PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Upon observation of the physical facility it was noted that dishwasher was not operational and had old soap and dishes loaded.
Corrective Action(s): Please ensure that dishwasher is operational so that proper cleaning and sanitization is maintained for kitchen utensils
Date to be Corrected: February 14th, 2020
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Upon inspection of the physical facility it was noted that 4 PICs' (Person in Care) bedroom doors had many scratches on the paint. There were paint peel off observed on the walls of common areas as well.
Corrective Action(s): Ensure that rooms and common areas are maintained in good state of repair.
Date to be Corrected: February 14th, 2020
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: Restraints are used for preventative measures to ensure PIC’s safety. No PIC consents were found on file.
Corrective Action(s): Please ensure that the agreement(s) for the use of restraint is signed by the PIC or the relative who is closest to and involved in the life of the person in care
Date to be Corrected: February 14th 2020
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: : No Physician or Nurse practitioner approval is in place for the restraints.
Corrective Action(s): Ensure that for PIC’s who need on-going restraint have the agreement for the use of restraint signed by the medical practitioner or nurse practitioner responsible for the health of the person in care
Date to be Corrected: February 14th, 2020
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: Upon observation of 3 PIC files, it was noted that 1 PIC had major recreational activity listed as music but this was not evidenced in the monthly activity plan and there was no activity planned for Thursdays and Fridays for the entire month of January for the same PIC. Per Manager plan is ready with HSCL.
Corrective Action(s): Please ensure that care plan is monitored and implemented properly by staff.
Date to be Corrected: February 14th, 2020
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: 3 PICs file review found that Personal Care Plan documents were not reviewed annually. Per Manager the plan is revised but still with HSCL.
Corrective Action(s): Please ensure that personal care plans are reviewed annually and is current.
Date to be Corrected: February 14th, 2020.
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation (CORRECTED DURING INSPECTION): It was observed that a bag containing edible food was stored on the floor of the pantry closet across the kitchen entrance.
Corrective Action(s): Please ensure that food items are safely stored on the shelves
Date to be Corrected:
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Observation of the substitution list found that menu substituted twice were not from same food group
Corrective Action(s): Ensure that all menu substitution is documented clearly identifying the similar food groups.
Date to be Corrected: February 14th, 2020
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