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: Criminal record checks for 4 staff members were expired in December 2018. Prior to the drop off of the report on Feb 13th the site manager confirmed that the new CRC's had been received.
Corrective Action(s): Ensure that a process is in place so that CRC's are never expired.
Date to be Corrected: April 15, 2019
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: As identified at a recent investigation, all staff evaluations have not been completed within one year as outlined in BACI policy. The site has had a change in manager since Nov 2018 that is new to the site and the previous manager did not have a chance to complete the evals before he left.
Corrective Action(s): Ensure that all evaluations are completed annually as outlined in BACI policy
Date to be Corrected: August 15, 2019
POLICIES AND PROCEDURES: 33150 - RCR s.68(3(b)(ii) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (ii) the immediate response to and reporting of medication errors and adverse reactions to medications.
Observation: The site manager confirmed that the MSAC did not meet in 2018, so there were no meeting minutes to review.
Corrective Action(s): Ensure that the MSAC meets as required, and reviews all of the items outlined in RCR section 68
Date to be Corrected: April 15, 2019
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A review of the menus found that no menu audit has been completed for the current fall/winter menu. Review of one week of the menu found that it does appear to meet the serving requirements.
Corrective Action(s): Ensure that each week of the menu being used has been audited to ensure compliance with the serving requirements of the Canada Food Guide.
Date to be Corrected: Current CRC's corrected on inspection. Please outline a plan to ensure that CRC's do not expire.
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