LICENSING: 30040 - RCR s.8(2)(b) - A licensee must not make any structural change to a community care facility unless the licensee (b) receives written approval from the medical health officer.
Observation: On day one of the inspection it was observed that a wall had been erected in the large recreation room on the first floor. The space was divided into two areas connected by a door. No written request or health and safety plan for this change was submitted to CCFL for approval prior to it being erected. Licensee has stated that the wall will be removed immediately.
It was confirmed on day 2 of the inspection that the wall had been removed.
Corrective Action(s): Please ensure that no structural changes are made without first receiving written approval from CCFL.
Date to be Corrected: Immediately.
LICENSING: 30160 - RCR s.11(1)(b) - A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility (b) the most recent routine inspection record made under section 9 (1)(d) of the Act.
Observation: The last routine inspection was not displayed as required.
Corrective Action(s): Please ensure that the most recent routine inspection is displayed in a prominent place.
Date to be Corrected: July 30, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: The temperature of water was tested at four sources, two of the four exceeded 49 degrees Celsius.
Corrective Action(s): Please ensure that water accessible to PIC does not exceed 49 degrees Celsius.
Date to be Corrected: July 30, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31200 - RCR s.19(3) - If a licensee installs electronic devices for the purposes of transmitting or recording images of persons in care or members of the public, the licensee must display in a prominent place notice that electronic surveillance is being used.
Observation: One persons in care (PIC) has a video monitoring device in their bedroom and a second PIC has an audio monitoring device in their bedroom. There is no notice posted that either devices are installed or in use.
Corrective Action(s): Please ensure that notice of electronic surveillance is prominently posted.
Date to be Corrected: Immediately
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: During the routine inspection, the following was noted:
- One bathroom wall requires repainting
-One bedroom has an area that requires repainting behind the TV due to holes.
-One bathroom counters caulking is peeling and needs to be repaired.
-Floor tiles in first floor recreation room are lifting, of concern is the potential to be a tripping hazard.
-The corner of a wall in one bedroom is damaged, with the metal exposed beneath the paint.
-The bottom of a bathroom counter top is chipped and broken, leaving a sharp edge.
-Baseboard trim removed from one wall in a bedroom, the trim was left leaning against a wall behind the door.
Corrective Action(s): Please ensure that at all times, rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 30, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: During the routine inspection, the following was observed:
-One bedroom had a large amount of personal items belonging to a PIC stored on the floor, of concern is the ability to clean the floor.
-One communal shower room had multiple bottles of personal hygiene items belonging to different persons in care, this system does not ensure that PICs are using only their own hygiene items.
-The window sills in the upstairs recreation room were dirty and had loose screws resting on them.
-The upstairs recreation room had several items being stored in there, in discussion it was confirmed that these items were going to be disposed of at some point and were not currently in use. Some of the items belonged to a PIC who did not have room in their bedroom.
-A three drawer storage system in the bathroom of a PIC was dirty, liquids had spilled in the drawers and personal items were stuck in the substance.
-Basement of the facility has a large amount items being stored. These are items that are no longer being used by persons in care and are stacked against the walls in numerous areas. This was identified as a hazard during the last routine inspection, however was not resolved. Licensee states that items will be removed by August 1, 2021.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: July 30, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: Facility contains exercise equipment that is used by persons in care within their rehabilitation program, however, in discussion, it was determined that there is no formal system in place to inspect and maintain this equipment to ensure that it is in safe, usable condition for PICs at all times.
Corrective Action(s): Please ensure there is a system in place to ensure that all exercise equipment used by PIC is inspected, and maintained in a safe condition.
Date to be Corrected: Immediately
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: One cupboard for chemical storage was left unlocked and accessible to persons in care. This was observed on day 1 and day 2 of the inspection.
Corrective Action(s): Please ensure that all chemicals and cleaning agents are secured at all time.
Date to be Corrected: Immediately
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: One person in care had three medications left in their bathroom unsecured and accessible.
Corrective Action(s): Please ensure that all medications are securely stored.
Date to be Corrected: Immediately
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: In a review of 4 employee files, 3 did not have evidence of compliance with the Provinces immunization and tuberculosis control programs, or the evidence was incomplete.
Corrective Action(s): Please ensure there is evidence that all employees have complied with the Provinces immunization and tuberculosis control program in full.
Date to be Corrected: July 30, 2021
STAFFING: 32080 - RCR s.37(2)(c) - A licensee must not employ a person in a community care facility unless the licensee is satisfied, based on the information available to the licensee under subsection (1), that the person (c) has the training and experience and demonstrates the skills necessary to carry out the duties assigned to the manager or employee.
Observation: In a review of one staff file, it could not be demonstrated how the licensee determined that the employee had the required training and experience for their duties. There was no evidence of an assessment of the employees skills to complete the job as required prior to being employed.
