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 nutrition audits summary sheet as to when the various audits are to be completed, it was noted for the April 6, 2021 meal service audit that nothing was documented (e.g., was it missed for a certain reason, etc). The Director of Wellness explained the April 6, 2021 did not occur as the staff that completes this was away.
Corrective Action(s): Please ensure the care and services provided by the facility are monitored regularly to ensure that the requirements of the Community Care & Assisted Living and Residential Care Regulation are being met.
Date to be Corrected: To be completed by September 13, 2021.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: A review of the physical plant indicated that in one ensuite washroom the hot water temperature was at 51.6 degrees Celsius. This room currently is not being occupied. The Director of Wellness stated that the Maintenance Staff would be made aware to address this.
Corrective Action(s): Please ensure that water accessible to a person in care from any source is not heated to more than 49 degrees Celsius.
Date to be Corrected: September 7, 2021 the Maintenance Staff was going to address this.
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: In review of four staff files, one file did not have references on file.
Corrective Action(s): Please ensure references are on personnel files as required.
Date to be Corrected: September 17, 2021.
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: Performance appraisals are to be completed on a yearly basis. Of the four staff files reviewed, one staff file did not have a performance appraisal noted and one staff file had a performance appraisal from 2019. The writer was advised for the one staff file with no performance appraisal that it was completed in 2020 and this will be looked into.
Corrective Action(s): Please ensure that the performance of each staff is reviewed on a regular basis.
Date to be Corrected: September 17, 2021.
STAFFING: 32270 - RCR s.44(2) - A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is (a) a nutrition manager with membership in the Canadian Society of Nutrition Management, (b) a person who is eligible to be a member of the Canadian Society of Nutrition Management, or (c) a dietitian.
Observation: Community Care Facilities Licensing was made aware on September 7, 2021 during the routine inspection that since February/March 2021 the previous Food Services Manager left their position. The facility currently is not meeting section 44(2) of the Residential Care Regulation and the facility will be submitting an exemption request. Community Care Facilities Licensing will review the exemption request, however there is no guarantee it will be approved.
Corrective Action(s): Please ensure you are meeting section 44(2) of the Residential Care Regulation and to notify Community Care Facilities Licensing in a timely fashion when someone has left their position as nearly 7 months went by before notification occurred.
Date to be Corrected: A plan is to be submitted by September 24, 2021.
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: In review of four staff files, one staff file did not have immunizations on the personnel file.
Corrective Action(s): Please ensure immunizations are documented and on personnel files as required.
Date to be Corrected: September 17, 2021.
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