarter of 2024 quarterly fire drill. MR #8, Start of Care: 1/7/13, review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 2nd quarter of 2025, 3rd and 4th quarters of 2024 quarterly fire drills. MR #9 Start of Care 10/6/2022, review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 3rd and 4th quarter of 2024 quarterly fire drill. MR #10, Start of Care: 11/2/22, review of quarterly fire drills for the 1st and 2nd quarters of 2025 and the 3rd and 4th quarters of 2024 revealed no documentation of the 4th quarter of 2024 quarterly fire drill. An interview conducted with the Facility Administrator and Regional Director of Operations on June 5, 2025, at approximately 1:00 PM confirmed the above findings.”