Temple Kidney Center

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 43999 Based on facility documentation, observation and staff interviews, the facility failed to comply with applicable State laws and regulations pertaining to licensure and any other relevant health and safety requirements, when the facility did not report hospital transfers or patient deaths to the department within ten working days and did not ensure the registered nurse functioning as charge nurse not be assigned direct care staff. Findings: Review of the facility patient admission/discharge report for January 2024 to August 6, 2025, revealed eight patient deaths with no documentation found for the required report to the department within 10 working days. In staff interviews 8/7/25, it was shared the staff do not report hospital transfers or patients deaths to the state department as required. The last incident report submitted was dated May 15, 2021 by previous management. During review of patient/staff assignments for April 2025 to present the scheduled/assigned charge nurse was providing direct patient care . In an interview with staff # 1 and #5 it was shared the CN is always assigned direct patient care and all other charge responsibilities, there is not a fulltime Charge Nurse at the facility. All eligible charge nurses provide direct patient care. In an interview on 8/7/25 with the FA, staff #1 and DO (Director of Operations) , staff #2 the above findings were confirmed.”

“PR-RECEIVE UNDERSTANDABLE INFORMATION CFR(s): 494.70(a)(2) The patient has the right to- (2) Receive all information in a way that he or she can understand; This Standard is not met as evidenced by: 43999 Based on record review and interview, the facility failed to ensure that patient #1 received all information in a way the patient could understood. Findings: Review of patient #1 medical record revealed no documentation was found that provided education to the patient and/or family concerning complications and other functional status during and after treatments. Interview during record review on 8/7/25 with the FA confirmed the above findings.”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 43999 Based on record review and staff interview, the facility staff failed to initiate patient #1 with an individualized and comprehensive assessment to develop the patient’s treatment plan and expectations for care. Findings: The facility staff could not provide evidence that members of the facility’s interdisciplinary team : social worker and dietitian documented contact with the new patient and/or patient’s family to discuss dialysis therapy during the nine treatment visits. The patient started treatment on 5/29/25 at the facility and was hospitalized multiple times during the first 30 days. An interview conducted with Staff # 1 on 8/7/25 confirmed there was no documentation that the patient or patient’s family member had received information/education to facilitate understanding of the dialysis therapy, associated risks, benefits, and consequences to the patient during the patient’s first nine visits from the social worker or the dietician.”

“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: 43999 Based on observation, record review and interview, the facility staff failed to provide education and training in aspects of the dialysis experience and management, how to prevent or reduce complications and to maximize the patient’s functional status. Findings: Review of patient #1 medical record revealed no documentation was found that provided education to the patient and/or family concerning complications and other functional status during and after treatments. Interview during record review on 8/7/25 with the FA confirmed the above findings.”

“QAPI-INDICATOR-PT SATIS & GRIEVANCES CFR(s): 494.110(a)(2)(viii) The program must include, but not be limited to, the following: (viii) Patient satisfaction and grievances. This Standard is not met as evidenced by: 43999 Based on record review and interview, the facility failed to measure, analyze and track patient #1 satisfaction and grievance in the facility Quality Assessment and Performance Improvement Program. Findings : A review of the facilities complaint reported to facility via Staff # 6, Hospital Liaison, revealed the patient was to be discharged and did not want to return to the facility for dialysis. The complaint/grievance report was initiated but had not been resolved at the time of the survey. In an interview with Staff # 1 & #2 regarding the complaint/grievance the following was revealed: The meeting held 7/11/25 with the patient’s family members provided documentation of the family’s concerns about the patient’s care and the events leading up to the complaint with no identifiable resolution. The FA and DO stated they provided information to the family members and shared the family could sit with the patient during treatment after initiation if they would like. This was thought to be a resolution to the complaint, with no further documentation on the complaint report. In an interview with the patient’s daughter via phone on 8/7/25, it was shared, the staff at the patient meeting did not provide a resolution and they were not provided the name or contact information to speak to the physician. There was no information provided during the meeting in regards to the family concerns for the patient’s care. In am interview with the staff # 1 & #2 on 8/8/25 confirmed the above findings. In an interview with staff #3, Medical Director on 8/13/25 via phone it was confirmed the physician was unaware the patient’s family wanted to speak to him about the patient and he was not invited to attend the family meeting held 7/11/25. The complaint was shared with him initially with no further followup during Quality meetings or when rounding at the facility.”

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 43999 Based on observation, interview and record review, the facility failed to have a full-time registered nurse in charge of nursing who provides supervision and manages care and services of patients and staff in the facility. Findings: There is no supervising nurse identified in the facility and the Facility Administrator (FA), Staff # 1 is not a nurse. The FA splits her time between this facility and another facility over an hour away. In an interview 8/6/25 with the Facility Manager, it was shared the Charge Nurse (CN) assigned daily is the supervising nurse and they also provide direct patient care. A full time CN II has been hired and will be the supervising nurse, a start date was not provided during the interview.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 43999 Based on a review of facility policies, documentation and staff interviews, the facility Medical Director failed to ensure that policies and procedures relative to patient care and safety are adhered to by all individuals who treat patients in the facility. Findings: Review of “ Guidelines for Staff Response during Cardiopulmonary (CPR) Arrest published 11/4/25 partly stated, “Documentation - Document all interventions in the patient ’ s medical record including: - The course of events including medications administered and defibrillation performed by rescue personnel, must be documented on the Cardiopulmonary Arrest Record. - Scan the completed Cardiopulmonary Resuscitation Record form into the patient ’ s electronic record via Doc Manager. Review of documentation for patient #1 revealed the following: In an interview on 8/7/25 with staff #1 & # 2 the above findings were confirmed. There was no CPR Record form completed and no other machine followup performed per policy.”