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 review of the care planning system and two persons in care charts indicated the daily record of care documents had in various locations staff initials not documented which was reviewed with the Director of Care (Specifics were provided at the time of the inspection).
Corrective Action(s): Please ensure self monitoring is occuring to ensure the care and services provided by the facility are being met as per the Community Care & Assisted Living Act and pursuant Residential Care Regulation.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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 writer completed a tour of the facility inside and outside and reviewed at random the physical plant. For example, on the 2nd floor by the Recreation Manager's office there is a bottom portion of the wall that is showing white marks (possibly drywall) and the corner of the wall across the Recreation Manager's office a corner protector will be put in-place as the writer was made aware.
Corrective Action(s): Please ensure there is a on-going maintenance plan to ensure maintenance items are addressed as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: A review of four staff files indicated that a staff file did not have references noted on file.
Corrective Action(s): Please ensure staff files have references on file as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of four staff files indicated a staff file did not a copy of the staff's diploma/certificate of education training. For another staff member their professional registration was not current as noted on their personnel file.
Corrective Action(s): Please ensure staff files have copies of any diplomas, certificates or other evidence of the staff's training and skills as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of four staff files indicated that for a staff member the performance appraisal is overdue and the General Manager will follow-up. Specifics provided during the inspection.
Corrective Action(s): Please ensure performance appraisals/reviews occur on a a regular basis.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: A random review of two persons in care charts indicated for one chart the written restraint agreement did not have the Doctor complete their portion.
Corrective Action(s): Please ensure as per section 74 (1)(b)(ii) of the Residential Care Regulation that there is agreement to the use of a restraint given in writing by the medical practitioner.
Date to be Corrected: Please ensure this is in-place for all persons in care where applicable.
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: For example the Corporate and Human Resources policies and procedures reviewed and the policies and procedures are not current/up to date. The General Manager showed the writer more up to date policies and procedures that were received on a USB stick and there are no dates noted except for "modified date" when the document was modified. Please ensure all policies and procedures as per section 85 of the Residential Care Regulation are reviewed and/or revised once a year and that this is documented. For all remainder of policies and procedures there should be a system in-place for review and/or revision.
Corrective Action(s): As per above.
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: Fire Drills are to be completed once a month. There is no fire drill for April 2019. The General Manager explained there was a transition period until a new Maintenance Staff came on board.
First aid kits: For example on the first floor in the medication room states to check the kit once a month and there is only one month checked for January (assuming for 2019).
Corrective Action(s): Please ensure fire drills are completed as per protocol/policy.
Please ensure first aid kits are checked as per protocol.
Date to be Corrected: Please provide a written response to these items by the timeline noted in this report.
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A random review of four staff files indicated for a staff member the tuberculosis clearance and immunizations were not noted on file. A random review of volunteer files indicated a volunteer did not have tuberculosis clearance on file. The writer will email the Community Care Facilities Licensing Tuberculosis and Immunization Guideline for Staff/Volunteers to the General Manager.
Corrective Action(s): Please ensure staff have tuberculosis clearance and immunizations on file where required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Nutrition audits could not be found at the time of the inspection.
Corrective Action(s): Please ensure a nutrition audits schedule is developed and audits completed accordingly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39480 - RCR s.87(d) - A licensee must keep a record of the following matters respecting food services: (d) food services and nutrition care education and training programs attended by food services employees.
Observation: At the time of the inspection the records pertaining to food services/nutrition care education could not be found.
Corrective Action(s): Please ensure there is a education schedule developed for the dietary staff for the entire year and records kept accordingly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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