PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31330 - RCR s.23(a) - A licensee must ensure that (a) no one other than a person in care smokes or uses tobacco, holds lighted tobacco, uses an e-cigarette or holds an activated e-cigarette while on the premises of a community care facility,
Observation: On both days of the inspection staff and visitors were observed to be smoking on site with the PICs.
Corrective Action(s): Ensure that only PICs smoke on the premise of the facility.
Date to be Corrected: Nov 20, 2019
STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person.
Observation: 1 out of 9 employee files did not contain a current criminal record check. A check was conducted but the results did not indicate the staff passed the check and a further check needed to be obtained.
Corrective Action(s): An employee must not be employed without a criminal record check first being completed.
Date to be Corrected: Nov 20, 2019
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: 1 out of 9 employee files did not have evidence of reference checks being completed and on the checklist in the employee file, reference checks was marked as not being applicable.
This also contravened at the routine inspection conducted in 2017 (inspection #SCLY-ATKTEM).
Corrective Action(s): It is a legislative requirement to obtain reference checks before employing a person in a community care facility.
Date to be Corrected: Nov 20, 2019
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: Review of 9 staff files found 8 of them to not have current employee appraisals going back to 2015. Staff stated that these should be conducted once each year.
This is a repeat contravention from the previous two routine inspections (inspection #SCLY-ATKTEM and CJOS-B78MTK).
Corrective Action(s): Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer.
Date to be Corrected: Nov 20, 2019
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: The emergency plan policy does not speak to practicing drills in order for staff and PICs to be prepared in the case of an emergency.
Corrective Action(s): Please ensure that you update your policy to include procedures for PICs and staff being prepared in the case of an emergency
Date to be Corrected: Nov 20, 2019
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: Review of policies and procedures found that they have not been reviewed and/or revised in the past year. It was last completed in June of 2018.
The smoking policy has not been updated to reflect the change in legislation which prohibits anyone, who is not a PIC, from smoking on the premise.
The smoking policy states that PICs, staff, and visitors are not encouraged to smoke. Discussion with staff determined that this means that staff and visitors are allowed to smoke on site. Residential Care Regulations section 23 specifies that staff and volunteers are not to smoke on premise or when supervising PICs off premise.
These are all repeat contraventions from a previous routine inspection (inspection #SCLY-ATKTEM)
Corrective Action(s): Ensure that policies and procedures are reviewed at least once each year and revised as necessary.
Date to be Corrected: Nov 20, 2019
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: Review of MARs found that 2 out of 4 records were missing 1 or more signatures. When this was pointed out to staff, the staff member began to sign for one MAR that had at least 6 missing signatures. MARs are to be signed after given and if not given it is to be indicated why they were not.
These are all repeat contraventions from a previous routine inspection (inspection #SCLY-ATKTEM)
Corrective Action(s): Ensure that staff comply with the policy and procedures of the medication safety and advisory committee.
Date to be Corrected: Nov 20, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Review of 6 person in care (PIC) records found that none of them had evidence of immunization records being obtained and 5 of them had to evidence of TB screening.
This is a repeat contravention from 2 previous routine inspections (inspection #CJOS-B78MTK and KDHL-AFPUHL).
Corrective Action(s): Ensure that each PIC admitted to the facility complies with the Province's immunization and tuberculosis control programs.
Date to be Corrected: Nov 20, 2019
MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation: 3 out of 4 medication administration records and blister packs had evidence of medication that is not prescribed to the PIC being administered.
Corrective Action(s): Ensure that only medication that is prescribed to the PIC is administered to them.
Date to be Corrected: Nov 20, 2019
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