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: One staff person did not have a valid criminal record check.
Corrective Action(s): Ensure a Criminal Record Check must be obtained.
Date to be Corrected: April 22, 2022
STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: PICs did not have access to employees with valid first aid and CPR during at least twenty shifts in the month of April.
Corrective Action(s): Ensure an employee with a valid first aid and CPR certificate is immediately accessible to PICs.
Date to be Corrected: April 26, 2022
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: For one medication, licensing observed administration entries to be crossed out and re-entered at a different administration time. This process differed from MSAC requirements regarding documentation errors and changes to the Medication Administration Record.
Corrective Action(s): Ensure employees comply with the MSAC policies and procedures.
Date to be Corrected: May 13, 2022
POLICIES AND PROCEDURES: 33080 - RCR s.51(2) - A licensee must ensure that the plans described in subsection 51(1) are updated if there is any change in the facility
Observation (CORRECTED DURING INSPECTION): The emergency plan contained out of date information regarding the PICs’ medication, contact information and included the name of one person who is no longer cared for at this home (Repeat contravention from Routine Inspection #KTRR-C3SUB3 dated June 8, 2021).
Corrective Action(s):
Date to be Corrected:
POLICIES AND PROCEDURES: 33220 - RCR s.85(1)(a) - A licensee must do all of the following: (a) have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care.
Observation: Policies and procedures were not in place to guide staff in the use and tracking of PIC financial transactions. Existing policies around tender used and audit frequency provided conflicting instructions.
Corrective Action(s): Ensure there are policies and procedures to guide staff in all matters related to care and supervision.
Date to be Corrected: May 20, 2022
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: Policies and procedures regarding the tracking and review of PIC monies had not been implemented for more than five out of the past eight months.
Corrective Action(s): Ensure policies and procedures are implemented by employees.
Date to be Corrected: April 22, 2022
CARE AND/OR SUPERVISION: 34120 - RCR s.52(1)(a) - A licensee must ensure that a person in care is not, while under the care or supervision of the licensee, subjected to (a) financial abuse, emotional abuse, physical abuse, sexual abuse or neglect as those terms are defined in section 1 of Schedule D.
Observation: Financial abuse is defined as the misuse of a person in care’s funds and assets by a person not in care. The Licensee used the PICs' funds to purchase items required for care including shared equipment and care supplies. (Repeat contravention from Routine Inspection #KTRR-C3SUB3 dated June 8, 2021).
Corrective Action(s): Ensure PICs are protected from abuse and neglect.
Date to be Corrected: April 26, 2022
RECORDS AND REPORTING: 39230 - RCR s.79(1)(a) - A licensee must keep a record in respect of each person in care showing the following information: (a) all money, valuables and other things held by the licensee in trust or safekeeping for persons in care.
Observation: PICs’ financial transactions could not be traced due to missing receipts or failure to record purchases. Each PICs' record of valuables was incomplete.
Corrective Action(s): Ensure records are kept of PIC’s monies and valuables.
Date to be Corrected: May 6, 2022
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