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: Review of 3 CRC's in the staff files found that they are the local police CRC's.
Corrective Action(s): CRC's from the Criminal Records Review Program in Victoria, BC are required for all employees of licensed programs. Please ensure all staff have these CRC's.
Date to be Corrected: January 31, 2017
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: Review of 3 staff files found that 1/3 was missing an immunization record and 1/3 was incomplete. TB 1/3 was missing.
Corrective Action(s): Ensure that all staff have evidence of compliance with the province's immunization and TB control programs in their files.
Date to be Corrected: December 31, 2017
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: Review of 3 PIC files found that 2/3 had incomplete immunization information.
Corrective Action(s): Ensure that all PIC's have evidence of immunization in their files
Date to be Corrected: December 31, 2017
MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record.
Observation: Review of MAR records found that one PIC had a medication that was prescribed by the physician as a PRN medication. The MAR provided by the pharmacy for this medication stated it was provided once daily at night.
Corrective Action(s): Ensure that MAR records are accurate compared to the prescription
Date to be Corrected: October 31, 2017
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Review of non-reportable incidents found 3 examples of transfers to hospital where CCFL was not sent a reportable incident. Site Manager clarified that the understanding for staff was that any incidents involving privately funded clients did not need reporting to CCFL. The LO clarified that all reportable incidents regarding any PIC's require reporting.
Corrective Action(s): Ensure all reportable incidents are reporting to licensing as required.
Date to be Corrected: October 30, 2017
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