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 (CORRECTED DURING INSPECTION): One bottle of disinfectant cleanser was stored in an unlocked cabinet in PIC's spa room.
Corrective Action(s): Please ensure to have a secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Date to be Corrected: December 5, 2023
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: One of 12 staff files did not have the evidence of compliance to Province's immunization and TB on file.
Corrective Action(s): Please ensure that all employees in the community care facility provide evidence of compliance to Province's immunization and tuberculosis control program.
Date to be Corrected: December 28, 2023
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: The Licensee’s policy and procedure required that staff’s performance review are completed annually. One of 12 staff had the last performance review completed in 2020.
Corrective Action(s): Staff performance review must be completed according to the licensee's policies and procedures.
Date to be Corrected: December 28, 2023
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: A medication has no date when it was opened, this medication has the pharmacy label that can be stored outside the fridge for 28 days. Medication count sheets were missing 12 second signatures.
Corrective Action(s): A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: December 5, 2023
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - 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 (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Two persons in care has no current signed consent from the medical practitioner or nurse practitioner for the use of restraint on file.
Corrective Action(s): Please ensure that there is an agreement to the use of a restrain given in writing by medical practitioner or nurse practitioner responsible for the health of the PIC.
Date to be Corrected: December 28, 2023
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: Three of 16 persons in care has no dental consult on file, no evidence to support encouragement and no oral care plan.
Corrective Action(s): A licensee must encourage the person in care to be examined by a dental health care professional at least once every year.
Date to be Corrected: December 28, 2023
CARE AND/OR SUPERVISION: 34350 - RCR s.63(3)(c)(ii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (ii) indicated in the care plan of a person in care.
Observation: Two persons in care were provided with ongoing room tray service however this service was not written in the PICs care plan.
Corrective Action(s): Please ensure that meals are provided by ongoing room tray service must be indicated in the care plan of a person in care.
Date to be Corrected: December 28, 2023
CARE AND/OR SUPERVISION: 34360 - RCR s.63(3)(c)(iii) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iii) approved by the person in care's medical practitioner or nurse practitioner.
Observation: One person in care with meals provided by ongoing room tray service does not have the physician's order in file.
Corrective Action(s): Please ensure that meals are provided by ongoing room tray service if approved by the person in care's medical practitioner or nurse practitioner.
Date to be Corrected: December 28, 2023
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation (CORRECTED DURING INSPECTION): One of three medication rooms has person in care's medication and contingency supplies passed its expiry date.
Corrective Action(s): Please ensure to return person in care's medication to the dispensing pharmacy if the expiry date on the medication has passed.
Date to be Corrected: December 6, 2023
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