PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: An inspection of all bedrooms for persons in care found that none were equipped with a safe and secure place in which persons in care may store valuable property.
Corrective Action(s): Ensure that, at no cost to persons in care, bedroom furnishings include a safe and secure place in which persons in care may store valuable property.
Date to be Corrected: May 19, 2021
STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: A review of facility staff files found no evidence of an annual performance review as per agency policy for one employee since March 2019.
Corrective Action(s): 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Date to be Corrected: May 19, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A review of facility staff files found that two staff did not have evidence of TB status.
Corrective Action(s): Ensure that persons employed in a community care facility provide evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Date to be Corrected: May 26, 2021
MEDICATION: 36130 - RCR s.70(4)(a) - A licensee may permit a person in care to self-administer medications if a plan for self-medication is (a) approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Observation: In the care plan of one person in care there was a plan for self-administration of medications; however, for one of the medications that is self-administered, there was no evidence available that self-administration had been approved by a medical practitioner or nurse practitioner who prescribed or ordered the medication.
Corrective Action(s): Ensure that self-administration of medications is approved by the medication safety and advisory committee and the medical practitioner or nurse practitioner who prescribed or ordered the medication.
Date to be Corrected: April 26, 2021
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