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 inspection a number of areas in the hallways were observed to have have deep scrapes, scuffs and missing paint, this includes walls, doors and doorway trim.
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 29, 2022
STAFFING: 32040 - RCR s.37(1)(d) - 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: (d) copies of any diplomas, certificates or other evidence of the person's training and skills.
Observation: Upon review of 3 employee files, 2 of 3 have an expired food safe certificate on file; this is a requirement of their employment.
Corrective Action(s): Ensure to obtain copies of any diplomas, certificates or other evidence of the employees training and skills.
Date to be Corrected: July 29, 2022
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: Review of the fire safety binder documentation shows that for many years until December 2019 fire drills were done monthly, the documentation shows a drill completed in March of 2020; there is no evidence of fire drills completed since that time. In discussion with staff, it was confirmed that drills used to be completed monthly.
Corrective Action(s): Ensure that each employee is trained in the implementation of the plans described in subsection (1), including the use of any equipment noted in the plan.
Date to be Corrected: July 29, 2022
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 3 persons in care charts and found that 3 of 3 charts contain no evidence of childhood immunization records.
Corrective Action(s): Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.
Date to be Corrected: July 29, 2022
RECORDS AND REPORTING: 39440 - RCR s.86(d) - A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Observation: In discussion with staff it was confirmed that performance reviews are completed annually. Upon Review of 3 employee files, evidence that 1 of 3 employees' perfomance review is overdue.
Corrective Action(s): Ensure that records are kept in repsect of each employee: (d) a record of any performance reviews made under section 40(continuing monitoring of employees) and any attendance at continuing education programs.
Date to be Corrected: July 29, 2022
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