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: The policies and procedures required as per section 85 of the residential care regulation have not been reviewed and/or revised. The Manager will ensure this takes place for the entire building for the hospice and long term care components.
Corrective Action(s): Please ensure the policies and procedures required by section 85 of the residential care regulation are reviewed and/or revised once a year and that this is documented so it is evident.
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.
CARE AND/OR SUPERVISION: 34360 - RCR s.63(3)(c)(iii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iii) approved by the person in care's medical practitioner or nurse practitioner.
Observation (CORRECTED DURING INSPECTION): A review of the persons in care charts indicated the medical practitioner had not been approved (signed off) for on-going tray service.
Corrective Action(s): Please ensure the medical practitioner or nurse practitioner approve on-going tray service and that this is reassessed every 30 days thereafter for example by a Dietitian.
Date to be Corrected: This was correct at the time of the routine inspection.
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: For the hospice program, immunizations and tuberculosis clearance is not on the persons in care files. The writer emailed the Tuberculsosis and Immunization Guideline for persons in care on May 28, 2021 to the Manager and the Hospice Team Lead.
Corrective Action(s): Please ensure this is implemented immediately.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: For the long term care floors a random review of the persons in care charts indicated that some weights were not documented on a monthly basis (Specifics provided during the routine inspection).
Corrective Action(s): Please ensure that each person in care is weighed at least once each month. If there is a reason a weight is not taken, please document this (e.g., weight scale is functioning, etc).
Date to be Corrected: Please provide a written response to this item by the response timeline noted in this report.
RECORDS AND REPORTING: 39480 - RCR s.87(d) - A licensee must keep a record of the following matters respecting food services: (d) food services and nutrition care education and training programs attended by food services employees.
Observation: Currently there is no formal education around food services and nutritioncare provided for food service employees, and there is no documentation around this as well. The writer e-mailed to the Manager on May 28, 2021 sample education schedules to guide the management at the site to develop their own schedule(s).
Corrective Action(s): Please ensure a record of the following matters respecting food services is kept:
- food services and nutrition care education and training programs attended by food services employees.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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