The following items were observed/reported to be completed
-all physical plant issues have been attended to. The crack in the ceiling has been repaired and the beams have been tested and confirmed suitable for load bearing by ceiling track when carrying a PIC.
-the opaque window coverings have been removed from 2 bedrooms
-the fence has been repaired
-all medication items have been secured
-the manager states she has completed writing all performance reviews, meetings with the staff will occur to complete the reviews with the staff by Friday May 20, 2016.
-the fridge/freezer temperatures are now being completed accurately
-the policy and procedure for dispute/complaint resolution to include reference for Licensing and/or Patient Care Quality office will be reviewed at head office on May 25, 2016 and is expected to be reviewed by the board of directors and signed off in September.
-restraint policies have been written and signed off by parents and the doctors for 3 PIC's
-the closets that did not have closet doors have been fitted with draperies and the rooms appear more comfortable
-the monthly weights were completed at a sister house in April, a new scale for the ceiling lifts has been obtained and is expected to be in operating this month
-food service audits have been completed, there will be menu changes based on the outcomes of the audits. All the staff completed the "Caring About Food" online training session.
These actions appear to address all outstanding contraventions. No further action is required.
I would like to thank the staff for assistance in the completing of this follow-up inspection. |