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: One staff of the files reviewed has an expired CRC.
Corrective Action(s): CRC must be current and renewed in order to be in compliance. Discussion occurred ensuring ways to minimize risk.
Date to be Corrected: January 6, 2023
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: Evidence reference check was completed was missing for 2 of the staff file that was reviewed.
Corrective Action(s): Please ensure staff records are complete
Date to be Corrected: January 13, 2023
STAFFING: 32030 - RCR s.37(1)(c) - 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: (c) a record of the person's work history.
Observation: Evidence of resume was unavailable for one of the staff file reviewed.
Corrective Action(s): Please ensure staff records are complete
Date to be Corrected: January 13, 2023
STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Two of the staff files did not show evidence of diplomas, certificates or other evidence of training.
Corrective Action(s): Please ensure records are complete
Date to be Corrected: January 13, 2023
STAFFING: 32083 - RCR s.37(3)(c) - Despite this section, a licensee may employ a person as a volunteer who does not provide care to persons or supervise persons if the licensee or manager has first met with the person and obtained all of the following: (c) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Staff file review indicates 2 staff were missing their immunization information, 1 staff is missing their TB information
Corrective Action(s): Please ensure staff records are complete
Date to be Corrected: January 6, 2023
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: 3 staff last performance evaluation was completed 2019. Facility Policy is a yearly review. This is a repeated contravention.
Corrective Action(s): Please ensure staff performance is conducted yearly as per the Policy and Procedure.
Date to be Corrected: February 7, 2023
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: Two of the staff do not have evidence of a valid first aid
Corrective Action(s): Please ensure PIC have at all times immediate access to an employee who holds a valid first aid.
Date to be Corrected: January 6, 2023
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Sampling of review of Policies and Procedures indicates none of the Policies and Procedures have had a yearly review, majority was reviewed in 2019.
Corrective Action(s): Policies and Procedures must be reivewed and reivsed if necessary at least once each year. Licensing was informed that review of the Policies is currently being undertaken.
Date to be Corrected: January 17, 2023
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Review of the weekly menu indicates there are times the snacks do not have at least 2 nutritious snacks, each with at least 2 food groups as described in Canada's Food Guide.
Corrective Action(s): Please ensure snacks are nutritious and also have at least 2 food groups from the Canada Food Guide.
Date to be Corrected: January 6, 2023
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: Review of 3 PIC records indicate immunization status information is unavailable.
Corrective Action(s): Please ensure PIC's records are complete. Sample copy was provided.
Date to be Corrected: Jan 6, 2023
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