PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: The Basement emergency exit had some garbage and rotting leaves on the stairs creating a potential slipping hazard.
Corrective Action(s): Please ensure that all common areas are maintained in a good state of repair.
Date to be Corrected: July 14 2017
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: A review of facility policy and procedure manual showed that they have not been reviewed within the last year. The facility Director stated that upper management is in the process of completing this.
Corrective Action(s): Please ensure that policy and procedures are reviewed at least once each year.
Date to be Corrected: September 30 2017
CARE AND/OR SUPERVISION: 34180 - RCR s.54(3)(a) - A licensee must (a) encourage persons in care to be examined by a dental health care professional at least once every year.
Observation: Review of 4 PIC's files found that 1 contained no record of the PIC being encouraged to be examined by a dental health care professional within the last year.
Corrective Action(s): Please ensure there is a system in place for tracking when PIC's are encouraged to be examined by a dental health care professional. Please ensure that all PIC's are being encouraged to see a dental health professional at least once each year.
Date to be Corrected: July 31 2017
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Review of 4 PIC's files found that 1 did not contain a recreation and leisure plan.
Corrective Action(s): Please ensure that all PIC's care plans contain a recreation and leisure plan.
Date to be Corrected: July 31 2017
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: Review of 4 PIC's files noted the following:
- 1 PIC's oral care plan was due to be reviewed in April 2017.
- 1 PIC's nutrition care plan was due to be reviewed in May 2016.
- 1 PIC's Recovery Care Plan was due to be updated in April 2017.
Corrective Action(s): Please ensure there is a system in place for identifying when care plan reviews are due and that they are being reviewed at least once every year.
Date to be Corrected: July 31 2017
CARE AND/OR SUPERVISION: 34790 - RCR s.83(1)(a) - A licensee of a community care facility with 24 or fewer persons in care must (a) develop a nutrition plan for each person in care.
Observation: A review of 4 PIC's files found that 1 PIC had no nutritional care plan on file and 2 PIC's had no food/nutrition screening form completed.
Corrective Action(s): Please ensure that all PIC's have a nutritional care plan in place.
Date to be Corrected: July 31 2017
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: A review of 4 PIC's files found that 2 had no information regarding immunization/TB status.
Corrective Action(s): Please ensure that all PIC's care plans contain a record of their immunization status.
Date to be Corrected: July 31 2017
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 4 PIC's files found that 1 contained no consent to call for medical assistance in the case of an accident or illness.
Corrective Action(s): Please ensure that all PIC's care plans contain the consent for medical assistance in the case of an accident or illness.
Date to be Corrected: July 31 2017
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