PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: Inspection of the computer area chairs found that the fabric/bonded leather on the chairs is peeling off in large areas.
Corrective Action(s): Ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair.
Date to be Corrected: March 8, 2018
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: Review of the facilities policies and procedures for 'serious incidents' found that the policy was created in February 2015. Although the policy was recently reviewed, it contained old language and did not include 'aggression between persons in care' or a subsequent definition for this incident.
Corrective Action(s): Ensure that policies and procedures are current.
Date to be Corrected: March 8, 2018
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation: Review of 2 of 10 PIC's care plans found that one 'recovery plan' was dated August 2015. Further investigation found that a new 'recovery plan' had been completed in February 2, 2017 but there was no documentation in the PIC's care plan.
Corrective Action(s): Ensure that care plan documentation is current.
Date to be Corrected: March 8, 2018
CARE AND/OR SUPERVISION: 34770 - RCR s.81(4)(c) - A licensee must ensure that (c) to the extent reasonably practical, persons in care participate in the review and modification of their own care plans.
Observation: Review of 2 of 10 PIC's care plans identified that there was a care plan but no completed 'recovery plan' (the care plan that is created with the PIC and the facility) for a newly admitted PIC.
Corrective Action(s): Ensure that the recovery plans are completed to ensure that PIC's participate in their own care plan reviews and if necessary, modification of their care plan.
Date to be Corrected: March 8, 2018
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