LICENSING: 30060 - RCR s 8(3)(b) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (b) replace the manager, either by hiring a person who, or using a hiring process that, is approved in writing by the medical health officer.
Observation: Discussion with the manager indicates she has been in this role for approximately three months. Licensing has not received an application to amend the license.
Corrective Action(s): Submit an application to amend the license and obtain written approval from the medical health officer.
Date to be Corrected: 23 Nov 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: One of three bedrooms inspected was found to be in an untidy state. Numerous clothing and personal items were on the floor and as such it was not in a clean condition. Discussion with the Manager indicates that all bedrooms are inspected for cleanliness once per week and this room was clean for that inspection, however this person in care has not maintained the room in a clean condition.
Corrective Action(s): Ensure room is maintained in a safe and clean condition.
Date to be Corrected: 18 Nov 2018
MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: One of four medication administration records (MAR) observed found that one medication was not listed on this record. Discussion with the Manager about this indicates that although this medication was in a blister pack , it was not on the MAR because it was brought to this facility by the person in care from a previous facility. This medication is a PRN medication and has not been administered since this person in care has been at this facility.
Corrective Action(s): Ensure that the pharmacist records all medications on the person in care's MAR.
Date to be Corrected: This was corrected during the inspection. The pharmacist faxed an updated copy of the MAR to the facility.
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