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: In review of the policy regarding complaints/appeals and the information provided to residents/family on admission, there does not appear to be any information regarding expressing concerns or making complaints to the MHO.
Corrective Action(s): Ensure the above noted information is made available to residents/family and the policy is revised accordingly
Date to be Corrected:
POLICIES AND PROCEDURES: 33370 - RCR s.85(2)(f)(i) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (f) release of children, youths and vulnerable adults from the community care facility, including (i) if a person who is authorized to remove the person in care from the community care facility appears to be incapable of providing safe care to the person in care.
Observation: In review of the policy regarding the release of vulnerable persons in care, there does not appear to be information as per the above noted legislation..
Corrective Action(s): Ensure there is a written policy available to guide staff in the event a person who is authorized to remove a resident does not appear to be capable of providing safe care.
Date to be Corrected:
POLICIES AND PROCEDURES: 33380 - RCR s.85(2)(f)(ii) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (f) release of children, youths and vulnerable adults from the community care facility, including (ii) if a person who is not authorized to remove the person in care from the community care facility requests the release of the person in care.
Observation: In review of the policy regarding the release of vulnerable persons in care, there does not appear to be information available to guide staff in the event a person who is not authorized in writing requests to remove the resident. (from the facility)
Corrective Action(s): Ensure there is a policy to guide staff as per the above noted legislation.
Date to be Corrected:
POLICIES AND PROCEDURES: 33420 - RCR s.85(2)(j) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (j) responding to reportable incidents.
Observation: In review of the policy for Reportable Incidents (RI's), the information and some definitions are contrary to legislation. The policy refers to critical incidents and reportable incidents. The definition/examples of aggressive/unusual behavior are identified as critical incidents, however some are actually RI's and reportable to CCFL. Also, under procedures, it does not identify the requirement to submit RI's to CCFL
Corrective Action(s): Please review and revise the policy to reflect the requirements as per legislation.
Date to be Corrected:
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