PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The water temperature in 3 person in care (PICs) bathrooms was measured and 3/3 temperatures were found to be above 51 degrees.
Corrective Action(s): Ensure that all water sources accessible to PICs is not heated to above than 49 degrees.
Date to be Corrected: March 5, 2021
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: Review of 3 employee files found that one employee file did not contain evidence that a criminal record check had been conducted for this employee.
Corrective Action(s): Please ensure that criminal record checks are being obtained for all employees.
Date to be Corrected: March 5, 2021.
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: Review of facility policies has determined that they have not been reviewed on an annual basis, with 3 policies reviewed in 2016, 2017, and 2018 respectively.
Corrective Action(s): Ensure that facility policies and procedures are reviewed, and if necessary, revised at least once each year.
Date to be Corrected: March 15, 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: Review of medication administration practices determined that the narcotic count was not occurring at the frequency required by the medication administration policy, which indicates a daily count is required. It was further observed that the effectiveness of PRN medication was not being documented on a regular basis. There were at least 5 missing entries where medication effectiveness was to be documented.
Corrective Action(s): Ensure that policies are implemented by employees.
Date to be Corrected: March 5, 2021.
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: Review of PIC records found that 1 PIC was having difficulty swallowing when eating bread. This was noted on a couple of occasions whereby the staff felt the PIC was at risk for choking. Although this was noted to be of concern, the care plan was not revised to reflect this change in the PIC's circumstances.
Corrective Action(s): Ensure the care plan is revised when there is a substantial change in the circumstances of the PIC.
Date to be Corrected: March 5, 2021
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: In discussion with facility manager it was determined that due to COVID-19 there are no longer group activities occurring and the PICs are no longer going on outings. There does not appear to be any planned activities that occur, aside from the live-streamed church service that occurs weekly. The manager indicated that the staff do interact with the PICs regularly, however this does not meet the intent of this section of the Residential Care Regulation.
Corrective Action(s): Please ensure that the PICs are provided with an ongoing planned program of physical, social and recreational activities that are suitable to their needs.
Date to be Corrected: March 5, 2021.
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