PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31200 - RCR s.19(3) - If a licensee installs electronic devices for the purposes of transmitting or recording images of persons in care or members of the public, the licensee must display in a prominent place notice that electronic surveillance is being used.
Observation: Video monitoring equipment was observed in the ceiling at the front entrance. There was no notification displayed in the area to alert members of the public or residents.
Corrective Action(s): Please provide a plan to ensure that there is always appropriate notification displayed to alert PICs and the public to the use of video surveillance as per regulation above.
Date to be Corrected: Nov. 2, 2016
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: Only selected rooms from 211-250 were observed. Topical medications were observed in 3 rooms. the medications include, polysporin ung (non-prescription), prescription Sebrun shampoo, clotromazole ung., fucidin ung., and Preparation H.
Corrective Action(s): Please provide a plan to ensure that all medications are appropriately and securely stored.
Date to be Corrected: Nov. 2, 2016
STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: Of 3 staff files reviewed, 2 staff had not had recent performance review. one was a new employee and was due for review next week. In discussion with the Director of Residential Services it was made clear that the performance reviews had not been brought up to date over the last 3 inspections. The reviews for the LPN/RN's have been reported to be completed. The Director has developed a schedule to complete the remaining reviews by the end of December.
Corrective Action(s): Please provide a plan that will ensure that the performance reviews are completed by the end of December as planned. Also, please provide a sustainable plan that will ensure that performance reviews are completed in a time frame as directed by facility policy moving forward.
Date to be Corrected: Nov. 2, 2016
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: Of the mandatory policies per RCR 85 (2)(a through l) the last review dates were October 2014.
Corrective Action(s): Please provide a plan that will ensure that policies are reviewed and only if needed, revised yearly.
Date to be Corrected: Nov. 2, 2016
POLICIES AND PROCEDURES: 33350 - RCR s.85(2)(e) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (e) access to persons in care by persons who are not employees of the community care facility;
Observation: A policy providing guidelines for staff with relation to visitation and release of PIC's from the care of the facility was not observed. The Director of Residential Care states there is a "Release of Jurisdiction" form that has recently been developed. This will be added to the present visitor policy that simply describes sign-in procedure.
Corrective Action(s): Please provide a plan to ensure that the intent of RCR 85(2)(e to f)(ii) is met by policy.
Date to be Corrected: Nov. 2, 2016
MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation: An unlabelled tube of Polysporin was observed in a beside drawer.
Corrective Action(s): Please ensure that all medications are prescribed as Regulation above, and provide a plan to ensure compliance.
Date to be Corrected: Nov. 2, 2016
RECORDS AND REPORTING: 39010 - RCR s.49(2) - A licensee must record the height and weight of each person in care on admission.
Observation: Of 2 PIC files reviewed, there was no admission weight observed for 1 PIC. Please ensure that each PIC record contains the admission height and weight. In the absence of this record please provide and identify as such, the oldest known weight and height for the record.
Corrective Action(s): Please provide a plan that will ensure that the admission height/weight, or the oldest known height/weight is retained in all files.
Date to be Corrected: Nov. 2, 2016
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