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Bishop Gadsden’s DHEC Certification: How It Works, What It Means, and How We Did It

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As a Medicare Certified Community, Bishop Gadsden’s Read Cloister Skilled Nursing is inspected by South Carolina’s Department of Health and Environmental Control (DHEC), in accordance with the strict guidelines administered by the Centers for Medicare and Medicaid Services. Preparation for the unannounced inspections is a constant, daily effort by the Read Cloister Skilled Nursing Team to ensure we maintain the highest of standards in our Skilled Nursing area.

The Survey

At a minimum, the inspections are conducted on an annual basis. This year, Read Cloister has had a total of four surveys. Read Cloister Skilled Nursing was surveyed three times for a one-day, infection control survey related to COVID-19 pandemic, and the last survey was an annual three-day survey. All four of the surveys were deficiency-free

The term “deficiency-free” means during the inspection, surveyors found zero deficiencies in care, services, or the physical environment. These surveys evaluate different aspects of Read Cloister such as resident care, quality of life, compliance with policies and procedures, medication administration, compliance with maintaining medical records, kitchen sanitation, team member competencies, resident and team member safety, resident dietary needs, resident rights, and the overall satisfaction of the residents and their families.

It’s a Team Effort

Deficiency-free surveys are not typical. They indicate the facility is providing services that meet or exceed all of the federal and state regulations and standards. These types of results are not achievable without the help of an incredible team. This includes everyone from nursing to administration to environmental services to culinary.

The Read Cloister team treats each day as if DHEC is going to walk through the door. They are continuously preparing aspects such as implementing policies that promote quality care, resident rights, and compliance with the regulations; conduct daily rounds, focus on exceeding standards in the physical environment, ensure compliance with infection control guidelines; and random medication administration observation.

Education is Key

“Education, education, education,” said Director of Health Services Jonna Cook. She continued, “Our Staff Clinical Educator focuses on ensuring that all of our team members are competent and up-to-date with the latest guidelines for care.”

In addition to the continuous education, the Read Cloister team also works through risk meetings which provide an opportunity to identify potential risks in various areas. Identifying potential risks helps the Read Cloister team keep a focus on quality assurance and performance improvement to ensure we are continually working to identify opportunities for improvement and to then develop a plan to do so.

The Read Cloister team regularly communicates with residents and family members to assist with issues, complaints, and help maintain the utmost quality of life in the safest atmosphere as possible. The deficiency-free certification was not completed without the collaboration of the Bishop Gadsden Community. We are so grateful for this team and their dedication to the BG Way.

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