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): During the inspection of the 1st floor linen room, the door was observed to be propped open using a rag and no staff were present around the room at the time. The room is also used to store cleaning supplies and is accessible to PIC's.
Corrective Action(s): Please ensure that all cleaning supplies are stored in a safe and secure manner.
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: A review of 6 staffing files found 3 had no references completed/on file.
Corrective Action(s): Please ensure that character references are obtained for all staff before they begin employment.
Date to be Corrected: September 30 2017
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: During a review of 6 staffing files, the following was noted:
- 1 staff file had no record of a TB check on file.
- 1 staff had no immunization record on file.
Corrective Action(s): Please ensure that all staff have an immunization and TB record on file.
Date to be Corrected: September 30 2017.
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: As per facility policy, staff performance reviews are to be completed annually. During discussion with the DOC it was noted that there are 47 out of 150 staff who have overdue performance reviews.
Corrective Action(s): Please ensure that all staff receive a regular performance review. Please send Licensing an action plan on how this will be addressed.
Date to be Corrected: September 30 2017
POLICIES AND PROCEDURES: 33030 - RCR s.48(1)(c)(i) - Before admitting a person to a community care facility, a licensee must advise the person, or the person's parent or representative, of (c) how the person, or the person's parent or representative, may express concerns or make complaints to (i) a medical health officer.
Observation: No information regarding expressing complaints could be found in the facility's intake package. During a discussion with the DOC it was found that a form with the information does exist but it was not in use at the time and needed to be updated with the current information.
Corrective Action(s): Please ensure that PIC's or their representatives are given information on how to express concerns or make complaints to Licensing before being admitted to the facility.
Date to be Corrected: September 15 2017
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: A review of the policy and procedure manual found some policies that were last reviewed in 2015.
Corrective Action(s): Please ensure that all policies and procedures are reviewed at least once each year.
Date to be Corrected: September 30 2017
CARE AND/OR SUPERVISION: 34950 - CCALA s.7(1)(b)(i) - A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: During the inspection one PIC was observed to be getting shaved by an RCA while in the dining/social area. This was not noted in the PIC's ADL.
Corrective Action(s): Please ensure that all PIC's are cared for in a manner that will promote dignity.
Date to be Corrected: September 30 2017
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