LICENSING: 30020 - RCR s.8(2)(a)(i) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (i) plans for the change.
Observation (CORRECTED DURING INSPECTION): At the arrival to facility, it was observed the facility tub room had been cordoned off and sounds of construction present. Staff informed LO the tub room was currently being renovated and had started on January 31, 2022, with a completion date of February 14, 2022. No renovation plan or health and safety plan had previously been provided to LO nor had approval been provided to the facility.
Corrective Action(s): Ensure there is a plan for changes of the facility, and a health and safety plan provided to the LO and receipt of approval by same.
Date to be Corrected: February 8, 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: The following was noted during inspection:
-Upon review of five person in care's MARs, there were three MARs which showed no evidence of documentation of PRN medication effectiveness,14 missing responses in one, 16 missing responses in a second, and 19 missing responses in a third, over a two month period.
-There were two instances where the MAR book was left open with confidential information present and the staff had walked away from the med cart.
Corrective Action(s): Ensure all employees are implementing facility policies.
Date to be Corrected: Feb 28, 2022
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: Upon review of five person in care's charts, one person in care's chart showed missing responses of safety checks completed, as per person in care's care plan requirements.
Corrective Action(s): Ensure all employees are implementing care plans as written.
Date to be Corrected: February 9, 2022
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: A review of five person in care's Care Plans showed one person in care's care plan was not consistent in areas information is provided.
Corrective Action(s): Ensure all care plans reviewed and modified consistently.
Date to be Corrected: February 28, 2022
MEDICATION: 36090 - RCR s.69(2) - A licensee must ensure that, except as authorized by the medication safety and advisory committee, a person in care's medications remain in the original labelled container or package provided by the dispensing pharmacy until administered.
Observation (CORRECTED DURING INSPECTION): Within the medication room, there were 6 medications in their original packaging, but no pharmacy label found.
Corrective Action(s): Ensure all medications are labelled and provided by the pharmacist.
Date to be Corrected: February 8, 2022
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