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 review of the care flow sheets for a person in care, it was noted not all entries are being documented (one specific example provided during the inspection to the Manager).
In review of the nutrition binder for persons in care noted with for example:
- Screening form for when to get a Dietitian involved dated January 25, 2020 which is not current,
- Food and Nutrition Information document dated January 25, 2020 which is not current, and the nutrition assessment (Yes or No not checked off at the bottom of the form).
Corrective Action(s): Please ensure the care and services provided by the community care facility is regularly monitored to ensure the requirements of the Act and this regulation are being met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A review of the physical plan indicated that there is a pole where the main dining room is by the kitchen, and the at the bottom of the pole for example are chip marks in the pole and the blue paint is coming off. The Manager stated plexiglass is proposed to be put near the bottom of the pole.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of two staff files indicated for both files that the Criminal Record Check through the Ministry for Public Safety & Solicitor General are not on file.
Corrective Action(s): Please ensure Section 37(1)(a) of the Residential Care Regulation is met as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of two staff files indicated for one file there are no written references noted.
Corrective Action(s): Please ensure references are noted on staff files as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of two staff files indicated copies of any diplomas/certicates were not on one file.
Corrective Action(s): Please ensure Section 37 (1)(d) of the Residential Care Regulation is met as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: There is no emergency menu in-place. The writer emailed a sample emergency menu to the Licensee Contact on March 6, 2021 to assist in guiding the site to develop their own.
Corrective Action(s): Please ensure there is a emergency menu in-place.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: A review of the Medication Safety and Advisory Committee (MSAC) meeting minutes, a review of the policies and procedures in respect of the safe and effective storage, handling and administration of the person in care's medication, in compliance with the Pharmacy Operations and Drug Scheduling Act not noted in-writing. There is a Pharmacist for the facility and the process to review the policies and procedures around medications needs to be formalized. The writer recommended having this item as a "standing agenda item" as part of the MSAC meetings. The Manager stated this will be brought up at the next MSAC meeting on March 19, 2021.
Corrective Action(s): Please ensure the required policies and procedures are reviewed by the MSAC.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation: As per section 74(1)(b)(ii) of the Residential Care Regulation.
Corrective Action(s): As above.
Date to be Corrected: As above.
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: In discussion with the Manager and a random review of a person in care's chart/records indicated Section 74 (1)(b)(ii) of the Residential Care Regulation has not been met. The Manager stated this would be addressed.
Corrective Action(s): Please ensure Section 74 (1)(b)(ii) of the Residential Care Regulation is met for all persons in care where this is applicable. In addition, please ensure all requirements as per section 73, 74, 75, and 84 of the Residential Care Regulation are met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: A random review of a person in care's chart/records indicated there is no oral/dental care plan. The writer emailed to the Manager a sample oral care plan, and other relevant resources around oral/dental care on March 9, 2021.
Corrective Action(s): Please ensure all persons in care have a oral/dental care plan in-place.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A random review of two staff files indicated one staff file did not have Tuberculosis Clearance on file. The Manager does have a copy of the Community Care Facilities Licensing Tuberculosis and Immunization Guideline for staff.
Corrective Action(s): Please ensure Tuberculosis clearance is noted on staff personnel files as required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: There is a nutrition binder with nutrition audits. The Summary Monitoring System for Nutrition is from 2018 and 2019 which is not current. For a person in care, the nutrition satisfaction survey has no date noted, Nutrition Care Plan Checklist is dated January 25, 2020, and other applicable audits such as menu audits are not documented.
Corrective Action(s): Please review the Meals and More Manual which has standardized audits included that can be adapted to your setting. Please ensure all relevant audits are completed and in-place specific to your setting.
Date to be Corrected: Please provide a written response by the timeline noted in this report.
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