STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Review of 5 staff files found that 1 staff did not have a current criminal record check on file (previous one expired in 2017).
Corrective Action(s): Ensure that all staff have current criminal record check on file as per regulation.
Date to be Corrected: February 26 2020
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 were observed:
1) Review of 2 files of PIC with wounds found that wound assessment and flow sheets are incomplete.
2) A review of 6 PIC files found that all 6 had admission checklists with missing signatures, dates and nursing assessment information.
Corrective Action(s): Ensure that staff follow and implement the policy and procedures of the facility.
Date to be Corrected: February 26 2020
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: A review of the wound care binders found the following:
1) 1 PIC's file had incomplete documentation regarding wound care being provided (e.g. dates on photographs, goal or treatment, start dates of treatment).
2) 1 PIC's file had inconsistency with the frequency of the wound treatment plan being implemented.
Corrective Action(s): The facility had a Quality Assurance Clinical Review conducted in October 2019. During this review issues were also identified with wound care. As a result the facility has created a thorough action plan (see comment box below for more details). Please ensure that care and supervision are consistent and care plans are followed with evidence of proper documentation and that the action plan created is implemented and completed.
Date to be Corrected: January 31 2020
RECORDS AND REPORTING: 39160 - RCR s.78(1)(d) - A licensee must keep, for each person in care, a record showing the following information: (d) information by which the person in care may be described or identified in an emergency, including a photograph.
Observation: A review of 2 PICs' files with Wander Alert found no additional information that can be used in case of a missing person incident.
Corrective Action(s): Ensure that there is detailed information to describe or identify the PIC in the event of an emergency.
Date to be Corrected: December 23 2019
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: A review of the attendance for workshops and continuing education series noted missing signatures for staff who were listed on the attendance sheet.
Corrective Action(s): Ensure that all staff sign in to confirm attendance at education and trainings sessions.
Date to be Corrected: February 26 2020
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