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: Review of approximately 10 person in care bedrooms determined the mirrored cabinets in the bathrooms were with various levels in corrosion in the storage portion of the cabinets
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: May 3, 2019
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: 3 of 8 staff files did not have evidence of character references.
Corrective Action(s): Ensrue character references are obtained for staff.
Date to be Corrected: May 3, 2019
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: 2 of 8 staff files did not have the required documentation as evidence that staff have complied with the Province's immunization and tuberculosis control programs.
Corrective Action(s): Ensure all employee's files have evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 3, 2019
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: Review of 8 staff files, 3 performance reviews were not completed in the timelines as required.
Corrective Action(s): Ensure regular performance reviews are completed regularly to ensure the employee continues to meet the requirements of this regulation.
Date to be Corrected: May 3, 2019
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: The medication room reviews are occurring every 6 months. Policy requires these reviews every 3 months. the Medication Safety and Advisory Committee meetings are occurring yearly. Policy requires this meeting to occur every 6 months. As well, review of medication rooms and carts, determined one cart not secured and potentially accessible to persons in care and others.
Corrective Action(s): Ensure compliance with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: May 3, 2019
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: Review of 8 staff files, for 5, orientation checklists were not in the staff files showing it was completed as part of the training of the position as per policy.
Job descriptions are required in each staff file as part of employee file and job requirement. 4 of 8 employee files did not have a job description of their current job and one file had the wrong job description.
Corrective Action(s): Ensure orientation checklists are completed as part of the training and retained in the employee files as evidence of completion.
Ensure job descriptions are provided to staff and a copy retained in the staff file to confirm compliance as per policy.
Date to be Corrected: May 3, 2019
CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation: Review of 10 person in care records, care plans were not developed with enough detail to guide staff of all aspects of care. Such examples include - recreation care plans, behaviour plans, timelines of monitoring, how to approach persons in care, types of preventative tools used for fall prevention, person in care preferences for activities of daily living
Corrective Action(s): Ensure care plans are developed in a manner that takes into account all aspects of care and preferences required to guide staff.
Date to be Corrected: May 3, 2019
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: The care plan for one person in care was not updated to reflect a behaviour plan that was not previously assessed. As well, Activities of daily living sheets reviewed showed atleast two with information not updated to reflect changes to the care of persons.
Corrective Action(s): Ensure care plans are revised when there is a change in the care required for persons in care.
Date to be Corrected: May 3, 2019
RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: The organizational chart does not reflect the current reporting structure.
For 3 of the 8 staff files reviewed, a confirmation of professional registry was not in place to confirm evidence of current registry.
Corrective Action(s): Ensure all documentation is reflective of current practice.
Ensure current professional registry for professional staff is retained in staff files.
Date to be Corrected: May 3, 2019
|