Licensing completed the follow-up inspection over 2 days. The first day focused on the admission and care planning systems and was completed with the support of the facility Management Team including the new Executive Director/Manager and Chief Operating Officer of Trillium Care Services. The following was observed and discussed:
Care & Supervision
The Executive Director (ED) confirmed that all persons currently in care have had their care plans reviewed to ensure assessments have been initiated and or completed, dependant on the their quarterly and/or annual review. Point Click Care is used for all persons in care to complete assessments and create care plans. Review dates are flagged on the “dash board” of the electronic program to alert Management and staff of upcoming and/or overdue reviews.
Licensing completed a random audit of 7 person in care’s records which included persons newly admitted and those requiring a behaviour plan and/or the use of restraint. The audit confirmed all required information was on file with the exception of information noted in the violations section (immunization/TB screening) of this report. Licensing confirmed care plan review dates were documented, assessments were either complete or in progress dependant on the review date and evidence of on-going monitoring (care flow sheets, restraint monitoring) were available. The audit was completed with the support from nursing staff who explained the various steps they are required to complete from admission of persons in care, to completion of short and 30 day care plan, for their primary assignment of persons in care (approximately 9-10 per nurse). They also confirmed and explained their responsibility to audit flow sheets at the end of their shift to ensure care staff have signed for care provided. An admissions checklist tool is being utilized by nursing staff and DOC to ensure all documentation is completed within 72 hours.
Copies of the care plans and Activities of Daily Living (ADL) sheets are available at the nursing stations and ADL sheets are posted in each person in care’s room. Licensing audited the 7 ADL sheets for files reviewed. Although it was confirmed the care plan and ADL form were consistent with information Licensing discussed with the ED and DOC, if the level of detail on the ADL sheet was enough information to direct staff accordingly should it need to be referenced when providing care in the room. Licensing recommends a review be completed of the ADL system to ensure pertinent information is communicated.
Self-Monitoring
The ED demonstrated and explained she has audited every care plan for persons in care ensuring all requirements are met. Further she explained the various auditing systems implemented for care planning , which includes the DOC’s various daily/weekly/monthly audit reports being reviewed and signed off by herself, then she is required to report her audit findings monthly, to the Chief Operating Officer. In addition, the ED also completes random audits of various systems on her daily rounds of each care floor. Weekly audits have been implemented for restraints, and wounds with flow sheets being audited daily by the Registered Nurses (RN) and reporting their findings to the DOC.
After each baths/showers staff are required to document that the shower/bath rooms have been cleaned. Licensing observed the signature sheets posted in the rooms.
Staffing
The ED explained and demonstrated the new program currently being implemented for staff to encourage and track “teachable moments” to help identify areas for education and if necessary the next steps for progressive discipline. Staff appeared to be aware of the program as they did reference it during the inspection. The ED further explained various components of her strategic plan including Leadership Education Training and Development for all levels of staff.
The DOC explained training and discussions with staff will be ongoing regarding, Management’s expectations for care planning . In particular, ensuring plans are specific to each individual by editing the available statements that can be chosen from the electronic list on Point Click Care. As the quarterly and annual reviews are being completed staff direction is to focus on the details written for the goals and strategies being implemented.
The job description and duties for the RN position working Monday to Thursday from 7:00am – 3:00pm is currently under review and revision to ensure their time is used effectively. This position does not have a primary assignment of persons in care so to allot time for other nursing staff to complete assessments and revise/update care plans as required.
Summary
This follow-up inspection confirmed that previous non-compliance has been addressed but it is recognized and acknowledged by the Management team that continued monitoring is required to ensure the systems in place are sustainable and compliance is maintained. Licensing provided the Executive Director with a copy of the Licensing Data Base Coding form as a resource with the recommendation it could be used as a tool for self-inspecting.
This report was reviewed and discussed with the Executive Director/Manager and a copy provided. If you have any further questions please contact your Licensing Officer. |