During this inspection Licensing and the Mental Health, Clinical Coordinator, met with the Licensee and Manager of Care and reviewed and discussed the following:
Incident reporting - Licensing clarified the reporting time lines (24 hours for critical incidents (ie. missing wandering) and 5 days for non-critical) and who must be notified including funding, physician, and family. Licensing explained that if staff had additional information that the details of the incident can be documented on a separate sheet and attached to ensure complete details are provided to demonstrate staff have taken appropriate action to mitigate risk.
Resources provided: Reportable Incident Facility Instruction Sheet and instructions for setting up the facility's electronic reporting account
Care Planning - 2 person in care's care plans were reviewed and all required documentation was observed with review dates including nutrition plans and updated summaries. A tracking tool to monitor person in care's dental appointments has bee created, all have been to the dentist with the exception of 1 person in care who is scheduled this month.
Self-Monitoring - tracking forms for attendance of recreation and other activities is being implemented. A new goal monitoring tool was initiated at the beginning of September 2017, with the expectation that staff document weekly progress, physical facility inspections are being completed weekly and are audited by the Licensee monthly.
Physical Facility: and inspection of the 2 bathrooms Licensing observed new grout around the tiles and each room was clean of debris.
As all previous contraventions have been addressed no further response is required. This report was written off-site and delivered to the facility on the same date (1:40-2:00 PM). The report was reviewed and discussed with the Manager of Care and a copy provided.. Please contact your Licensing Officer if you have any questions or concerns regarding this report. |