STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: Review of 5 employee records found that 3 did not have evidence of reference checks.
Corrective Action(s): Please ensure that the licensee does not employ someone in a community care facility when character references have not been obtained for that individual.
Date to be Corrected: December 13, 2017
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: 3 out of the 5 employees whose records were reviewed have not had an employee performance evaluation since 2015.
This is a repeat contravention from two years ago routine inspection (inspection report #KDHL-A4ZQG2).
Corrective Action(s): Please ensure that employees receive regular performance reviews in order to ensure that the employee demonstrates the competence required for their assigned duties.
Date to be Corrected: December 13, 2017
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: Review of the medication safety and advisory committees (MSAC) policies and procedures found that medications are supposed to be initialed for having administered in the person in care's (PIC) MAR.
All 3 PICs MARs that were reviewed had at least 3 medications that were administered and not singed for having administered.
Corrective Action(s): Please ensure that all employees comply with the MSAC's policies and procedures for administering and recording PICs. medications.
Date to be Corrected: November 29, 2017
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: A random audit of policies and procedures was conducted and found the following:
- The policy for complaints has not been reviewed or revised since 2011.
- The smoking policy states that PICs, staff, and visitors are not encouraged to smoke. Discussion with staff determined that this means that staff and visitors are allowed to smoke on site. Residential Care Regulations section 23 specifies that staff and volunteers are not to smoke on premise or when supervising PICs off premise.
Corrective Action(s): Please ensure that policies and procedures are reviewed and revised as necessary at least once each year.
Date to be Corrected: December 13, 2017
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