LICENSING: 30030 - RCR s.8(2)(a)(ii) - A licensee must not make any structural change to a community care facility unless the licensee first (a) submits to a medical health officer (ii) a description of how the licensee intends to ensure the health and safety of persons in care while the change is being made.
Observation: A ceiling area in the main bathroom measuring approximately 4x3 feet has been sealed with plastic covering. As per staff person assisting with the inspection, the opening was created for renovation due to water damage. Questions regarding the cutting of the drywall and the asbestos lab test results remained unanswered during the time of this inspection. The exterior wall renovation of the entire building has been completed with new sidings installed and there was insulation material removal work in progress in the crawl space through the main entrance of the building. This LO had requested for work to be stopped until appropriate accepted health and safety measures were in place.
Corrective Action(s): Please ensure that the licensee must not make any structural changes (including renovations affecting the PICs) to a facility unless the licensee first submits and receives acceptance from a medical health officer (Licensing Officer) a description of how the licensee intends to ensure the health and safety of PICs while the change is being made.
Date to be Corrected: July 22, 2022
LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: The facility manager has resigned at the end of April this year and licensee did not notify the medical health officer (Licensing officer).
Corrective Action(s): Please ensure that medical health officer (Licensing Officer) is notified if the manager of a community care facility resigns or is or expects to be absent for at least 30 consecutive days.
Date to be Corrected: July 22, 2022
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: 1 PIC with PRN medication had the missing follow up documentation with the results of the PRN medication administration on the MAR sheet for this month.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the MSAC.
Date to be Corrected: July 22, 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: 1 PIC's Medical Orders for Scope of Treatment (MOST) form on file was dated 2019. No review of the MOST form has occurred within the last 2 years. The staff person assisting with the inspection informed the Licensing Officer that the elevator is not working at the doctor's office and this form will be reviewed soon.
Corrective Action(s): Please ensure that each care plan is reviewed at least once each year to ensure it continues to meet the needs and preferences of the PIC.
Date to be Corrected: July 22, 2022
|