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: Upon review of 6 employee files, 3 did not contain evidence of completed criminal record checks.
Corrective Action(s): Please ensure that all employees have on file a completed criminal record check as required.
Date to be Corrected: March 20, 2020
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Upon review of 6 employee files, all 6 were found to be missing evidence of the person complying with the Province's immunization and tuberculosis control programs. This is a repeat contravention.
Corrective Action(s): Please ensure that all staff files include evidence of complying with the Province's immunization and tuberculosis control program.
Date to be Corrected: March 20, 2020
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: Upon review of 6 employee files, 4 did not contain evidence of completed performance reviews. This is a repeat contravention.
Corrective Action(s): Please ensure the performance of all employees is reviewed regularly to ensure the employee demonstrates the competence for the duties for which they are assigned.
Date to be Corrected:
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: Upon review of 6 employee files, 3 did not have evidence of valid first aid and CPR certificate.
Corrective Action(s): Please ensure that persons in care have at all times immediate access to an employee who has valid first aid and CPR.
Date to be Corrected: March 20, 2020
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: Upon review of 3 clients Medication Administration Records it was observed that several PRN medications did not have documented follow up to note the effectiveness after administration. Facility states that it is the policy to complete this action.
Corrective Action(s): Please ensure that all PRN medications administered to clients have documented evidence to demonstrate it's effectiveness as per policy.
Date to be Corrected: March 20, 2020
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: Upon review of 5 client charts, all 5 did not contain completed evidence to demonstrate they have complied with the Province's immunization and tuberculosis control programs. Screening forms were incomplete. Upon admission staff do note on the Kardex that the person in care does not show signs and symptoms of tuberculosis. this does not provide adequate information to comply with the control programs. This is a repeat contravention.
Corrective Action(s): Please ensure that all persons admitted into care comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: March 20, 2020
MEDICATION: 36010 - RCR s.68(1)(a) - A licensee must appoint a medication safety and advisory committee consisting of at least the following persons: (a) the manager or a person designated by the manager.
Observation: The facility reports that it does not have a active medication safety and advisory committee. This is a repeat contravention
Corrective Action(s): The licensee must appoint a medication safety and advisory committee consisting of at least the following persons: a manger or person designated by the manager, the supervising pharmacist, and a health care provider responsible for the immediate supervision of health care services in the facility.
Date to be Corrected: March 20, 2020
NUTRITION AND FOOD SERVICES: 37030 - RCR s.62(2)(a) - A licensee must ensure that each menu provides (a) for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada's Food Guide.
Observation: Discussion with facility determined that there are no audits completed for the menus. This is a repeat contravention
Corrective Action(s): Pleas ensure that there is evidence of the menus meeting the minimum nutrition requirements as outline in Canada's Food Guide.
Date to be Corrected: March 20, 2020
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: 1 person in care has been admitted into the facility longer than 30 days and did not have a comprehensive care plan
Corrective Action(s): Please ensure that if a person is admitted for a period of more than 30 days that a care plan is made in accordance with the regulations.
Date to be Corrected:
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