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 light above the sink is missing the cover and there are exposed wires.
-extension cords in bedrooms were unsecured and could be a possible tripping hazard
-It was noted that in many of the rooms the paint is chipped and worn on both walls and baseboards, there is metal showing on corners and drywall chunks are missing in high traffic areas
-The condition of the flooring throughout is poor and in need of repair or replacement specifically wood floors and carpeting. -Through discussion with the manager it was explained that the carpets are cleaned frequently there but the still staining is still present due to wear and tear.
-Damage to the wall at the top of the stair where the gate latch is mounted and the latch is loose and falling off
-The stairs to the shed are missing non slip grip and are slippery
-There is a large amount of funrinture and house hold items being stored under the deck
-One chair in the second living room is in need of replacement due to wear and tear
-The cabinet in the pantry room is rotten on the bottom on the back and is falling over
Corrective Action(s): Ensure that all rooms and common areas are maintained in a state of good repair
Date to be Corrected: November 29, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31310 - RCR s.22(2) - A licensee must ensure that emergency exits are not obstructed or secured in a manner that may hinder exit in an emergency.
Observation: Both downstairs bedroom windows on the backside of the house were blocked by furniture and cardboard and other items which would hinder exit in an emergency
Corrective Action(s): Ensure all emergency exits are not obstructed
Date to be Corrected: October 4, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31590 - RCR s.30(b) - A licensee must ensure that all bathrooms have (b) slip resistant material on the bottom of each bathtub and shower.
Observation: There were no non-slip mats or slip resistant material in the tubs/showers in 2 of the bathrooms and the roof in the 1 shower was peeling.
Corrective Action(s): Ensure slip resistant mats or material is in tubs and showers
Date to be Corrected: Oct 18 2018
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: The training and orientation programs for employees who store, handle or administer medications is not discussed iin the MSAC meeting minutes
Corrective Action(s): It is recommended that these items be added as a standing agenda item to address during the MSAC annual meeting.
Date to be Corrected: The next MSAC meeting -
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: Upon review of the policy manual it was observed that there were some policies that had been reviewed in 2017 and some that had no dates on them as to indicate when they were last reviewed. The manager explained that they policies are reviewed and revised often but no documentation was available to show when.
Corrective Action(s): Review and revise policies and procedures at least once per year
Date to be Corrected: October 18 2018
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: It has been noted during the routine inspection that the facility policy and legislation in regards to the safe handling and administration of medication to persons in care is not being implemented.
Missing signatures is a trend that was noted on daily and PRN MARs and on previous months MAR sheets. The facility has been in noncompliance in previous inspections.
Corrective Action(s): A process of self-monitoring must be implemented by the Licensee to ensure that the policies are being implemented by the employees in relation to the medication and administration policies of the facility the MSAC.
Date to be Corrected: October 18, 2018
POLICIES AND PROCEDURES: 33340 - RCR s.85(2)(d) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (d) how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60 [dispute resolution].
Observation: Although there is a policy for complaint resolution and the procedures are available in the hand book for PIC's, there is no physical form available at the time of inspection
Corrective Action(s): Ensure the complaint forms are available and accesible for PIC's and family
Date to be Corrected: October 18, 2018
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: Review of the care plans and discussion with staff found that oral health care plans are in place but are missing some information related to the daily care and specifics of care. PIC's are independent with oral health care and need little to no direction.
Corrective Action(s): ensure oral health care plans are included in PIC's care plans
Date to be Corrected: October 27, 2018
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: Shower and personal items were unlabelled in the bathrooms and stored together.
Corrective Action(s): It is recommended that the PIC’s personal hygiene items are labelled individually and stored separately from other PIC’s personal hygiene products.
Date to be Corrected:
MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation: Vitamins belonging to PIC’s were stored together in a basket with no division of mediations and were not stored in a locked area of the medication room. Through discussion with the manager it was explained that the PIC’s self-administer these medications without direct supervision from staff and no medication self-administration plan has been implemented or approved by the MSAC and Medical practitioner
Corrective Action(s): Ensure a self administration plan is approved by the MSAC and Medical practitioner
Date to be Corrected: October 18 2018
RECORDS AND REPORTING: 39410 - RCR s.86(a) - A licensee must keep the following records in respect of each employee: (a) criminal record check results,.
Observation: upon review of 2 employee files it was noted that both had expired Criminal Record Checks. There were previous years record checks in the files
Corrective Action(s): Ensure all amployees have current Criminal record Checks in their files
Date to be Corrected: October 27, 2018
RECORDS AND REPORTING: 39430 - RCR s.86(c) - A licensee must keep the following records in respect of each employee: (c) compliance with the Province's immunization and tuberculosis control programs.
Observation: TB status forms for volunteers were missing in 3 out of 3 files reviewed and Immunization record in 1 out of 2 staff files reviewed were missing
Corrective Action(s): Ensure all staff are in compliance with the TB and Immunization program and have supporting records in their files
Date to be Corrected: October 27, 2018
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