LICENSING: 30050 - RCR s.8(3)(a) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (a) notify a medical health officer.
Observation: The current manager on file with CCFL resigned from the position approximately 9 months ago. No notification of this has been received by licensing.
Corrective Action(s): Please ensure that Licensing is notified if the manager of the facility resigns.
Date to be Corrected: Feb 28, 2018
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: As per medication policy, all dispensed medications must be signed for. During the inspection of the facility MAR's there were 6 instances of medications not being signed for.
Corrective Action(s): Please ensure that all employees are complying with the policies and procedures of the medication and safety advisory committee.
Date to be Corrected: February 28 2018
RECORDS AND REPORTING: 39430 - RCR s.86(c) - A licensee must keep the following records in respect of each employee: (c) compliance with the Province's immunization and tuberculosis control programs.
Observation: During a review of the facility employee files, the following was noted:
- 1 out of 4 employee files has no record of compliance with the Province's immunization control program.
- 1 out of 4 employee files had no record of compliance with the Province's tuberculosis control program. This was corrected during the inspection.
Corrective Action(s): Please ensure a record is kept in respect for all employees compliance with the Province's immunization and tuberculosis control program.
Date to be Corrected: Feb 28 2018
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