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: At the time of inspection, the facility was in the process of having structural changes completed at the facility without first submitting a description of how the licensee intended to ensure the health and safety of persons in care during the changes, a plan for the change and, as per RCR s. 8(2)(b), without having obtained written approval for the changes from the geographic Licensing Officer.
Corrective Action(s): Ensure a plan for change and health and safety plan is completed/submitted and that approval of the plan is obtained from the geographic Licensing Officer prior to commencing structural changes.
Date to be Corrected: Corrected during inspection
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: Upon inspection of rooms and common areas, the following was observed:
- The non-slip tread on the stairs leading from the deck to the back yard was peeling on some stairs and missing from sections of other stairs. This is one of the facility's emergency evacuation routes. (Corrected during inspection)
- The wall behind the kitchen table had an elongated patch approximately 1' x 2", exposing the drywall (Corrected during inspection)
- The door to the downstairs linen closet was off the track
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: July 6, 2021
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: 4 regular employee files and 1 casual employee file were reviewed. 2 employee performance appraisals were completed 50 months ago and 25 months ago. Licensee policy states that employee performance appraisals are to be conducted annually.
Corrective Action(s): Ensure that employee performance appraisals are completed annually, as per licensee policy, to ensure employees demonstrate competence for required duties and ensure compliance with regulations.
Date to be Corrected: July 6, 2021
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: Upon inspection of the medication administration records, the following was observed:
- Charting for the administration of medication for one person in care had not been completed for the morning
- The signature for the administration of a second person in care's PRN medication was missing
- The effects for the administration of a third person in care's PRN medication was missing twice
- The effects for the administration of a fourth person in care's PRN medication was missing once
Corrective Action(s): Ensure all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: Corrected at time of inspection
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: During review of the medication binder, it was noted that the medication safety and advisory committee meeting and pharmacy inspection of medication storage, handling, and administration last occurred on February 3, 2020. Staff reported that the licensee is in the process of obtaining a new pharmacist for the facility.
Corrective Action(s): Ensure the medication safety and advisory committee attends the facility as required to review training and orientation programs for employees and review the policies and procedures in respect of the safe and effective storage, handling and administration of the person in care's medication.
Date to be Corrected: July 6, 2021
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: Restraints are in use for 3 of 5 persons on occasion when in community and 1 of 5 persons on an ongoing basis as a measure to ensure each PIC’s safety; however, signed consents have not been obtained from the parents, representatives or medical practitioner or nurse practitioner for the use of the restraint. Additionally, agreement to the use of restraints, including the type or nature of restraint and the frequency of reassessment, have not be included in PIC care plans as required as per RCR s. 81(3)(a)(iii).
Corrective Action(s): Ensure signed consents for the use of restraints are obtained from the parent or representative of persons in care, the medical practitioner or nurse practitioner, and that agreement to the use of restraints, including the type or nature of restraint and the frequency of reassessment, are included in PIC care plans.
Date to be Corrected: July 6, 2021
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: Upon review of dental examination records for persons in care, records for 2 of 5 PICs indicated the last dental exam took place July 2019.
Corrective Action(s): Ensure persons in care are encouraged and or access an exam by a dental health care professional at least once every year.
Date to be Corrected: July 6, 2021
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: 3 of 5 PIC files reviewed did not include a record of immunization or compliance with the Province's tuberculosis control program.
Corrective Action(s): Ensure person in care records include a record of immunization and compliance with the Province's tuberculosis control program.
Date to be Corrected: July 6, 2021
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Menu substitution records are in place and in use by staff; however, it was observed that substitutions for some food items during the month of June were not from the same group and did not have a similar nutritional value.
Corrective Action(s): Ensure menu substitutions are from the same group and have the same nutritional value.
Date to be Corrected: July 6, 2021
NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: Upon review of facility menus and menu audits, the following was observed:
- there were morning, noon, and evening meals on the rotating menus that did not include 3 food groups per meal
- rotating menus did not include 2 nutritious snacks with 2 food groups per snack
- audits had not been completed for each menu
- audits and menus did not meet minimum serving and food group requirements as per Canada's Food Guide
Corrective Action(s): Ensure each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Date to be Corrected: July 6, 2021
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Upon review of internal incident report records, it was observed that an incident that occurred April 21, 2021 had not been reported to CCFL.
Corrective Action(s): Ensure that reportable incidents involving a person in care are reported immediately in the form and manner required.
Date to be Corrected: July 6, 2021
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: 5 out of 5 PIC files were reviewed and it was observed that the weight of 1 PIC had not been recorded for April 2021 and the weight for a second PIC had not been recorded since March 2020 and an exemption request including an alternative means of assessing the weight of the second PIC had not be submitted and approved by CCFL.
Corrective Action(s): Ensure each person in care is weighed at least once a month.
Date to be Corrected: July 6, 2021
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