PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: The garage and storage room appeared untidy and not well organized. Of concern were food items stored with cleaning supplies, unused medical equipment cluttering the garage, and a lack of cleanliness in these areas.
Corrective Action(s): Ensure storage practices are safe and ordered to allow the areas to be maintained in a clean condition.
Date to be Corrected: 12 Oct 2018
STAFFING: 32080 - RCR s.37(2)(c) - A licensee must not employ a person in a community care facility unless the licensee is satisfied, based on the information available to the licensee under subsection (1), that the person (c) has the training and experience and demonstrates the skills necessary to carry out the duties assigned to the manager or employee.
Observation: Evidence for this contravention was gathered from the Manager’s performance review, the Licensee Declaration form, and observations during this inspection.
The Licensee Declaration form indicates the skills and competencies possessed by the Manager being put forth. Included in this list is knowledge of, and ability to, interpret and apply legislation and policies. During the inspection the Manager was unable to demonstrate a comprehensive knowledge of the legislation as he was unsure what the requirements are and as such was unable to provide certain documentation requested by the Licensing Officer. Examples of this would include all Policies and Procedures required by Residential Care Licensing Regulation.
The Manager’s list of demonstrated skills and abilities was listed on the Declaration Form. Indicated was the oversight and monitoring of individual’s finances. The Manager has been unable to demonstrate this has the reconciliation of cash and receipts have not been signed off on since March 2018, when it is required monthly.
Corrective Action(s): Please submit a detailed action plan of how Opportunities for Growth and Development and the requirements of the Licensee Declaration form are going to be addressed to ensure the Manager has the training and experience and demonstrates the skills necessary to carry out all assigned duties. Please also include what supports will be in place until this occurs.
Date to be Corrected: 12 Oct 2018
STAFFING: 32081 - RCR s.37(3)(a) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (a) a criminal record check for the person;
Observation: Volunteer file was reviewed and the criminal record check was no longer valid as it had expired 30 Jun 2016..
Corrective Action(s): Ensure all volunteers have current criminal record checks in their files.
Date to be Corrected: 12 Oct 2018
POLICIES AND PROCEDURES: 33240 - RCR s.85(1)(c)(i) - A licensee must do all of the following: (c) make all policies and procedures available (i) to employees at all times.
Observation: The manager was unable to provide for review, all policies and procedures required by Licensing. Of concern is they are not readily available to staff.
Corrective Action(s): Ensure all policies and procedures, Sec 85 (1)(a)(b)(c)(d)(e)(f)(g)(h)(i)(j)(k)(l) of Residential Care Licensing Regulation are available to all employees.
Date to be Corrected: 05 Oct 2018
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 2 PIC files were found to be missing consent in writing to call a medical practitioner, nurse practitioner, or an ambulance in the case of an emergency.
Corrective Action(s): Ensure each person in care has in their record consent to call a medical practitioner, nurse practitioner, or an ambulance in case of emergency.
Date to be Corrected: 12 Oct 2018
RECORDS AND REPORTING: 39570 - RCR s.90(1) - A licensee must maintain separate financial records for each community care facility, made in accordance with generally accepted accounting practices.
Observation: Review of financial records of PIC indicated that monitoring of all PIC cash and receipts was not completed during the past 4 months. Discussion with the manager and the assistant indicated that this should be completed monthly. The manager last signed off on a completed reconciliation of cash and receipts in March 2018.
Corrective Action(s): Submit a plan to Licensing that outlines how monthly reconciliation of cash and receipts will occur and what procedures will be in place to have appropriate checks in place to ensure compliance.
Date to be Corrected: 05 Oct 2018
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