PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Licensing observed a prescription topical medication stored in an unlocked drawer in the bedroom of a person in care.
Corrective Action(s): Please ensure medications in the community care facility are safely and securely stored.
Date to be Corrected: Please submit a written response by March 19, 2021 and identify in your response how you will address this requirement.
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: Licensing observed that 1 of 6 employee files contained no record of tuberculosis screening.
Corrective Action(s): Please ensure that staff have provided evidence on hire of compliance to BC's tuberculosis program.
Date to be Corrected: Please submit a written response by March 19, 2021 and identify in your response how you will address this requirement.
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: REPEAT CONTRAVENTION
Licensing reviewed 6 employee files and found 2 of 6 employee’s performance appraisals were completed 23 months ago, where the Licensee’s policy and procedure required this to occur every 12 months.
Corrective Action(s): Please ensure that employee performance appraisals are completed regularly and according to the Licensee’s policies and procedures.
Date to be Corrected: Please submit a written response by March 19, 2021 and identify in your response how you will address this requirement.
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: A staff with a FoodSafe in good standing was not onsite to monitor the preparation of meals and snacks. Licensing confirmed that food service staff were hired with a FoodSafe in good standing, but these staff had not completed a recertification course. (FoodSafe certificate must be rectified every 5 years in order to be in good standing.)
Corrective Action(s): Please ensure that the preparation of meals and snacks is monitored by a staff with a FoodSafe certificate in good standing.
Date to be Corrected: Please submit a written response by March 19, 2021 and identify in your response how you will address this requirement.
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: A PIC's Activities Daily Living sheet had not been reviewed in 24+ months and it was not consistent with information documented in their Care Plan.
Corrective Action(s): Please ensure that Care Plans and other information related to a PICs plan of care is reviewed and, if necessary, revised at least once each year.
Date to be Corrected: Please submit a written response by March 19, 2021 and identify in your response how you will address this requirement.
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: 1 of 6 PIC files reviewed did not include a record of immunization.
Corrective Action(s): Please ensure that persons in care records include on admission a record of immunization.
Date to be Corrected: Please submit a written response by March 19, 2021 and identify in your response how you will address this requirement.
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Two PICs toiletry and hygiene items were stored together in a shared bathroom. These items could not be identified according to person and this could have led to accidental sharing.
Corrective Action(s): Please ensure personal hygiene products and items are stored in a manner that assists persons in care to maintain health and hygiene.
Date to be Corrected: Please submit a written response by March 19, 2021 and identify in your response how you will address this requirement.
|