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: A review of records for staff scheduled to work on day one of the routine inspection confirmed the new staff orientation checklists are not regularly being completed and retained. Two orientation checklists reviewed included information that the staff did not receive all the orientation they required, however no follow up plan was developed or implemented to ensure it was received. This is a repeat observation/contravention.
The license's heat response plan includes each PIC having a heat response care plan developed from them, however both of the PIC records reviewed contained no evidence this had been developed as required.
A review of two PIC records confirmed their new admission and resident orientation checklist had not been completed as required.
Corrective Action(s): Please ensure monitoring of the orientation and training program occurs regularly.
Date to be Corrected: August 12, 2023
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 review of records for staff scheduled to work on day one of the routine inspection confirmed 5 staff files did not contain evidence that a criminal record check had been obtained when hired. When asked, facility leadership confirmed that no evidence of criminal record checks for an additional 20 staff could be provided.
This is a repeat contravention and a critical hazard
Corrective Action(s): Criminal record checks must be obtained prior to employing a person and renewed as required.
Date to be Corrected: Immediately
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 review of records for staff scheduled to work on day one of the routine inspection confirmed 11 staff files did not contain evidence that one or both of the two minimum required references were obtained upon their hire.
This is a repeat contravention.
Corrective Action(s): Please ensure to obtained, a least two references prior to employing staff.
Date to be Corrected: August 12, 2023
STAFFING: 32030 - RCR s.37(1)(c) - 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: (c) a record of the person's work history.
Observation: A review of records for staff scheduled to work on day one of the routine inspection confirmed three contained no record of their work history. This is a repeat contravention.
Corrective Action(s): Please ensure to obtain a record of work history when employing staff.
Date to be Corrected: August 12 2023
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 review of records for staff scheduled to work on day one of the routine inspection confirmed 16 had either no evidence, or incomplete evidence of their compliance with the Provinces Immunization and Tuberculosis control programs.
This is a repeat contravention
Corrective Action(s): Please ensure you obtain evidence of staff compliance with the Provinces immunization and tuberculosis control programs.
Date to be Corrected: August 12, 2023
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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: A review of records for staff scheduled to work on day one of the routine inspection confirmed that 14 had no evidence that their performance had been reviewed as outlined in the licensee's own policy.
This is a repeat contravention
Corrective Action(s): Please ensure that performance is reviewed as required.
Date to be Corrected: August 12, 2023
CARE AND/OR SUPERVISION: 34210 - RCR s.54(3)(b)(iii) - A licensee must (b) assist persons in care to (iii) follow a recommendation or order for dental treatment made by a dental health care professional.
Observation: The records for two persons in care were reviewed and it was confirmed:
The oral health care plan developed for PIC #1 was not consistent with the recommendations made by their dental health care professional.
Corrective Action(s): Please ensure assistance is provided to PICs to follow recommendations and/or orders made by a dental health care professional.
Date to be Corrected: August 12, 2023
CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: The records of two persons in care we(PIC) re reviewed and it was determined that both PICs did not have a fall prevention plan developed.
This is a repeat contravention
Corrective Action(s): Please ensure all PICs in LTC have a fall prevention plan developed to meet their needs.
Date to be Corrected: August 12, 2023
CARE AND/OR SUPERVISION: 34700 - RCR s.81(3)(f)(i) - A care plan must include all of the following: (f) if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan (i) to prevent the person in care from leaving.
Observation: The records of two persons in care (PIC) were reviewed and one PIC had been identified as at risk for eloping from the facility, however did not have a plan to prevent them from leaving included in their care plan as required.
Corrective Action(s): Please ensure that if a PIC has been identified as at risk for eloping from the facility, that they have a plan to prevent them from leaving included in their care plan.
Date to be Corrected: August 12, 2023
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: A review of two person in care (PIC) records could not confirm compliance with the Province's immunization and tuberculosis control programs due to absent, incomplete, or incorrectly completed records for both.
Corrective Action(s): Please ensure that all PICs comply with the Province's immunization and tuberulosis control programs as required.
Date to be Corrected: August 12, 2023
NUTRITION AND FOOD SERVICES: 37105 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: The menu posted in the dining area contained no information regarding the required two snacks to be provided each day. This is a repeat contravention.
Corrective Action(s): Please ensure the menu posted contains all relevant information for the week.
Date to be Corrected: August 12, 2023
RECORDS AND REPORTING: 39126 - RCR s.77.1(1)(b) - Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: (b) in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable;
Records respecting admission
77.1
(2) Subsection (1) (b) and (c) does not apply to a person in care who is in a program described in section 2 (1) as Child and Youth Residential or is receiving a type of care described in section 2 (2) (d) as Community Living
(4) Subsection (1) (c) applies only in respect of an assessment report provided on or after November 4, 2019
Observation: The records of two persons in care (PIC) were reviewed and one contained no evidence that consent for the PIC to be admitted into care had been obtained.
Corrective Action(s): Please ensure you obtain evidence of consent for PIC admission into care.
Date to be Corrected: August 12, 2023
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: A review of two persons in care (PIC) records were reviewed and it was confirmed both did not have evidence of consent to contact their medical practitioner or ambulance as required
Corrective Action(s): Please ensure you obtain written consent to contact a PICs medical practitioner and/or ambulance as required.
Date to be Corrected: August 12, 2023
RECORDS AND REPORTING: 39440 - RCR s.86(d) - A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Observation: It was confirmed that care staff recently received First Aid & CPR Level C training, however a record of the training had not been retained as required.
Corrective Action(s): Please ensure you retain records of training
Date to be Corrected: August 12, 2023
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