LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Staff confirmed that no system had been established to monitor checklists and audits.
-Staff had not signed as completed, routine cleaning tasks and monitoring duties, each time a checklist required it for more than 6 months.
-The most recent audit, completed in 2019, of the licensee’s 4-week menu confirmed the minimum servings required were not met on 11 occasions for one food group and on 24 occasions for a second food group.
The licensee could not provide evidence that follow up had occurred and a plan developed to ensure staff were completing tasks and duties as required or to have the menu revised to meet the minimum food group serving requirements.
Corrective Action(s): Please ensure to regularly monitor the facility and the care and services provided
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: A plastic storage container and washbasin in a washroom was dirty with hair and dust. The back of a PICs reclining chair was stuck in the recline position. A side-rail on a PICs bed was broken and unusable.
Corrective Action(s): Please ensure any equipment used by PICs is clean and safe
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The walls behind a bedroom and bathroom door had gouges made through the paint and into the drywall.
Staff reported the emergency fire door release system on the second floor had been disengaged some months before and not repaired. The door could only be secured with the dead-bolt from the inside in order to prevent unsupervised PICs from opening it. It was unlocked at the time of the of the inspection.
Corrective Action(s): Please ensure walls are maintained in a good state of repair and emergency systems are in working order.
Date to be Corrected:
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: - A cabinet and cupboard in a bathroom contained unlabelled personal hygiene items and there was dust and hair on the shelves.
- A bathroom floor was dirty with a substance that began to flake off when scratched.
- Clutter of unused lamps, pictures and cardboard boxes were stored in a common area. Some were on the ground and a possible tripping hazard.
-Beside the sink in a bathroom was a cup that was dirty with liquid soap and grim. The dispenser was broken and leaking soap on a counter.
Corrective Action(s): Please ensure all areas are clean and safe.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Chemical cleaning products were found accessible to PICs in two closets.
Corrective Action(s): Please ensure cleaning products are secured and not accessible to PICs
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31830 - RCR s.36(2) - If necessary to protect the health or safety of persons in care, a licensee must ensure that the outside activity area is secured by a fence or other means.
Observation: The perimeter fence was to be secured at all times to mitigate the risk for wandering. The outdoor gate was open with no staff supervising at the time of this inspection.
Corrective Action(s): Please ensure areas required to be secure, are maintained.
Date to be Corrected:
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: Two medications were not secured and stored in the kitchen.
Corrective Action(s): All medications must be securely stored
Date to be Corrected:
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: The licensee did not have evidence of criminal record checks for two staff.
Corrective Action(s): A criminal record check must be obtained for all staff.
Date to be Corrected:
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: The licensee did not have evidence of character references for two staff.
Corrective Action(s): References must be obtained for all staff.
Date to be Corrected:
STAFFING: 32030 - RCR s.37(1)(c) - 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: (c) a record of the person's work history.
Observation: The licensee did not have evidence of two staff’s work history.
Corrective Action(s): Work history must be obtained for all staff.
Date to be Corrected:
STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: The licensee did not have evidence of training and/or skills for two staff
Corrective Action(s): Evidence of training and skills must be obtained for all staff.
Date to be Corrected:
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: The licensee did not have evidence of compliance with the Province’s immunization and tuberculosis program for two staff.
Corrective Action(s): You must obtain evidence of compliance with the Provinces immunization and tuberculosis program for all staff.
Date to be Corrected:
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: The licensee did not have evidence of valid first aid and CPR for one staff who accompanies PICs into the community.
Corrective Action(s): PICs must have access to staff who have valid first aid and CPR at all times.
Date to be Corrected:
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: While inspecting the emergency supplies, staff reported they had removed several canned food items and bottles of water and had not yet replaced them or updated the supply list.
Corrective Action(s): Please ensure you replace any items removed from your emergency supplies.
Date to be Corrected:
POLICIES AND PROCEDURES: 33130 - RCR s.68(3)(a) - The medication safety and advisory committee must establish and review as required (a) training and orientation programs for employees who store, handle or administer medications to persons in care.
Observation: While the Licensee had a medication orientation checklist, the areas covered was not sufficient to meet the requirements of the RCR (concerning the storage, handling and administration of medications).
Corrective Action(s): A program training and orientating staff to the storage, handling and administration of medication must be developed and established by the licensee.
Date to be Corrected:
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: Staff had not obtained a written agreement from representatives or family before applying restraints.
Corrective Action(s): Please ensure all restraints have an agreement in writing from the PIC, their relative or representative.
Date to be Corrected:
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: The Licensee did not have policies and procedures that guided staff in the following matters:
- The management, disbursement and safekeeping of PICs funds, such as valuables held in trust (i.e., cash and or gift cards)
-The development, implementation and monitoring of PICs financial care plans (i.e., budgets, financial goals)
- Personal care services for PICs (i.e., Hair Stylist, foot care)
-The development, implementation and monitoring of an activity/recreation program for PICs
-Additional fees for services (i.e., transportation, companion costs etc.)
- Transportation of PIC in facility car, van or staff vehicle.
Corrective Action(s): Please ensure written policies and/or procedures are in place in all matters related to PICs.
Date to be Corrected:
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: The Licensee’s procedures to manage two health situations had not been updated, even though these procedures did not reflect the Licensee current practice.
