PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: Noted during inspection, both shower rooms need some maintenance. The grey tiled shower room has a section of the wall with a deep scrape that exposes the drywall underneath, the scrape is approximately 80-90cm long and 3cm wide.
The other shower room has a section of wood baseboard missing, approximately 45-60cm in length.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 21, 2022
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 two employee files determined that one of two files does not have evidence of a current criminal record check.
Corrective Action(s): Please ensure that criminal record checks are obtained for all employees.
Date to be Corrected: November 21, 2022.
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: During review of two employee files, one of two files did not have evidence of any character references completed.
Corrective Action(s): Ensure that character references are obtained for all employees.
Date to be Corrected: November 21, 2022
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 (CORRECTED DURING INSPECTION): Review of two employee files determined that one of two files did not have evidence of compliance with the provinces immunization and tuberculosis control programs.
Corrective Action(s):
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 (CORRECTED DURING INSPECTION): Review of 2 employee files determined that 1 of 2 employees had expired First Aid and CPR Certification, expired in 2019.
During discussion with Manager it was confirmed this staff member and 3 others are scheduled to renew First Aid/CPR on Nov 9 and 10, 2022
Corrective Action(s):
Date to be Corrected:
POLICIES AND PROCEDURES: 33130 - RCR s.68(3)(a) - The medication safety and advisory committee must establish and review as required (a) training and orientation programs for employees who store, handle or administer medications to persons in care.
Observation: Review of medication safety and advisory committee documentation did not show evidence of established training and orientation programs for employees who store, handle or administer medications to persons in care.
Corrective Action(s): Ensure that the medication safety and advisory committee establish and review, as required, training and orientation programs for employees who store, handle or administer medications to persons in care.
Date to be Corrected: November 21, 2022
RECORDS AND REPORTING: 39200 - RCR s.78(2)(b) - A licensee must keep, for each person in care, a medication administration record showing (b) the date, amount and time at which the medication was administered.
Observation: Review of two Persons in Care(PICs) medication administration records determined that 1 PICs record for PRN medication had evidence of a signature but no date on the Blister Pak for a PRN medication given.
Corrective Action(s): Ensure that each PICs medication administration record shows the date, the amount and the time at which it was administered.
Date to be Corrected: November 21, 2022.
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