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: In a review of systems in place, it is observed that there lacks a system for the monitoring of care and services provided by the facility. Such examples include review of staff sign off of daily forms and checklists; duplication of forms; staff performance reviews; use of forms by persons in care; and ensuring information to guide staff is current. As well, there was documents in various areas, which were either difficult to locate or lacked the ease of access for staff should they require them. One examle being 3 emergency/ disaster plans with differing information in three separate areas.
Corrective Action(s): Ensure system is in place to monitor the facility and the care and services provided by it. Licensing reviewed with the manager, where licensing information is available online for referrence.
Date to be Corrected: February 16, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: Review of person in care's rooms and discussion with the manager, each person in care's bedroom furnishings do not include a safe, secure place in which the person in care may store valuable property should they choose.
Corrective Action(s): Ensure each person in care is provided with a safe, secure place in which they can store valuable property should they choose.
Date to be Corrected: February 16, 2018
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31820 - RCR s.36(1)(c) - A licensee must provide outside activity areas that have (c) comfortable seating including a reasonable amount of shelter from sun and inclement weather.
Observation: Review of outdoor lounge area and discussion with the manager, there is no comfortable seating including a reasonable amount of shelter from the sun and inclement weather for persons in care who are not smokers.
Corrective Action(s): Ensure all persons in care have comfortable seating including a reasonable amount of shelter from sun and inclement weather.
Date to be Corrected: February 16, 2018
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: Audit of 2 staff files: performance reviews were last completed in 2016. These are to be completed yearly. The manager stated performance reviews were not completed in 2017.
Corrective Action(s): Ensure regular performance reviews are completed to ensure that staff demonstrate the competence required for the duties to which the employee is assigned.
Date to be Corrected: February 16, 2018
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: Medication Safety and Advisory committee (MSAC) meeting was not conducted in 2017 as indicated in the previous MSAC meeting minutes in June 2016 and MSAC policy.
Corrective Action(s): Ensure meetings are held in accordance to policy and in respect to the Pharmacy Operations and Drug Scheduling Act. This includes meetings conducted to meet the intent of RCR s.68(3)(a)(b)(i)(ii).
Date to be Corrected: February 16, 2018
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Review of emergency and disaster plans, and discussion with the manager, there were no procedure for evacuation aside from meeting across the street. There was no information for relocation for persons in care or documentation on alternate sources for emergency supplies off site.
Corrective Action(s): Ensure the emergency plan includes that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedure for the evacuation of persons in care.
Date to be Corrected: February 16, 2018
POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Observation: The emergency plan did include information on how the person in care will be continued to be cared for in the event of an emergency.
Corrective Action(s): Ensure the plan sets out how persons in care will continue to be cared for in the event of an emergency.
Date to be Corrected: February 16, 2018
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: Although the manager has reviewed the policies and procedures in a timely manner, updates are required in some areas, including manager name and menu for emergency which contains food not available on site.
Corrective Action(s): Ensure policies are revised the policies and procedures at least once each year.
Date to be Corrected: February 16, 2018
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Minimum of 5 staff have not signed in 2017 for the following forms for review and understanding: fire safety plan, disaster plan, operating manual, admission and discharge binder, records, daily food logs, grooming checklists, and staff sign off for key logs.
Corrective Action(s): Ensure policies and protocols implemented by employees.
Date to be Corrected: February 16, 2018
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