LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: Licensing received the appropriate documentation that there had been a change in manager, but it wasn't filled out correctly. Licensing contacted the manager and the licensee contact and discussed it. Licensing sent the licensee contact an email about a month later reminder them to send in the corrected documentation. Licensing has still not received it.
Corrective Action(s): Please ensure that licensing is notified of manager resignation within 30 days.
Date to be Corrected: November 28, 2016
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation (CORRECTED DURING INSPECTION): Review of the facility found the following:
- One of the outside patios had a loose tile.
- Review of the fridge and freezer found pancakes and Popsicles out of the box that were not labelled.
- Two salad dressings in the pantry which had expired in April and October of 2016.
Corrective Action(s): Please ensure that the licensee regularly monitors the physical environment of the facility and the care and services provided by it.
Date to be Corrected: December 12, 2016
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Review of the employee checklist and conversation with the manager determined that there is not a record of immunization for employees.
Corrective Action(s): Please ensure that employees comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: December 12, 2016
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: A review of 3 Persons in Care (PIC) wound care charts found that the wounds had not been checked for the following amount of days:
- 1 PIC's had not been checked for 5 days.
- Another PIC's had not been for 10 days.
- Another PIC's had not been for 5 days.
Discussion with staff determined that the nurses had been checking the wounds daily, but had not been charting it in the wound care chart and that it should be documented on the chart.
Corrective Action(s): Please ensure that a care plan is monitored on a regular basis to ensure implemented.
Date to be Corrected: November 23, 2016
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: 1 out of 3 PICs' care plans reviewed showed that 1 PIC had been using a cane for mobility. Discussion with staff determined that this PIC is now using a wheelchair, but that it has not been updated on the care plan.
Corrective Action(s): Please ensure that care plans are reviewed and if necessary modified if there is a substantial change in the PIC's care.
Date to be Corrected: December 12, 2016.
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