LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: While some improvements in systems have been noted, there are still some systems of monitoring that have not been implemented, which potentially place the health and safety of persons in care at risk. This was discussed with management during the inspection.
Corrective Action(s): Please provide an updated plan regarding a plan for monitoring the environment of the community care facility, and the care and services provided by it.
Date to be Corrected: Please submit plan by October 22, 2021
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Review of a checklist of performance evaluations found that there are a number of performance reviews overdue.
Corrective Action(s): Ensure performance reviews are completed regularly to ensure that the employee continues to meet the requirements of this regulation.
Date to be Corrected: Please submit a plan by October 22, 2021
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: On review of 5 person in care records, the following was found:
-3 persons in care had incomplete or missing immunization records
-2 persons in care had incomplete or missing TB records
Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Province's immunization and TB control program.
Date to be Corrected: October 22, 2021
MEDICATION: 36070 - RCR s.69(1)(a) - A licensee must ensure that a pharmacist (a) packages all medications.
Observation: Review of the medication room found that 2 medications did not have a pharmacy label affixed.
Corrective Action(s): Ensure that a pharmacist packages all medications.
Date to be Corrected: immediately
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: Review of the July, August, and September monthly weights found that, weights were missing for 3 or more persons in care each month, and there was no reason for the missing weights documented.
Corrective Action(s): Ensure that each person in care is weighed at least once each month.
Date to be Corrected: October 22, 2021
RECORDS AND REPORTING: 39430 - RCR s.86(c) - A licensee must keep the following records in respect of each employee: (c) compliance with the Province's immunization and tuberculosis control programs.
Observation: Review of 3 staff files found that for one staff member there was no record of immunization.
Corrective Action(s): Ensure each employee complies with the Province's immunization and TB control program.
Date to be Corrected: October 22, 2021
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Staff at the facility were unable to locate menu audits during the inspection. It was explained that they may not have been completed for the current menus. This is was contravened on the routine inspection in March, and again on the follow-up inspection in May, 2021.
Corrective Action(s): Ensure that there are menu audits that correspond with each of the 4 weeks of the spring/summer menus, and each of the 4 weeks of fall/winter menus.
Date to be Corrected: Please submit a plan for correction to licensing by October 22nd, 2021.
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