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: The following was found in the house keeping rooms:
- one of the rooms had boxes, chemical products, and a bag containing soiled cleaning products stored or left on the floor.
- the other room had boxes stored on the floor.
Corrective Action(s): Please ensure that all rooms are kept in a safe and clean manner to allow for proper sanitization of the floor and storing of chemical agents.
Date to be Corrected: March 30, 2018
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: 1 out of 7 staff records does not contain a criminal record check from the criminal records review program (CRRP). The staff only has a municipality criminal records check.
Corrective Action(s): Ensure that a person is not hired in a community care facility without criminal record check being obtained and cleared from the CRRP.
Date to be Corrected: March 30, 2018
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: 3 out of 7 staff files do not contain reference checks.
Corrective Action(s): Ensure that a person is not hired in a community care facility unless character references have been obtained.
Date to be Corrected: March 30, 2018
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: 2 out of 7 staff files do not contain evidence of immunization status and tuberculosis screening.
Corrective Action(s): Please ensure that staff immunization staff and tuberculosis screening are obtained before working in a community care facility.
Date to be Corrected: March 30, 2018
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: 4 out of 7 staff files reviewed found that staff, who were hired within the past year and who have been working past their probation period, do not have performance appraisals.
Corrective Action(s): Please ensure that staff who complete their probationary period have a performance appraisal.
Date to be Corrected: March 30, 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: The following MAR errors were found:
- 1 person in care's (PIC) MAR had 1 PRN administered and did not have the effectiveness recorded.
- Another PIC's MAR had 3 PRNs administered and no effectiveness recorded.
Staff confirmed that the effectiveness should be recorded for each PRN administered.
Corrective Action(s): Please ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: March 16, 2018
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: Review of 10 PIC's weight records found the following months to have weight records not present:
- November had 6 out of 8.
- December had 1 out of 10.
- January had 2 out of 10.
- February had 9 out of 10.
Corrective Action(s): Please ensure that weights are recorded monthly and when a PIC refuses or equipment does not work, that it is documented.
Date to be Corrected: March 16, 2018
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