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: A random review of one person in care's documentation indicated their screening form to when to have a Dietitian involved is from May 2016. In discussion with the Interim Manager there is a schedule and these screening forms are to be done every May of each year. The Interim Manager will review this for all the persons in care.
Menu audits: The Interim Manager stated the previous Manager completed these, however they are not able to locate the documentation. The Interim Manager is in the process of revising the Winter Menu at which time it is finalized, a menu audit will be completed.
Corrective Action(s): Please ensure documentation is reviewed on a regular basis as required.
Please ensure nutrition audits are being completed on a regular basis.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A random review of the medication systems including the medication cupboard, medication fridge, and medication administration records indicated that for one person in care their PRN (as needed) medications for two dates had no charting including effect/result on the back of the medication administration records (Please note: The writer advised the Interim Manager of the two entries including dates, name of the medication and for which person in care). The Interim Manager stated that staff should be according to policy be charting on the back of the medication administration records as to the result/effect for PRNs and that they will follow-up on this.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A review of the fire drills records indicate that they are to be done once a month. Since the Interim Manager has come on board, there is no drill noted for May or July 2017. The Interim Manager advised they will follow-up on this. There are fire drills from the year 2016 not on file, however these were addressed with the previous Manager.
Corrective Action(s): Please ensure that staff ensure that policies and implemented as is required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: A random review of one person in care's documentation indicated a care plan is dated from the year 2014. A phone call was made by the Interim Manager to the Health Resource Nurse and the writer confirmed with the Health Resource Nurse that the care plans for all the persons in care will be updated if no changes and if there are changes, then the familiies/representatives for the persons in care will be consulted prior to finalizing the care plans.
Corrective Action(s): Please ensure all care plans are reviewed and if necessary modified at least once a year.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A random review of the physical plant indicated for one refrigerator in the ktichen, the fridge component does not have a thermometer in it while the freezer component does. The Interim Manager will ensure a thermometer is placed in the fridge component.
Corrective Action(s): Please ensure there are appropriate system(s) in-place to ensure food(s) are safely stored (i.e., at the correct temperature).
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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