STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Review of 3 staff files determined that 3 of 3 staff have Criminal Record Checks(CRCs) completed through the RCMP, this is not the manner in which the MHO requires that CRCs are completed. CRCs must be conducted through the provincial Criminal Record Review Program(CRRP) under the ministry of Public Safety and Solicitor General.
Corrective Action(s): Please ensure that a criminal record check is obtained for staff, in the manner required by the MHO.
Date to be Corrected: November 3, 2022
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: During review of documents there was no evidence of fire drills completed since May 31, 2022. The sites fire safety/emergency preparedness policy requires drills to be completed monthly.
Corrective Action(s): Please ensure that policies are implemented by employees.
Date to be Corrected: November 3, 2022
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection 77(3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Noted during inspection that Reportable Incidents have not been reported to CCFL since May 31, 2022 .
Corrective Action(s): Please ensure that the medical health officer is notified, in the form and manner required, if a person in care is involved in a reportable incident.
Date to be Corrected: November 3, 2022
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