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 random review of 1 person in care's records/chart indicated:
- The Menu checklist is not fully completed (A sample menu checklist that is completed with the date of July 10, 2008 with page 1 prefilled with all the answers as yes is noted and page 2 of the checklist, yes is checked off for all the categories noted). There is no current date as to when the menu checklist was completed and it is not complete.
- Resident Satisfaction Survey on one page is noted with n/a (not applicable) and on a second document for resident satisfaction survey is noted with some things documented, but no actual date of the survey. The Manager stated she will be discussing with the staff to put in the reasoning why something is n/a.
Corrective Action(s): Please ensure you are self monitoring to ensure documentation is thorough and complete.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A review of the staff checklist indicated for one staff their criminal record check is not checked off. The Manager stated that they review a staff's documentation prior to starting employment.
Corrective Action(s): Please ensure the staff checklist is updated to ensure the criminal record check is in-place.
Date to be Corrected: Please provide a written response to this item 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 review of the staff checklist indicated one staff is not noted with tuberculosis checked off on the checklist. The Manager stated they review all the documentation and that the staff would have this in-place prior to starting employment.
A review of the staff checklist indicated for one staff their immunizations are not checked off on the checklist. The Manager stated they review all the documentation and that the staff would have this in-place prior to starting employment.
Corrective Action(s): Please ensure all legislative required staffing documentation is documented where required for all the staff.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: A random review of one person in care's chart indicated that the weight for May and June 2017 are not documented on Sharevision (computerized system).
Corrective Action(s): Please ensure monthly weights are recorded for all persons in care. If a weight is not documented, please ensure it is documented as to why the weight was not taken.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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