STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Of 7 staff files reviewed, one person did not have evidence of a current first aid certificate on file.
Corrective Action(s): Ensure the facility keeps records of current certificates, or other evidence of a persons training and skills.
Date to be Corrected:
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: Of 7 staff files reviewed, 2 staff did not have a recent performance review, in accordance with the facility's performance review policy.
Corrective Action(s): Ensure the performance of each employee is reviewed regularly, and following the facility's policy for the required timeline.
Date to be Corrected:
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 facility's fall policy, requires all persons in care to have universal fall precautions in place, if they haven't been deemed a falls risk. Care plans did not include universal fall precautions, as per the facility policy.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Though persons in care/ their representatives had given consent to receive an annual dental examination, there was no documentation available to demonstrate the last time persons in care had been seen by a dental health care professional.
Corrective Action(s): Ensure persons in care are encouraged to be examined by a dental health care professional at least once every year.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Of 5 people in care reviewed, 2 had incomplete immunization records, and one had no immunization record included in their chart.
Corrective Action(s): Ensure all persons admitted to a community care facility comply wit the Province's immunization and TB control program.
Date to be Corrected:
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection 83(5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: Review of 5 people in care found that 4 of 5 had missing monthly weights for 2021, for anywhere between 2-6 months.
Corrective Action(s): Ensure that each person in care is weighed at least once each month. If a person is unable to be weighted, document a reason why the person was not weighed.
Date to be Corrected:
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