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: As per facility policy, employee performance evaluations are to be completed annually. A review of 5 staffing files found 2 staff without current performance evaluations.
Corrective Action(s): Please ensure that as per facility policy regular performance evaluations are completed to ensure employees demonstrate the competence required for their duties.
Date to be Corrected: December 31 2019
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: During the inspection the Director of Care stated that all nurses and RCA’s are required to hold a current first aid certification. During a review of 9 staff files no evidence was found of current first aid certification for 4 staff.
Corrective Action(s): Please ensure all required staff hold a current first aid certification as per facility policy, to ensure that PIC’s have access to a first aid attendant at all times.
Date to be Corrected: August 31 2019
STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: During a review of 8 files for staff involved in the food serving and preparation it was noted that 4 did not have evidence of current food safe certification (as of 2018 food safe expires after 5 years so if taken in 2014 or prior it is now expired).
Corrective Action(s): Please ensure that all employees responsible for food preparation and service have the necessary training.
Date to be Corrected: August 31 2019
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: During the review of the facilities emergency food supplies it was noted that numerous supplies were well beyond their best before date, with some items having expired in 2017 and 2018.
Corrective Action(s): Please ensure that the plan of how PIC will continue to be cared for in an emergency is monitored and maintained.
Date to be Corrected: August 31 2019
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Facility policy states that staff should complete the online wound protocol for each PIC along with photographs and wound progress notes. During the inspection it was noted that numerous wound charting was in complete with no photographs and/or progress notes completed.
Corrective Action(s): Please ensure that policies are being implemented by all staff.
Date to be Corrected: August 31 2019
CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner, nurse practitioner or dietitian at least once every 30 days.
Observation: Licensing reviewed the care plans for 4 PIC’s who are currently receiving ongoing tray service. It was noted that 2 PIC’s had not had their tray service reassessed within the last 30 days:
-One was last reviewed in December 2018.
-The second was not reviewed between December 2018 and June 2019.
Corrective Action(s): Please ensure the ongoing tray service is reassessed by the PIC’s medical practitioner or dietitian at least once every 30 days.
Date to be Corrected: August 31 2019
CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: The care plan of 1 PIC stated that the restraint being used should be reassessed at least every 90 days. However at the time of the inspection it had been 120 days since the restraint had been reassessed
Corrective Action(s): Please ensure the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Date to be Corrected: August 31 2019
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A review of 2 of the servery fridges found that the temperature monitoring sheets were not being completed as required (twice daily). One fridge was not completed at all in May 2019 and both fridges were only approximately 50% for June 2019.
Corrective Action(s): Please ensure that all food is being safely stored before being served.
Date to be Corrected: August 31 2019
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: A review of 10 PIC’s care plans found:
-1 PIC without evidence of TB status.
-5 PIC’s without evidence of immunization status.
Corrective Action(s): Please ensure that for all PIC’s a record is kept of TB and immunization status.
Date to be Corrected: August 31 2019
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: During the inspection it was noted that a long term resident had recently been admitted to hospital for a few days before returning to the facility. During this time the PIC’s care plan was deleted and not reinstated. At the time of the inspection the PIC had been back at the facility for 13 days without having a current care plan in place.
Corrective Action(s): Please ensure that all PIC’s have a current and complete care plan in place.
Date to be Corrected: August 31 2019
|