LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: It was observed, and discussion with the manager determined that the food and nutrition system within the home was not meeting legislative requirements in the following areas:
-RCR 62(2)(a)- 3 food groups offered in each meal
-RCR 62(2)(b) - 2 food groups offered in 2 snacks per day
-RCR 87(c) - Current Menu audit for the menus being used
The manager described that the menus are in progress, and being redone currently.
Corrective Action(s): Please provide a written plan by November 30th, 2022
Date to be Corrected:
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: Though the pharmacist has been in for a medication room inspection within the past year, there was no evidence that the Medication Safety and Advisory committee had a meeting, as no MSAC meeting minutes were available.
Corrective Action(s): Ensure that when a MSAC meeting takes place the minutes are available and document that the required areas under RCR 68 have been discussed.
Date to be Corrected: November 30, 2022
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: One of two care plans & guidelines reviewed did not have evidence that an annual review had occurred. It was described that the plan is for the care plan to be updated in the coming weeks.
Corrective Action(s): Ensure that each care plan is reviewed and if necessary, modified if there is no substantial change in circumstance, at least once per year.
Date to be Corrected: November 30, 2022
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