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: Menu Substitution Tracking Form and Audit indicates that Part B (Standards Met) of the Audit portion was not completed for the 7 substitutions,
Corrective Action(s): Please ensure evidence of regular monitoring ( Menu Audit) is completed
Date to be Corrected: July 30, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The Game room area located in the Pioneer Program has a lower corner wall section where plaster has come off.
Corrective Action(s): Please ensure that all common areas are in a good state of repair
Date to be Corrected: July 30, 2021
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Policy regarding the frequency and process for performance evaluation was unavailable. Management could not provide information regarding how often an employee performance evaluation is completed. Review of Staff files indicates that there was a gap of 2.5 years between the last two completed evaluations (2016, 2019)
Corrective Action(s): Please ensure Policy is developed and followed for employee performance evaluation
Date to be Corrected: July 30, 2021
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: Due to the current COVID Pandemic, both the CRESST and Pioneer program smoking Policy has not been in place. The PIC are not using the designated smoking area, but rather are smoking close proximity to the front entrance. This practice is also concern regarding the tobacco fumes entering into the building.
Corrective Action(s): Please ensure the the Policies and Procedures are implemented by the employees
Date to be Corrected: July 9, 2021
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Menu Substitution Tracking form has the following substitution: Grilled Cheese sandwich was substituted with French Toast.
Corrective Action(s): Please ensure that substitutions are made from the same food group.
Date to be Corrected: July 30, 2021
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: A snack menu is not available. The facility provides regular snack items that are provided everyday. Prior to COVID, the PIC were able to access the snack items throughout the day, the current practice is staff fill provide the requested snack items to the PIC.
Corrective Action(s): Please ensure snack menu is available that includes the following: at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Date to be Corrected: July 19, 2021
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