PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation: Refrigerated medications were stored in a refrigerator with a temperature measuring 10.0°C. Temperature checks were missing 3 times from May 1 - May 5, 2021. Refrigerated medications are to be stored at a temperature range of 2°C to 8°C and fridge temperature is to be monitored twice daily, as per the site's Medication Safety Advisory Committee (MSAC) policy.
Corrective Action(s): Ensure all medications are safely stored and monitored as per MSAC policy.
Date to be Corrected: May 14, 2021
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: Upon review of a spreadsheet documenting employee file records, 3 of 11 active employees had expired criminal records checks and 2 employees had no record of a criminal record check having been completed prior to commencing employment at the facility.
Corrective Action(s): Ensure a record of valid criminal record checks obtained through the Ministry for Public Safety & Solicitor General are on file for employees prior to expiry and that criminal record checks are completed prior to commencing employment.
Date to be Corrected: Health and Safety Plan addressing this contravention to be submitted to geographic LO by May 14, 2021.
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: A record of 11 active employee files were reviewed. 2 employee files contained no record of immunization or tuberculosis screening.
Corrective Action(s): Ensure that staff have provided evidence on hire of compliance to BC's immunization and tuberculosis programs.
Date to be Corrected: May 28, 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: 12 out of 12 direct care staff last had performance appraisals conducted in 2018. The facility's Continuing Monitoring of Employees policy states that employee performance appraisals are to be conducted annually.
Corrective Action(s): Ensure the performance of each employee is reviewed annually, as per facility policy, to ensure that employees continue to meet regulatory requirements and to ensure competence for assigned duties.
Date to be Corrected: May 28, 2021
STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: 1 of 4 staff that prepare meals for persons in care had a FoodSafe certificate that was no longer valid. FoodSafe certificates must be recertified every 5 years in order to be in good standing.
Corrective Action(s): Ensure that the preparation of meals and snacks is monitored by a staff with a FoodSafe certificate in good standing.
Date to be Corrected: May 28, 2021
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: Records indicate the emergency response drill/training for facility employees last occurred in February 2020.
Corrective Action(s): Ensure all employees are trained in the implementation of emergency response plans and that drills are conducted on an annual basis, as per facility policy. Management reported that emergency response plan training with staff is anticipated to take place in June 2021.
Date to be Corrected: June 30, 2021
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: The policy and procedure manual indicated the date of last review occurred in 2018.
Corrective Action(s): Ensure policies and procedures are reviewed and, if necessary, revised at least once each year.
Date to be Corrected: May 28, 2021
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: REPEAT CONTRAVENTION - Upon review of medication administration records for 4 persons in care (PIC), documentation on the effect of PRN medication was missing for one PIC x 1, a second PIC x 4, and a third PIC x 1. The pharmacist's facility audit in April 2021 observed that documentation of PRN medication effects were missing and are required.
Corrective Action(s): Ensure the effects of PRN medications are recorded as per pharmacy and MSAC policy requirements.
Date to be Corrected: May 14, 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: REPEAT CONTRAVENTION - Review of 5 person in care records showed no evidence of compliance with the provinces immunization and TB programs.
Corrective Action(s): Ensure person in care records include on admission a record of immunization and compliance with the Province's tuberculosis control program.
Date to be Corrected: May 28, 2021
NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: Facility menus were observed to contain 1 nutritious snack from 1 food group.
Corrective Action(s): Ensure menus provide at least 2 nutritious snacks daily, with each snack containing at least 2 food groups.
Date to be Corrected: May 28, 2021
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