PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: The chemical/cleaning supply cupboard in the laundry room did not have a lock. The laundry room area can be accessed by persons in care.
Corrective Action(s): Ensure cleaning agents, chemicals, and hazardous materials are stored in a safe and secure area.
Date to be Corrected: June 11, 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: 6 employee file records were reviewed. The criminal record check for 1 of 6 employees was expired and results of a new criminal record check have not been submitted.
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: June 23, 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: 6 employee files were reviewed. 3 of 6 staff had not had a performance appraisal completed in over 1 year, with date of last appraisal recorded as September 2013, May 2015, and January 2020. Licensee policy stated that performance reviews are to occur 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: June 23, 2021
MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: 1 expired inhaler medication was stored with current medications.
Corrective Action(s): Ensure expired medications are returned to the pharmacy.
Date to be Corrected: Corrected at time of inspection.
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 16, 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: June 23, 2021
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