PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: Water temperature from 3 sources tested, were all hotter than 49 degrees, on day 1 of the inspection. Discussion with the manager determined, site was working to adjust the water temperatures as they had just installed a new regulator.
Corrective Action(s): Ensure that water accessible to persons in care, is not heated more than 49 degrees.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34610 - RCR s.81(3)(a)(ii) - A care plan must include all of the following: (a) a plan to address (ii) behavioural intervention, if applicable.
Observation: On review of 7 PIC records, it was observed that at least 2 persons in care had a safety plan in place, which was not included on the care plan for those persons in care.
Corrective Action(s): Ensure that each care plan has a plan in place to address behavioral interventions and safely plan information to guide care provided to each person in care.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34650 - RCR s.81(3)(c)(ii) - A care plan must include all of the following: (c) a nutrition plan that (ii) specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets.
Observation: On review of 7 person in care records, at least 3 persons in care had a therapeutic diet information provided by the dietician, that was only included on a list from the dietician, and was not included on the care plan.
Corrective Action(s): Ensure that nutrition plans, including requirements of any therapeutic diet, are included on the care plan for each person in care.
Date to be Corrected: March 10, 2021
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: On review of 7 person in care records and discussion with the manager, it was determined that care plans were not being updated with substantial changes in circumstance, and the site is working to develop an efficient system to communicate substantial changes, and all care plan information to staff, in one place. Currently there are many different areas that staff would need to look to gather information to direct them in providing care to the persons in care.
Corrective Action(s): Ensure that care plans are reviewed and if necessary modified if there is a substantial change in the circumstance of the person in care.
Date to be Corrected:
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: All 7 of the care plans reviewed, and discussion with the manager determined that the care plans/ recovery plans showed last evidence of review or modification in 2019.
Corrective Action(s): Please ensure that each care plan is reviewed and if necessary modified at least once each year.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: On inspection of the dry goods pantry, it was observed that there were a number of bins (10 or more) of dry goods that had been removed from the original packaging and poured into the bins, and while the bins were labelled with the contents, there was no expiry date or date opened included on the bin. Food items include: Rice, oats, flour, pancake mix, etc. It was also observed that a bag of onions, as well as a bag of flour were being stored on the floor. In the fridge where were eggs (provided by a local farm), that were not labelled with the date received or an expiry date.
Corrective Action(s): Please ensure all foods are safely prepared, stored, served and handled.
Date to be Corrected:
MEDICATION: 36140 - RCR s.70(4)(b) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (b) included in the care plan of the person in care.
Observation: Discussion with the manager determined that 4 persons in care self administer medications (with supervision), however the care plans for all 4 persons in care does not have a plan to address self administration of medications.
Corrective Action(s): Please ensure that all persons in care who self administer medications, have a care plan that addresses a plan self administration of medications.
Date to be Corrected:
RECORDS AND REPORTING: 39410 - RCR s.86(a) - A licensee must keep the following records in respect of each employee: (a) criminal record check results,.
Observation: On review of 7 staff files, it was observed that one staff had a copy of a criminal record check addressed to a different work site (not an original from the CRRP), and one other staff person did not have their current criminal record check on file (as the internet was down on day 2 of the inspection, the manager was unable to print the recent CRRP).
Corrective Action(s): Please ensure that criminal record check results are on file for each employee employed at the community care facility.
Date to be Corrected:
RECORDS AND REPORTING: 39420 - RCR s.86(b) - A licensee must keep the following records in respect of each employee: (b) character references.
Observation: On review of 7 staff files it was observed that 2 staff had no references on file, and 3 other staff only had references from 1 source on file.
Corrective Action(s): Please ensure that there are character references (2 or more) on file for each employees, to meet this section of the RCR.
Date to be Corrected:
RECORDS AND REPORTING: 39430 - RCR s.86(c) - A licensee must keep the following records in respect of each employee: (c) compliance with the Province's immunization and tuberculosis control programs.
Observation: On review of 7 staff files, it was observed that one staff did not have any record of TB on file, and for another staff the facility portion of the TB form was incomplete.
Corrective Action(s): Ensure that records of each employee's compliance with the Province's immunization and TB control program, are kept on the employees file.
Date to be Corrected:
RECORDS AND REPORTING: 39440 - RCR s.86(d) - A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Observation: On review of 7 staff files, it was observed that:
-for 2 staff their last performance review was completed in 2018, and one staff person hired in 2019 did not have a performance review on file.
-other information reviewed and noted to have some gaps in information on file include: continuing education, first aid, food safe, and medication transfer of function forms. This was discussed with the manager, and examples provided.
Corrective Action(s): Please ensure records are kept for each employee, including performance reviews, and continuing education.
Date to be Corrected:
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