During this inspection, the Licensing Officer met with the Director and the new Facility Supervisor. The following was reviewed and discussed:
- Licensing – self-monitoring
A self-monitoring system has been implemented, with records available to review
- Physical Facility, Equipment and Furnishings – staff smoking on site
A corresponding policy has been developed, staff have been formally advised.
- Staffing – new management, approved staffing hours
A new manager has been hired and orientated as of September 2016. The funder has approved staffing hours.
- Policies and procedures – medication safety and advisory committee, policy availability and review, audits, implementation
Systems have been implemented to ensure all outstanding items are addressed.
- Care and Supervision – care plans, nutrition plan
Systems have been implemented to ensure outstanding items are addressed.
- Hygiene and Communicable Disease – food safety
Compliance plan submitted will be monitored by the manager
- Medication – medication records
A new pharmacist has been hired to ensure compliance to the regulations and Schedule F of Pharmacy Act.
- Records and Reporting – care plan.
Updates have been made to systems, compliance will be monitored by management
This report was reviewed and discussed with the Supervisor and Director for this site. All previous contraventions appear to have been addressed appropriately |