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: Review of 15 employee files found there were several resident care aide (RCA) files that were missing a copy of a diploma or certificate as evidence of training.
Corrective Action(s): Please ensure that all employee files contain a copy of diplomas, certificate or other evidence of training and skills.
Date to be Corrected: March 26, 2021
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: Review of 15 employee files found that 3 were missing or had incomplete evidence of compliance with the Province's immunization and tuberculosis control program. This is a repeat contravention.
Corrective Action(s): Ensure all employees provide evidence of compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: March 26, 2021
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 (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: In discussion with facility leadership it was determined that all departments, with the exception of the cooks, are up to date with staff performance reviews. Facility policy states that performance reviews are required annually. Review of staff files determined that all care staff had evidence of a completed performance review, within the last year. This is a repeat contravention.
Corrective Action(s): Ensure that the performance of each employee is reviewed regularly as required to ensure compliance with the Residential Care Regulation.
Date to be Corrected: March 26, 2021
STAFFING: 32170 - RCR s.42(1)(a) - A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to (a) meet the needs of the persons in care.
Observation: Review of the staff schedule and call out sheet determined that over the past month there were 4 shifts where HCA shifts were not filled, even when overtime was authorized. Additionally there were 5 shifts when nursing shifts were not able to be filled. In discussion with facility leadership, it was determined that the contingency plan includes having some care shifted to the next shift, specifically baths. Additionally, when a nursing (LPN) shift cannot be filled, the RN on duty will fill the LPN role. However this then leaves the RN role unfilled. This role includes supervision, assessments, and a higher level of clinical support for persons in care.
Corrective Action(s): Ensure that at all time there is sufficient staff in numbers, training and experience to meet the needs of persons in care.
Date to be Corrected: March 26, 2021.
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: Review of facility policies determined that several have not been reviewed within the last month. As the facility has recently implemented the use of EMAR and POC, policies related to the use of this technology should be reflected in the policies.
Corrective Action(s): Please ensure that polices are reviewed, and if necessary revised at least once each year.
Date to be Corrected: March 26, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Inspection of the refrigerator found that temperature monitoring was occurring twice daily, however it was determined that most of the recorded temperatures for the month were above the recommended safe zone as documentation was showing 6 degrees or above. Of concern is, this was occurring regularly and there was no direction provided to staff how to respond in the event the temperature is found to outside of the recommended temperatures and no evidence that any action was taken. This is a repeat contravention.
Corrective Action(s): Ensure that all food is safely and securely stored, served and handled.
Date to be Corrected: March 26, 2021
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