STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: The site's Disaster Response Emergency Drills binder indicated that fire drills are to be completed at least once a month. Upon review of fire drill records for the previous 12 months, it was observed that 4 fire drills have been completed.
Corrective Action(s): Ensure all employees are trained in the implementation of emergency response plans and that fire drills are conducted at least monthly, as per facility policy.
Date to be Corrected: July 13, 2021
POLICIES AND PROCEDURES: 33080 - RCR s.51(2) - A licensee must ensure that the plans described in subsection (1) are updated if there is any change in the facility
Observation: Upon review of the emergency response plan and emergency contact information, it was observed the site's floor plan listed a PIC who no longer resided at the facility and the emergency contact information had not been updated to reflect changes.
Corrective Action(s): Ensure that emergency response information remains current.
Date to be Corrected: July 13, 2021
CARE AND/OR SUPERVISION: 34120 - RCR s.52(1)(a) - A licensee must ensure that a person in care is not, while under the care or supervision of the licensee, subjected to (a) financial abuse, emotional abuse, physical abuse, sexual abuse or neglect as those terms are defined in section 1 of Schedule D.
Observation: Upon review of person in care financial records and disbursements, the following misuse of funds and assets was observed:
- The finances of persons in care were disbursed by the licensee to purchase shared equipment required to meet the needs of 3 of 4 persons in care. As per RCR s. 21(a), the provision of shared furniture and equipment required to meet the needs of persons in care is a requirement of the licensee.
- The finances of persons in care were disbursed by the licensee to repair a piece of shared equipment required to meet the needs of 4 of 4 persons in care. As per RCR s. 21(b), the maintenance and repair of shared furniture and equipment required to meet the needs of persons in care is a requirement of the licensee.
- The finances of persons in care were disbursed by the licensee to purchase shared equipment for the program of recreational and leisure activities offered at the facility. As per RCR s. 55(3)(a), the provision, without charge, of materials and equipment for the program of recreational and leisure activities offered at the facility is a requirement of the licensee.
Corrective Action(s): Ensure that there is no misuse of persons in care’s funds and the use of persons in care’s funds meets the requirements of the Community Care and Assisted Living Act, Resident Care Regulation, and funding agency.
Date to be Corrected: July 13, 2021
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Upon review of 4 PIC care plans, it was observed that 3 out of 4 care plans were last reviewed in September 2019 and behaviour restraint approvals for 2 out of 4 PICs were last reassessed by all persons who agreed to the use of the restraint in 2019.
Corrective Action(s): Ensure each care plan is reviewed and, if necessary, modified at least once each year to ensure care plans continue to meet the needs and preferences, and are compatible with the abilities, of persons in care and that behaviour restraint approvals are reassessed by all persons who agreed to the use of the restraint.
Date to be Corrected: July 13, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation (CORRECTED DURING INSPECTION): PIC oral hygiene products located on the counters in the shower room and tub room could not be identified according to PIC.
Corrective Action(s): Ensure personal hygiene products are stored in a manner that clearly identifies the PIC.
Date to be Corrected: Corrected at time of inspection
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation (CORRECTED DURING INSPECTION): One discontinued PRN medication stored was with current medications.
Corrective Action(s): Ensure discontinued medications are returned to the pharmacy.
Date to be Corrected: Corrected at time of inspection
RECORDS AND REPORTING: 39230 - RCR s.79(1)(a) - A licensee must keep a record in respect of each person in care showing the following information: (a) all money, valuables and other things held by the licensee in trust or safekeeping for persons in care.
Observation: Upon review of persons in care financial records, it was observed that a transfer of cash to a PICs day program moneys from the PICs residential monies had not been recorded and the cash on hand did not balance with amounts on either ledger.
Corrective Action(s): Ensure records of money and values in respect of person in care are regularly maintained and PIC finances are accurate/balance.
Date to be Corrected: July 13, 2021
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