LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A menu audit on a corporate level has been completed and on the corporate menu audit it states a site specific menu can be completed. The Dietitian will complete a site specific menu audit as well.
In discussion with a Recreation Management staff there is no formal process to document the activities persons in care have participated in or not and that recreation staff are going by "memory" as to what a person in care may have participated in or not. A formal process needs to be in-place to document participation in activities by persons in care.
Corrective Action(s): Please ensure the care and services provided by the care facility are regularly monitored to ensure that the requirements of the Community Care & Assisted Living Act and the Residential Care Regulation are being met.
Date to be Corrected: August 10, 2022.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: A random review of the hot water temperature at a ensuite washroom sink had a reading of 50.6 degrees Celsius (specific bedroom number provided during the inspection). When the Licensing Officer started the inspection, the Maintenance Staff stated the hot water temperature has been lowered.
Corrective Action(s): Please ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Date to be Corrected: July 29, 2022.
STAFFING: 32360 - RCR s.92(3)(a) - A licensee must keep (a) in the case of employees, all records required under section 37 (1) [character and skill requirements] for the entire time that the subject of the records is an employee of the community care facility.
Observation: In review of the staff personnel files/documentation, it was noted 2 staff did not have references noted. In addition, volunteers list their references, however they are not documented and they should be.
1 staff did not have their criminal record check to be completed through the Ministry for Public Safety & Solicitor General.
1 staff did not have copies of their credentials that could be reviewed at the time of the inspection.
Corrective Action(s): Please ensure all records required under section 37 (1) of the Residential Care Regulation for the entire time that the subject of the records is an employee of the community care facility.
Date to be Corrected: August 31, 2022.
CARE AND/OR SUPERVISION: 34220 - RCR s.56(1) - A licensee must ensure that a person in care who leaves a community care facility for a temporary purpose has in his or her possession written documentation indicating the person in care's name, the community care facility's name and emergency contact information.
Observation: During group outings there is documentation that accompanies the persons in care handled by staff. During outings persons in care have with family members, there is currently no documentation taken during the temporary outing. The Licensing Officer discussed what other sites have done in terms of meeting this legislative requirement.
Corrective Action(s): Please ensure persons in care who leave a the facility for a temporary purpose has in his or her possession written documentation indicating the person in care's name, the community care facility's name and emergency contact information.
Date to be Corrected: August 2, 2022.
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: In review of the care planning system and in discussion with the Director of Wellness and Manager, it was determined only for example recreation interests are listed. There aren't recreation care plans in-place for the persons in care.
Corrective Action(s): Please ensure that all persons in care have a recreation and leisure plan.
Date to be Corrected: August 10, 2022.
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: In review of volunteer/staff files, it was noted for 2 files there is no immunizations in-place.
For 1 file there was no evidence to indicate compliance with the Province's tuberculosis control programs.
Corrective Action(s): Please ensure there is evidence of compliance with the Province's immunizaiton and tuberculosis control programs.
Date to be Corrected: August 31, 2022.
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