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: On inspection the LO noted:
- a hole in the wall near the front entrance (a work order has been submitted for this repair)
- marks on the wall, door frame paint chipping in a bathroom
Corrective Action(s): Ensure that all rooms and common areas are maintained in a good state of repair
Date to be Corrected: February 15, 2017
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: Out of 4 employee snapshots reviewed, 3/4 have not had a performance review in the past 12 months as per facility policy. The most recent reviews were Sept 2015, Dec 2014 and Sept 2014. This is a repeat contravention from the 2015 inspection.
Corrective Action(s): Ensure that employees have regular performance reviews, as per facility policy. In your written response to this inspection please include details of the plan to complete all of the performance evaluations.
Date to be Corrected: January 15, 2017
POLICIES AND PROCEDURES: 33410 - RCR s.85(2)(i) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (i) the use of restraints in an emergency.
Observation: On review of the organization policies and procedures the LO and staff could not find one with respect to the use of restraints in an emergency. Staff reports that a policy is currently being written for restraint protocol.
Corrective Action(s): Ensure that there is an organizational policy with respect to the use of restraints in an emergency
Date to be Corrected: January 15, 2017
CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan.
Observation: Review of 2 care plans found that 1/2 PIC's does not have an oral health care plan. Staff reports that the PIC has an appointment made for this purpose.
Corrective Action(s): Ensure that all care plans include an oral health care plan
Date to be Corrected: January 15, 2017
CARE AND/OR SUPERVISION: 34660 - RCR s.81(3)(d) - A care plan must include all of the following: (d) a recreation and leisure plan.
Observation: Review of 2 care plans found that 2/2 did not have a recreation and leisure plan. Staff was able to describe the recreation needs and likes for PIC's and the LO was able to review the day program calendar for December, and the facility program schedule for December. The staff reported that each month the calendar and activities are updated to meet the needs and desires of the PIC's.
Corrective Action(s): Ensure that each care plan includes a recreation and leisure plan
Date to be Corrected: February 15, 2017
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 care plans found that 1/2 had an oral health care plan last reviewed October 2015, and a nutritional care plan last reviewed in November 2015.
Corrective Action(s): Ensure that all care plans are reviewed and if necessary modified at least once per year
Date to be Corrected: January 15, 2017
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 2 care plans found that 1/2 did not have evidence of compliance with the province's immunization and TB control programs
Corrective Action(s): Ensure that all PIC's have evidence of compliance with the province's immunization and TB control programs
Date to be Corrected: January 15, 2017
NUTRITION AND FOOD SERVICES: 37050 - RCR s.62(2)(c)(i) - A licensee must ensure that each menu provides (c) a variety of foods, taking into consideration (i) the nutrition plan of each person in care and the nutrition needs, age, gender and level of activity of the persons in care.
Observation: A review of the menu found that it does not include the serving sizes required for the current PIC's. Staff reports that the dietician is coming the first week of January to help them update the menu as required.
Corrective Action(s): Ensure that the menu is current as required for the needs of the PIC's. Prior to the dietician visit, please ensure specific information on each PIC is easily available so that every staff has easy access to information on feeding all of the PIC's what they require.
Date to be Corrected: January 15, 2017
NUTRITION AND FOOD SERVICES: 37090 - RCR s.62(2)(d) - A licensee must ensure that each menu provides (d) for substitutions to be made that are from the same food group and have a similar nutritional value.
Observation: Review of the substitution list found that 1x a veggie sandwich that included avocado, tomato and lettuce was substituted with grilled cheese, and 1x a pita and Caesar salad was substituted with perogies.
Corrective Action(s): Ensure that all menu substitutions are from the same food group and have a similar nutritional value
Date to be Corrected: December 31, 2016
RECORDS AND REPORTING: 39210 - RCR s.78(3)(a) - A licensee must have, and keep with each person in care's record, consent in writing from the person in care or a parent or representative of the person in care (a) to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Observation: Review of 2 care plans found that 2/2 did not include a consent for emergency services. A blank form with this consent was found, but no signed version was found for either PIC reviewed.
Corrective Action(s): Ensure that all PIC's have a consent in writing to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness
Date to be Corrected:
RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: A review of weight records for 2 PIC's found that 1 PIC had 1/12 months where the weight was not recorded, and no record of a reason was documented.
Corrective Action(s): Ensure that all PIC's are weighed at least once a month, and if they are not - a reason is documented.
Date to be Corrected: December 31, 2016
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