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: A review of the physical plant (building inside and outside), for example indicated the outside of the door (near the bottom) before entering the tub room noted with black scuff marks and on another bedroom door as discussed with the Manager.
Corrective Action(s): Please complete a thorough review of the building inside and outside and please ensure you are ensuring all rooms and commons areas are maintained in a good state of repair.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: In the office is a brand new mini fridge noted with medications inside (as the Manager advised the writer) and the plan is to install a lock on the fridge to ensure medications are safely and securely stored.
Corrective Action(s): Please ensure all medications in the community care facility are safely and securely stored.
Date to be Corrected: Please provide a written response as per the timeline noted in this report.
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: A random review of the policies and procedures required by the Residential Care Regulation indicated for example the Incident Reporting policy under the catergory "Risk Management" was noted with a date for review/revision from October 2019.
Corrective Action(s): Please ensure all the required policies and procedures required by the Residential Care Regulation are reviewed and/or revised once a year. For the remainder of the policies and procedures, please ensure there is a system in-place for review and/or revision.
Date to be Corrected: Please provide a written response by the timeline noted in this report.
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: A random review of the care planning system indicated that a oral/dental care plan is not current (To be reviewed from April 2020).
Corrective Action(s): Please ensure all care plans are reviewed and if necessary, modified if there is no substantial change in the circumstances of the person in care.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: A random review of the care planning system indicated a weight was not recorded for a particular month for a person in care (Specifics provided to the Manager during the routine inspection).
Corrective Action(s): Please ensure that all persons in care are weighed once a month (If there are reasons that a weight can't be taken due to for example, weigh scale not working, etc, then please ensure this is documented accordingly).
Date to be Corrected: Please provide a written response by the timeline noted in this report.
RECORDS AND REPORTING: 39380 - RCR s.84(e) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (e) the result of any reassessment of the use of the restraint.
Observation: A review of restraints documentation and discussion with the Manager indicated the restraints documentation is to be reviewed every 6 months. Restraint documentation was not being reviewed every 6 months and signed off by the applicable individuals as discussed with the Manager at the time of the routine inspection (Specifics provided at the time of the routine inspection).
Corrective Action(s): Please ensure as per section 84(e) of the Residential Care Regulation is followed and implemented as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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