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: Review of staff files determined that staff performance reviews have not been completed on an annual basis as required by the facility's policy. In discussion with facility leadership it was learned that the 2020 reviews were not conducted, in part due to new staff joining the leadership team.
Corrective Action(s): Ensure that employee reviews are conducted to ensure the employees demonstrate the competence required for the duties to which the employee is assigned.
Date to be Corrected: June 25, 2021
STAFFING: 32260 - RCR s.44(1)(b) - A licensee must ensure that employees responsible for the preparation and delivery of food (b) receive ongoing education respecting the preparation and delivery of food, nutrition and, if required, assisted eating techniques.
Observation: Upon facility inspection and review of staff files, the leadership team revealed that there are several care staff with expired Food Safe certification. It was determined that staff with expired Food Safe certification will be recertified in July 2021
Corrective Action(s): Ensure that employees responsible for the delivery of food receive ongoing education.
Date to be Corrected: June 25, 2021
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: Upon inspection of facility records it was determined that a behaviour mapping tool required by a person in care (PIC) was incomplete. The tool was to be filled in over a 7-day period, however there were missing entries.
Review of Point of Care (POC) documentation revealed that there were instances whereby staff failed to document the completion of a task. Additionally, there is a policy in place indicating that supervising staff are to ensure that documentation is completed by the end of the shift, and in the noted instances, this monitoring was not occurring.
Both of these circumstances were in breach of the facility's own policies, one specifically related to documentation and the other related to monitoring staff's (POC) documentation.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected: June 25, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Upon inspection of the tub room there were several items, including a bar of soap and combs that were not labelled for use by a specific PIC, and were not suitable to be used as shared items. Of concern is that without labels, the item can inadvertently be used by more than one PIC.
Corrective Action(s): Ensure that all personal care items are labelled for use by individual PICs to assist in maintaining health and hygiene.
Date to be Corrected: June 25, 2021
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