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: One bedroom wall board has warped behind the electric head baseboard indicating water damage.
Corrective Action(s): Please ensure that all rooms are maintained in good state of repair.
Date to be Corrected: March 24, 2023
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: 1/3 PIC who has assessed for restraint use does not have the agreement document signed by the PIC or the relative or representative on file.
Corrective Action(s): Please ensure that an agreement document is obtained in writing from the PIC, parent or representative or relative closest to the PIC prior to restraint use.
Date to be Corrected: March 24, 2023
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: The HR records of 1/5 staff files reviewed did not show the immunization and TB records. The staff assisting with the inspection informed the LO that all staff are only allowed to start working once these documents were in place.
Corrective Action(s): Please ensure that HR staff implement all polices as appropriate and update the records of the employees.
Date to be Corrected: March 24, 2023
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: The PICs level of intervention are overdue as per the care plan and the advance care planning documents with the PIC/family representative and the doctor was not available. The staff assisting with the inspection advised LO that this was being followed up with the PICs' dcotor.
Corrective Action(s): Please ensure that the care plan is revised if necessary and reviewed at least each year.
Date to be Corrected: March 24, 2023.
|