LICENSING: 30060 - RCR s 8(3)(b) - 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 (b) replace the manager, either by hiring a person who, or using a hiring process that, is approved in writing by the medical health officer.
Observation: After more than 5 requests made by licensing to receive change of manager paperwork, a submission was made on July 10th, 2019. Although the forms were submitted, they were not complete and further requests were made by licensing for the completion of the forms. To date, complete forms have still not been received.
Corrective Action(s): Ensure that when a new manager has been hired that change of manager paperwork is submitted to licensing in the manner prescribed by licensing. Please submit a plan for submitting change of manager paperwork within in a timely and complete manner to licensing for current and future managers.
Date to be Corrected: October 2, 2019
LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Review of the facilities self-monitoring found the following:
- The interim DOC is supposed to complete rounds reviewing persons in care (PIC) who received meal tray service, have negotiated risk (the DOC wasn't sure if there are any PICs), and PICs with restraints (the DOC also wasn't sure if there are any PICs). These have not been completed in the past 3 months (June, July, and August) by the DOC providing coverage.
- The interim DOC has only completed audits of PICs nursing care plans, not quarterly assessments, or ADL sheets for June, July and August. The CMS assessment was completed for June, but not fully completed for July and August.
Corrective Action(s): The licensee must ensure that the care and services provided by the facility is regularly monitored to ensure the requirements of the Act and this regulation are being met. Please submit a plan to licensing.
Date to be Corrected: October 2, 2019
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: There is peeling wallpaper in the upstairs hallways.
Corrective Action(s): Please ensure that common areas are maintained in a good state of repair.
Date to be Corrected: October 2, 2019
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Review of the facility found the following:
- There was a hose left out beside the pond that would pose a potential tripping hazard.
- There are cabinets in each hallway that are not secured to the wall and could easy tip over.
Corrective Action(s): Please ensure that the facility is maintained in a safe condition.
Date to be Corrected: October 2, 2019
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 files were reviewed and found that 3 staff did not have evidence of valid criminal record checks.
Corrective Action(s): Ensure that a person is not employed by the facility unless a criminal record check has first been obtained.
Date to be Corrected: October 2, 2019
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 out of 6 employee files that were reviewed did not have current employee appraisals and at least 2 of the employees who were both hired in 2013 had no evidence of ever having an appraisal. This is a repeat contravention from the previous 2 routine inspections (inspection #'s CJOS-B5SR6X and WCLK-AQ5RTV).
Corrective Action(s): Ensure that employees have regular employee reviews to ensure employees demonstrate the necessary competence for required duties. Submit a plan for completing employee appraisals to licensing.
Date to be Corrected: October 2, 2019
STAFFING: 32170 - RCR s.42(1)(a) - A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to (a) meet the needs of the persons in care.
Observation: Review of the staffing schedule for August and September found the following:
- The facility was short staff for care aids on 9 out of the 20 days reviewed.
- They were also short staffed for RN's on 4 out of 26 days and they used an LPN to replace an RN 2 out of the 26 days reviewed.
Corrective Action(s): Ensure that there is sufficient numbers of employees, who have the required training and experience to meet the needs of persons in care.
Date to be Corrected: October 2, 2019
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 facility's policies and procedures found that they have not been reviewed or updated since January 2018.
Corrective Action(s): Please ensure that policies and procedures are reviewed, and if necessary, revised at least once each year.
Date to be Corrected: October 2, 2019
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: The following concerns were found regarding employees not implementing the facility's policies and procedures:
The Daily Record of Care (DRC) was reviewed for 4 PICs and found the following:
- 1 PIC's records was not signed 11 times.
- Another PIC's record was not signed 6 times.
- Another PIC's records was not signed 24 times.
- Another PIC's record was not signed 11 times.
Falls Assessments and monitoring was reviewed for 4 PICs and found the following for 3 of them:
- 1 PIC was not checked on on the 4th hour nor on every hour.
- The same PIC had 3 more falls on 3 different days where they were twice not checked every hour for both falls.
- Another PIC had 2 falls on 2 different days and was twice not checked every hour for both falls.
- Another PIC had a fall and was not checked every hour for 3 times.
All facility records are suppose to be complete and accurate.
The medication safety and advisory meeting is suppose to occur twice each year and has only happened once. The pharmacy indicated that they attempted to schedule it in June, when it was due, but there was no one to schedule it with.
There have been 4 internal complaints submitted to leadership staff that were not entered into their complaint log and also did not have any evidence of follow-up.
Corrective Action(s): A licensee must ensure that policies and procedures are implemented by all employees.
Date to be Corrected: October 2, 2019
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: 1 PIC has a lap belt restraint that was identified at the previous care conference as needing to be reviewed and re-signed for. It was last reviewed and signed for in 2016.
Corrective Action(s): Please ensure that each care plan is reviewed at least once each year.
Date to be Corrected: October 2, 2019
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: Review of 4 PICs care plans found that 3 did not have evidence of immunization and tuberculosis screening.
This is a repeat contravention from the previous routine inspection (inspection # CJOS-B5SR6X).
Corrective Action(s): Please ensure that each person admitted to the facility complies with the Province's immunization and tuberculosis control programs.
Date to be Corrected: October 2, 2019.
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Review of the facility's freezer found there to be at least 5 food items that were not in their original packaging and were not labelled.
Corrective Action(s): Please ensure that food is safely stored.
Date to be Corrected: October 2, 2019
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: There has not been a planned activity program at the facility since July 2019 as the activity manager quit and nothing has been implemented to provide a program.
Corrective Action(s): Please ensure that there is a suitable planned activity program to meet the needs of persons in care.
Date to be Corrected: October 2, 2019
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