Corrective Action(s): Please ensure procedures are updated as required or at least once each year.
Date to be Corrected:
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: The Licensee’s policy and procedure required that staff provide PICs and/or their representatives with monthly financial reports, invoices, and receipts. Staff were to review invoices and gain authorization for payment.
Four PICs financial records were reviewed and it was confirmed that staff have not implemented this policy, as invoices and reports had not been provided monthly and not reviewed with PICs or their representatives each time.
Corrective Action(s): Staff must implement the policies and procedures
Date to be Corrected:
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: An elopement risk assessment form was incomplete and did not identify whether a person was at risk of wandering.
Corrective Action(s): Please ensure all PICs are assessed for elopement as required.
Date to be Corrected:
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: The licensee did not have evidence a PIC had been encouraged to have a dental health examination since their last one in 2020.
Corrective Action(s): Please ensure each PIC is encouraged to have a dental exam at least once each year.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34310 - RCR s.59(b)(ii) - A licensee must provide an opportunity, at least annually, for persons in care and their parents or representatives, family members and contact persons to (b) meet with the licensee, either as a council, or, if no council is established, as a group, for the purpose of (ii) involving the persons in care in decision making on matters that affect their day to day living.
Observation: The license could not provide evidence that a council or group had been established to involve the PICs in matters related to recreation, food services and other activities of the home.
Corrective Action(s): PICs must be provided with the opportunity to be involved in matters that effect their day to day living, this must occur at least once a year.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: Four of five care plans reviewed had not been revised due to significant changes in the PICs diet, oral health, mobility and restraints
Corrective Action(s): Please ensure that PICs care plans are modified when changes in care needs occur.
Date to be Corrected:
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: A PIC’s immunization screening form had not been completed on admission.
Corrective Action(s): PICs must be screened on admission to ensure compliance with the Provinces immunization and TB control program.
Date to be Corrected:
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: The kitchen fridge contained an undated open container of food and another container was stored on a pantry’s floor. One food item in a cupboard expired in 2019. A staff was observed tasting food they were cooking for PICs and then returning the utensil back into the food.
Corrective Action(s): All food must be prepared, stored and handled in a safe manner.
Date to be Corrected:
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: The pharmacist last inspected of the medication room occurred in August 2021. It is required that a medication inspection occurred at least every 6 months.
Corrective Action(s): Please ensure medication storage areas are inspected at least every 6 months.
Date to be Corrected:
MEDICATION: 36160 - RCR s.72(a) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (a) the person in care is no longer taking the medication.
Observation: Five containers of medications not provided by the dispensing pharmacy and one discontinued medication had not been returned to the dispensing pharmacy.
Corrective Action(s): All medications no longer required must be returned to the pharmacy.
Date to be Corrected:
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: There was no evidence that a program of activities had been developed to meet the individual needs of persons in care. No resident council had been established to promote the leisure and recreational needs of group activities. An individual recreational and leisure plan had not been created for each person in care to meet their specific needs. There was no designated staff to organize and supervise recreation activities.
Corrective Action(s): Please ensure a program is provided that is suitable to the needs of the PICs for their physical, social and recreational activities.
Date to be Corrected:
RECORDS AND REPORTING: 39150 - RCR s.78(1)(c) - A licensee must keep, for each person in care, a record showing the following information: (c) name and telephone number of the person in care's parent or representative, contact person and primary health care provider.
Observation: One of five PICs’ records reviewed did not have contact information for their contact person. This was corrected during the inspection.
Corrective Action(s): Please ensure the contact information for a PICs contact person is in their records.
Date to be Corrected:
RECORDS AND REPORTING: 39160 - RCR s.78(1)(d) - A licensee must keep, for each person in care, a record showing the following information: (d) information by which the person in care may be described or identified in an emergency, including a photograph.
Observation: One of five PICs’ records reviewed A PIC’s record did not include a photograph or other means of identification in an emergency.
Corrective Action(s): Each PIC must have a picture in their record by which they can be ID'd
Date to be Corrected:
RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: The medication administration records for 10 PICs were reviewed and it was confirmed staff did not document on the MAR each time a medication was administered according to the directions given on the PICs MARs and a corresponding treatment protocol.
Corrective Action(s): All medications administered to PICs must be recorded on their MAR.
Date to be Corrected:
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: One PIC’s records reviewed did not contain evidence of a consent to contact their physician or an ambulance if required.
Corrective Action(s): Please ensure each PIC has consent to contact their medical practitioners and or ambulance if needed.
Date to be Corrected:
RECORDS AND REPORTING: 39260 - RCR s.79(1)(c)(ii) - A licensee must keep a record in respect of each person in care showing the following information: (c) any fee charged by the licensee (ii) to make disbursements on behalf of persons in care.
Observation: Staff had not maintained records of prepaid credit cards and gift cards purchased on behalf of two PICs in 2021
Corrective Action(s): Ensure records are retained for any disbursements or fees charged.
Date to be Corrected:
RECORDS AND REPORTING: 39280 - RCR s.79(2) - A licensee must issue or get a receipt, as applicable, for the matters described in subsection 79(1).
Observation: An invoice provided in 2022 to the representative of a PIC for supplies charged in 2020 was not itemized and did not include receipts.
Corrective Action(s): Receipts must be issued.
Date to be Corrected:
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