STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Review of 5 staff files found that 5/5 are not up to date. 3 did not have any evaluations in their file, 1 was from 2008 and 1 was from 2007. The Site Leader has now been at Finnish for 5 months and will start completing employee evaluations to get them all up to date.
Corrective Action(s): Please submit a plan to CCFL as to how the evaluations will be completed by the date below.
Date to be Corrected: March 15, 2017
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: A review of 12 instances of PRN documentation in the MAR found that 1/12 did not have effectiveness of the PRN documented. It is noted that this in an improvement from the routine inspection.
Corrective Action(s): Ensure that employees comply with the policies and procedures of the MSAC
Date to be Corrected: December 15, 2016
RECORDS AND REPORTING: 39130 - RCR s.78(1)(a) - A licensee must keep, for each person in care, a record showing the following information: (a) name, sex, date of birth, medical insurance plan number and immunization status.
Observation: Review of 5 PIC files found that 3/5 did not include historical immunization records.
Corrective Action(s): Ensure that all PIC's have historical immunization records in their file. Please submit a plan in your response to CCFL as to how these will be collected by the date below.
Date to be Corrected: May 1, 2017
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