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: The staff file of the new house leader (manager) was reviewed for performance review. The House leader has been in her role since the beginning of August. When questioned about when her performance appraisal was due, she indicated that is was scheduled for December 1, but had not occurred. The documentation in her file indicated that the review had taken place on Dec.1, 2016 and it had "passed".
Corrective Action(s): Please provide a plan that will reflect performance reviews of Nazirah staff completed in a timely manner as per policy and that the documentation is an accurate reflection of the performance review.
Date to be Corrected: Dec. 19. 2016
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Fire drill reports for April, May and June could not be located. the facility policy could not be found to provide direction for the frequency of fire drill practices.
Corrective Action(s): Please provide a plan that will ensure there is direction for the frequency of fire drills to be conducted and will ensure regular fire and disaster training as per facility policy is carried out.
Date to be Corrected: Dec. 19, 2016
RECORDS AND REPORTING: 39280 - RCR s.79(2) - A licensee must issue or get a receipt, as applicable, for the matters described in subsection (1).
Observation: Review of one PIC's financial records was conducted. The reconciliation record was consistent with the cash remaining in the wallet with the exception of an envelope of American money. The house leader stated this money was held for safe keeping for the PIC. The house leader stated that there was no receipt provided to the PIC at the time of receipt of the money and she did not know how much money should have been in the envelope. The records were not available to review as the person who manages the PICs' money is away until the end of December, and were not available to the house leader.
Corrective Action(s): Please ensure that there is a system in place to ensure that receipts are issued to PIC's for valuables entrusted for safekeeping, and that all financial records are maintained in a way that they can be inspected by licensing at any time.
Date to be Corrected: Dec. 19, 2016
RECORDS AND REPORTING: 39520 - RCR s.89(1) - A licensee must keep a record respecting complaints made and concerns expressed to the licensee under section 60 [dispute resolution], and the responses to them.
Observation: No records of complaints, concerns, and responses is kept by the manager. It was stated that concerns, complaints and the responses were managed in staff meetings, and kept in the minutes of staff meetings.
Corrective Action(s): While recording in staff meeting minutes essentially meets the intent of the regulation it does not provide a means to retrieve the record in a timely fashion should any further enquiry need to take place. Please provide a plan that will ensure that the records of resolution for concerns, complaints and disputes can be easily located for review and are available to demonstrate trending of complaints.
Date to be Corrected: Dec. 19, 2016
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