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: Review of the facility's self monitoring found that audits of the physical facility and care were only conducted in July and August.
Corrective Action(s): Ensure that the physical environment and the care and services provided are regularly monitored.
Date to be Corrected: Sept 9, 2019
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: 15 out of 19 staff reviews have not been completed in the past year.
Corrective Action(s): Ensure that employee appraisals are completed at least once each year.
Date to be Corrected: Sept 23, 2019
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: Review of emergency plan and supplies found that there were no personal items or personal toileting/hygiene items included in the supplies.
Corrective Action(s): Please ensure that emergency supplies, lists, and plans include for a complete provision of care of each PIC in the event of an emergency.
Date to be Corrected: Sept 23, 2019
CARE AND/OR SUPERVISION: 34120 - RCR s.52(1)(a) - A licensee must ensure that a person in care is not, while under the care or supervision of the licensee, subjected to (a) financial abuse, emotional abuse, physical abuse, sexual abuse or neglect as those terms are defined in section 1 of Schedule D.
Observation: Review of all three PICs' finances found the following:
- 1 PIC had to pay for a taxi twice in July.
- Another PIC had to pay for a taxi twice in July and once in June.
Discussion with the current manager found that house van is often in the shop for maintenance and that the previous manager told staff to take taxis with the PICs and for the PICs to have to pay for it.
PICs should not be having to pay for taxis when it is the responsibility of the facility to provide adequate transportation.
Corrective Action(s): Ensure that PICs finances are not used to pay for services that are supposed to be provided by the facility. Please submit a plan for correcting this.
Date to be Corrected: Sept 23, 2019
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: 1 PIC's nutrition care plan was reviewed this year and it was indicated that there were no substantial changes although the PIC had a significant weight gain in the past year that needed to be reviewed.
Corrective Action(s): Please ensure that care plans are accurately reviewed and modified when there are substantial changes.
Date to be Corrected: Sept 23, 2019
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: 1 out of 2 Person in Care (PIC) records reviewed found that there was no record of height and weight at time of admission for 1 of them.
Corrective Action(s): Please ensure that height and weight at the time of admission is recorded.
Date to be Corrected: Sept 23, 2019
RECORDS AND REPORTING: 39160 - RCR s.78(1)(d) - A licensee must keep, for each person in care, a record showing the following information: (d) information by which the person in care may be described or identified in an emergency, including a photograph.
Observation: Both care plans reviewed did not have information to describe the PICs in the case of an emergency.
Corrective Action(s): Please ensure that information to describe each PIC in the event of an emergency is available.
Date to be Corrected: Sept 23, 2019
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 2 PICs' weight records found the following:
- 1 PIC was not weighed in February, March, and July
- The other PIC was not weighed in March and July.
Corrective Action(s): Please ensure that PICs are weighed at least once each month.
Date to be Corrected: Sept 9, 2019
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