PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31090 - RCR s.16(3) - A licensee must ensure that the lighting, both natural and artificial, and temperature of a room intended for the private use of a person in care meets the needs and preferences of that person.
Observation: It was observed in 3 of the 4 bedrooms inspected, the temperatures were noticeably cooler than in the hallway. The patient care coordinator had indicated that here have been several complaints made by the persons in care.
Corrective Action(s): Ensure the temperature of a room intended for the private use of a person in care meets their needs and preferences.
Date to be Corrected: 28 Feb 2019
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Upon review of 4 staff files, 2 were found to be missing evidence of the person complying with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Ensure all staff files include evidence of complying with the Province's immunization and tuberculosis control programs.
Date to be Corrected: 28 Feb 2019
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: Of 4 staff files reviewed, 2 did not include completed performance reviews
Corrective Action(s): Ensure the performance of all employees is reviewed regularly to ensure the employee demonstrates the competence for the duties for which they are assigned.
Date to be Corrected: 28 Feb 2019
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Review of 4 person in care's record found they did not include evidence to demonstrate they have complied with the Province's immunization and tuberculosis control programs. Upon admission staff do note on the Kardex that the person in care does not show signs and symptoms of tuberculosis. This does not provide adequate information to comply with the control programs.
Corrective Action(s): This has been corrected. The TB screeening form and immunization screening forms have been added to the admission package.
Date to be Corrected:
MEDICATION: 36010 - RCR s.68(1)(a) - A licensee must appoint a medication safety and advisory committee consisting of at least the following persons: (a) the manager or a person designated by the manager.
Observation: This facility does not have a medication safety and advisory committee.
Corrective Action(s): The Licensee must appoint a medication safety and advisory committee consisting of at least the following persons: a manager, or person designated by the manager, the supervising pharmacist, and a health care provider responsible for the immediate supervision of health care services in the facility.
Date to be Corrected: 22 Feb 2019
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