Staffing:
- In review of staff/volunteer files the following was noted. For example, two staff files were noted with
*Immunization form adapted from the Community Care Facilities Licensing (CCFL) TB and Immunization Guideline, part B for the employer to complete was not completed for one staff and one volunteer.
*Immunization form was signed in 2022, otherwise the form was not completed in it's entirety.
Also for two files, the tuberculosis form adapted from the CCFL TB and Immunization Guideline did not have at the top whether the staff has no signs and symptoms for tuberculosis (there was an accompanying tuberculosis test), and on another form it was noted to have been checked off no signs and symptoms and also checked off evidence after being assessed for tuberculosis signs and symptoms for a volunteer. In discussion with the Manager/Administrator it was recommended if a document is going to be utilized, that the document be completed in it's entirety. In review with the staff that oversees the volunteers, recommended if a form is going to be utilized then to complete it in it's entirety and to only check off on the tuberculosis form evidence will be provided after being assessed for tuberculosis signs and symptoms, if this is an issue, otherwise this would not be checked off.
- Performance appraisal not noted in 1 staff file reviewed at the time of the inspection. Further discussion with the Manager/Administrator took place and there is a schedule to complete all performance appraisals. As the facility has a plan to complete performance appraisals, this was not noted as a contravention.
Thank you for your time to complete this routine inspection. If there are any questions related to this routine inspection report, please contact your Licensing Officer. |