STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Staff performance evaluations are to be conducted yearly as per the Policy and Procedure, review of the 5 staff files, 4 of the staff last performance review was conducted in 2020. Leadership is aware this is outstanding and is in the process of completing the evaluations.
Corrective Action(s): Please ensure yearly staff evaluations are completed as per the Policy and Procedure
Date to be Corrected: February 28, 2023
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: Random selection of Policies and Procedures reviewed and determined majority had not been reviewed since 2019.
Corrective Action(s): Please ensure review and if required revision of policies and procedures are done at least once a year.
Date to be Corrected: February 28, 2023
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Facility provides 3 snacks per day, only one snack has the required 2 food groups from the Canada Food Guide.
Corrective Action(s): Please ensure at least 2 snacks contain at least 2 food groups as described in Canada's Food Guide.
Date to be Corrected: January 31, 2023
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection 77(3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Review of PIC information indicated that the PIC had been seen by a doctor. The incident was not reported to Licensing. Leadership provided reason for not reporting. Licensing discussed Schedule D of the RCR.
Corrective Action(s): Please ensure that all reportable incidents are reported to Licensing.
Date to be Corrected: ongoing
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