LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: A major renovation to 1/2 PICs' bathroom involving drywall (installation of grab bars), tiling and plumbing has occurred without any written health and safety plan in place.
Corrective Action(s): Please ensure that a health and safety plan of PICs is submitted for structural changes involving a licensed facility.
Date to be Corrected: June 8, 2022
LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: The facility manager was on leave for almost 2 months and an assistant manager was appointed to be in charge of the facility.
Corrective Action(s): Please ensure that licensing officer is notified for any absence of a manager for at least 30 days and approval is sought for an interim person to be in charge.
Date to be Corrected: June 8, 2022
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: 1). 1/5 PIC bedroom windows are broken where one portion of the glass has a crack and the side glass is missing and a board has been placed temporarily to cover the space.
2). 1/5 window screen lock enclosure has come off and is hanging without any screw.
3). Pieces of metal, cartons and tiles are placed in the back patio. Of concern is the safety of the ambulatory PICs and during emergencies.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: June 8, 2022
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: Staff are documenting missed medications or medication error in the PRN administration section of the MAR sheet.
Corrective Action(s): Please ensure that all employees comply with the MSAC policies and procedures.
Date to be Corrected: May 27, 2022
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: Staff are paying for some expenses of the PICs with their personal credit cards and PICs are writing checks to reimburse the staff later. During the inspection copies of cheques written by PICs to staff were found in the file.
Corrective Action(s): Please review the accounting system used for the PICs funds to ensure that Generally Accepted Accounting principles are being followed.
Date to be Corrected: May 27, 2022
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