cms_DC: 79
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
79 | SERENITY REHABILITATION AND HEALTH CENTER LLC | 95015 | 1380 SOUTHERN AVE SE | WASHINGTON | DC | 20032 | 2018-07-20 | 865 | D | 0 | 1 | L7I811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to develop and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to implement systems to correct identified problems within the facility and anticipate potential problems and develop interventions to prevent their occurrence. Findings included . During the interview on (MONTH) 20, (YEAR), at approximately 2:00 PM, a review of the facility ' s quality assurance and performance improvement (QAPI) program conducted with Employees #1 and 6. The review of the program showed the facility failed to identify concerns, and develop and implement actions plans to correct identified areas of deficient practice in the following areas: The facility failed to implement a Dementia Program to provide person-centered care for residents with the [DIAGNOSES REDACTED]. Failed to establish a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Failed to provide policies and procedures related to water management to inhibit the growth and spread of Legionella. Failed to develop a risk assessment system to identify sites where waterborne pathogens such as Legionella could grow and spread. Failed to implement a water management program to test for, monitor and control Legionella and other waterborne pathogens. The facility failed to provide an environment that was free of pests Failed to implement a system for monitoring the dish machine Employees # 1 and 6 were made aware of the findings at the time of the interview. | 2020-09-01 |