Corrective Action(s): Please ensure that prior to employing a person, there is evidence that they have the training and experience and demonstrate the skills required to carry out their job duties.
Date to be Corrected: July 30, 2021
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: In a review of 4 employee files, there was no evidence of regular performance reviews as required. Facility policy states that performance is reviewed on an annual basis.
Corrective Action(s): Please ensure that all employees have regular performance reviewed completed to ensure compliance.
Date to be Corrected: July 30, 2021
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: In a review of 4 employee files, there was no evidence of any employee having valid first aid and CPR certificate.
Corrective Action(s): Please ensure that it can be demonstrated that all persons in care have access to an employee who holds a valid first aid and CPR certificate at all times.
Date to be Corrected: Immediately
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: In a review of medication protocol and policies it was determined that staff were not in compliance when they were administering standing order medication not as directed. In addition, staff were not documenting the effectiveness of medications as required on the MAR.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures for the medication safety and advisory committed
Date to be Corrected: July 30, 2021
POLICIES AND PROCEDURES: 33080 - RCR s.51(2) - A licensee must ensure that the plans described in subsection (1) are updated if there is any change in the facility
Observation: During the inspection, it was confirmed that staff do, stay in the facility outside of their scheduled work hours, however this is not reflected in the Emergency plans. Floor plans do not include the area as being in use for sleeping.
Corrective Action(s): Please ensure that plans are updated.
Date to be Corrected: July 30, 2021
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: It was confirmed that no PRN medication protocols have been developed by MSAC to support non-regulated staff in the safe administration of those medications.
Corrective Action(s): Please ensure that all PRN medications have protocols established to ensure safe medication administration.
Date to be Corrected: July 30, 2021
CARE AND/OR SUPERVISION: 34610 - RCR s.81(3)(a)(ii) - A care plan must include all of the following: (a) a plan to address (ii) behavioural intervention, if applicable.
Observation: In a review of 5 care plans, it was observed that the plans to address behaviors were incomplete and did not include all the relevant information that was found when observing the persons in care, their personal spaces, as well as other documentation present in their records. This was confirmed when speaking with staff.
Examples:
- One PIC requires their bathroom door to be locked at all times due to behaviors, this was not included in the care plan.
- A PIC keeps an abundance of personal items in their space as well as common areas due to behaviors, this was not included in the care plan.
- A PIC purchases a large amount of one item which is related to their behavior, however this was not included in the care plan
- Two persons in care have monitoring devices installed in their room (one video, one audio) for staff to monitor their safely and behaviors, however neither have it included in their care plans.
Corrective Action(s): Please ensure that each care plan addresses behavioral interventions for persons in care.
Date to be Corrected: July 30, 2021
CARE AND/OR SUPERVISION: 34620 - RCR s.81(3)(a)(iii) - A care plan must include all of the following: (a) a plan to address (iii) if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment.
Observation: In a review of care plans for two persons in care, it was confirmed that the restraints in use were not included in the care plan as required.
Corrective Action(s): Please ensure that the care plan includes the use of restraints, including the nature and frequency of reassessment.
Date to be Corrected: Immediately
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: During day 2 of the inspection, a review of the freezer temperature log was completed, Staff were unable to demonstrate how the temperature was monitored and upon review it was determined that the recorded temperature was inaccurate. It could not be confirmed how staff were determining the previously documented freezer temperatures. It was also noted that the freezer had condensation on the roof that not frozen, but liquid.
5 items were found in the fridges in the home that were either, past their expiration date, opened but not dated or absent a contents label entirely.
Corrective Action(s): Please ensure that freezer temperature is monitored accurately to ensure that food is safely stored.
Date to be Corrected: Immediately
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: In a review of documentation in persons in cares records, it was determined that not all incidents that met the definition of being reportable as per Schedule C were being reported. One example of this was an incident of Unusual Behavior involving two persons in care.
Corrective Action(s): Please ensure that all incidents that meet the definition of being reportable as per Schedule C, are reported in the time and manner required.
Date to be Corrected: Immediately.
RECORDS AND REPORTING: 39190 - RCR s.78(2)(a) - A licensee must keep, for each person in care, a medication administration record showing (a) all medication administered to the person in care.
Observation: It was observed that one person in care was administered a medication that was not documented as being given on the medication administration record.
Corrective Action(s): Ensure that all medications administered are documented as such on the medication administration record as required.
Date to be Corrected: Immediately
RECORDS AND REPORTING: 39670 - RCR s.93 - A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential.
Observation: One person in care had personal medical information posted on their bedroom door which was visible to all other persons in care, staff and visitors.
Corrective Action(s): Please ensure that all personal records and information related to PIC are maintained in a confidential way.
Date to be Corrected: Immediately
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