STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Four staff file information was reviewed, two of the staff did not have their yearly performance evaluation. One was completed in 2015 while the other was due in 2020. The Licensee's requirement is for the performance evaluation to be completed on a yearly basis.
Corrective Action(s): Please ensure regular perfomance evaluation is completed to ensure competence for their duties.
Date to be Corrected: October 12, 2021
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: The effectiveness of a PRN for a PIC is not recorded, which is a requirement in the Medication Safety and Advisory Committee Policy. The administration of the PRN is documented in the PIC care plan.
Corrective Action(s): Please ensure the Medication Safety and Advisory Committee Policy and Procedure is followed, which includes recording the information on the MAR.
Date to be Corrected: August 31, 2021
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: Based on review of the facilities Policies and Procedures, 2 Policies were last reviewed on January 2020.
Corrective Action(s): Please ensure all Policies and Procedures are reviewed yearly and if required revised.
Date to be Corrected: September 17, 2021
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: The menu contains examples where the snacks do not contain at least 2 food groups from the Canada Food Guide.
Corrective Action(s): Please ensure at least 2 nutritious snacks contain at least 2 food groups from the Canada Food Guide.
Date to be Corrected: September 8, 2021
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