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: Total number of call bells: 557
Total # of bells answered over the 10 minutes expected within the GDC policy: 78
This 14% reflects an improvement on the previous two months of 28% and 25%.
14 calls from 10-11 mins
28 calls from 11-15 mins
30 calls from 15-29 mins
5 calls from 29-45 mins
1 call over 45 mins
Corrective Action(s): The DOC reports that this will be reviewed at the next meeting with care coordinators to discuss the progress, and improvement still needed.
Date to be Corrected: November 30, 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 a contractor coming in next week to provide a quote for the work, and has requested an extension on the previous date provided to CCFL of November 1, 2016 to November 30, 2016 to have the work completed.
Corrective Action(s): Ensure that rooms and common areas are maintained in a good state of repair
Date to be Corrected: November 30th 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 all performance reviews up to date.
Corrective Action(s): Ensure all employees have up to date evaluations
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 as 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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