PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31160 - RCR s.19(1)(c) - If a person in care requires monitoring, or a signalling device, to ensure that person's health and safety, a licensee must provide a monitoring system or signalling device that (c) will signal to employees that the person in care needs immediate assistance.
Observation: A call bell audit for Main North was reviewed for November 14th - 20th 2016.
Total # of bells: 484
Total # of bells answered over the 10 minutes expected in GDC policy: 59
This 12% reflects an improvement from the past 3 months of 14%, 28% and 25%
12 calls from 10-11 mins
21 calls from 11-15 mins
21 calls from 15-29 mins
3 calls from 29-45 mins
2 calls over 45 mins
Corrective Action(s): The Care Coordinators are continuing to review call bell audits and discuss out of policy times with staff.
Date to be Corrected: December 31, 2016
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: Cupboard and counter surfaces in many areas of the building are showing signs of wear or are broken. The facilities manager has confirmed that a contractor is coming to complete the work November 29, 2016.
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: November 30, 2016
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: GDC is on track for the December 31, 2016 date provided to CCFL to have performance reviews up to date
Corrective Action(s): Ensure that every employee has up to date performance reviews
Date to be Corrected: December 31, 2016
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: The quality assurance team continues to work on this, and is on track with the completion date previously provided to CCFL of December 31, 2016
Corrective Action(s): Ensure that all PIC's have a record of compliance with the province's TB and immunization programs
Date to be Corrected: December 31, 2016
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