STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: Staff file systems were reviewed and indicated a staff file did not have references noted.
Corrective Action(s): Please ensure staff files have references noted where required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A review of one of the medication rooms indicated that several entries on the back of the narcotic medication was not initialed for by staff (two initials per entry are required). The specifics were discussed with the Management who will follow-up.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response by the timeline noted in this report.
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: In discussion with Management, the writer was advised that fire drills are to be completed on a monthly basis. In review of the fire drills binder, the writer was not able to see a fire drill for the following months, for example:
*January 2020, April 2020, May 2020, June 2020, July 2020, August 2020, September 2020 or December 2020
*February, and March 2021
Corrective Action(s): A discussion took place with Management and a recommendation to contact the Fire Department as to how often fire drills should be completed.
Date to be Corrected: Please ensure all staff are implementing policies and procedures.
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: A recreation care plan was not in-place as discussed with Management.
Corrective Action(s): Please ensure all persons in care have a recreation care plan in-place.
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: There is a weight not documented as discussed with Management.
Corrective Action(s): Please ensure weights are documented monthly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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