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 5 staff files found that one staff person personally shared their CRC directly with the site, and the CRC was not completed through the CRRA, to the site directly.
Corrective Action(s): Ensure that CRC sharing follows the process outlines through the Criminal record review act (CRRA), and criminal record check results are shared directly with the site.
Date to be Corrected: immediately
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: 1 of 5 staff files reviewed did not have a completed performance review within the timeline required by the facility's policy
Corrective Action(s): Ensure that the performance of each employee is reviewed regularly and as required by the facility's policy.
Date to be Corrected: Feb 24, 2023
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Upon review of 5 person in care records, and discussion with staff determined that annual encouragement or confirmation of dental visits is not recorded.
Corrective Action(s): Encourage each person in care to be examined by a dental health care professional at least once every year.
Date to be Corrected: Feb 24, 2023
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation (CORRECTED DURING INSPECTION): Upon review of food and nutrition services on day one of the inspection, there was not an audit of the menu available to review to correspond with each of the 4 weeks of the fall/winter menus. On day two of the inspection the menu audit had been completed for the 4 weeks of the fall/ winter menu by the FSM and dietician.
Corrective Action(s): Ensure that records are kept in matters respecting food services, the results of monitoring, including menu audits as required in the Audits and more manual.
Date to be Corrected: Feb 24, 2023
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