STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: The facility's clinical manager informed the Licensing Officer that not all of the employees' performance reviews have been completed annually, as required. This is a REPEAT CONTRAVENTION.
Corrective Action(s): Please ensure that the performance of each employee is reviewed to ensure the requirements of the regulation continue to be met.
Date to be Corrected: August 26, 2022
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Review of emergency plan training found that the last training/drill was in June 2021 and it was a code red/fire drill. There was no evidence to support more recent training or training to capture other emergencies, including procedures for the evacuation of persons in care. This is a REPEAT CONTRAVENTION
Corrective Action(s): Ensure that each employee is trained in the implementation of emergency plans including procedures to prepare for, mitigate, respond to and recover from.
Date to be Corrected: August 26, 2022
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Review of 4 Person on care's medication administration records found there to be numerous entries where the effectiveness of PRN medication was not documented. Of approximately 35 administered medications, there were only 23 documented responses of medication effectiveness. This is a REPEAT CONTRAVENTION.
Corrective Action(s): Ensure that all facility policies are implemented, including medication administration policies.
Date to be Corrected: August 26, 2022
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Upon inspection of the spa room, 2 sets of nail clippers were observed to be not labelled for use of a specific person in care (PIC). nor were there any available instructions or means to disinfect between uses. Of concern is the potential for contamination between PICs.
Corrective Action(s): Ensure there is a program in place to assist persons in care in maintaining health and hygiene.
Date to be Corrected: August 26, 2022
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