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 random review of one person in care records/care plan on the computerized system indicated the screening form to when to get a Dietitian involved is dated May 2016.
Corrective Action(s): Please ensure documents are reviewed and/or revised on a regular basis where required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: In review of the computerized staffing program, and a random review of 1 staff's documentation the last performance appraisal was completed in the year 2016.
Corrective Action(s): Please ensure performance appraisals are completed on a regular basis.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: As per section 40 (1)(a) of the Residential Care Regulation.
Corrective Action(s): As above.
Date to be Corrected: As above.
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A random review of the medication administration records and medication cupboard indicated that a PRN (As needed) medication did not have the result/effect noted on the back of the medication administration record (The specific date, medication, person in care involved, etc) was provided to the Program Coordinator for follow-up.
Corrective Action(s): Please ensure all staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Fire drills are completed on a monthly basis, however no drills noted for February and March 2017. The Manager will follow-up this and get back to the writer as to how this will be addressed moving forward.
Corrective Action(s): Please ensure all staff implement policies and procedures as required.
Date to be Corrected: Please provide a written response to this item 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 one person in care's records/care plan indicated their nutrition care plan summary refers to a next review date in 2016 as discussed with the Program Coordinator.
Corrective Action(s): Please ensure all care plans are reviewed once a year if there is no substanial change and if modified/updated if there is any change required as per the Residential Care Regulation.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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