PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: Inspection of one of the bathrooms found that the bottom of the shower curtain was discoloured
Corrective Action(s): Ensure that all equipment for use by PIC's are in a clean condition
Date to be Corrected: November 1, 2016
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 found:
- one of the mirrors in the bathroom is showing wear on the bottom
- there is paint chipping on a few windowsills in bathrooms and bedrooms
Corrective Action(s): Ensure all rooms and common areas are maintained in a good state of repair
Date to be Corrected: December 15, 2016
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: Review of 4 employee files found that 1/4 had a references form filled out but no signature to verify that references were in fact checked
Corrective Action(s): Ensure that all employees have character references provided
Date to be Corrected: December 15, 2016
STAFFING: 32030 - RCR s.37(1)(c) - 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: (c) a record of the person's work history.
Observation: Review of 4 employee files found that 2/4 did not have copies of work history/ resume
Corrective Action(s): Ensure that work history is obtained for all employees
Date to be Corrected: December 15, 2016
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: Review of 4 employee files found that 1/4 did not have evidence of compliance with immunizations, and 2/4 did not have evidence for compliance with the TB program
Corrective Action(s): Ensure that all staff have evidence of compliance with the province's immunization and TB control programs
Date to be Corrected: December 15, 2016
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: Review of 3 employee files found no employee reviews in 2/4 files and 1/4 from 2014.
Corrective Action(s): Ensure that all employees have regular performance reviews
Date to be Corrected: December 15, 2016
CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: A review of 3 PIC files found that 3/3 did not include a nutrition plan and assessment of PIC's nutrition status
Corrective Action(s): Ensure that all PIC's have a nutrition plan inlcuding an assessment of nutrition status
Date to be Corrected: December 15, 2016
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 3 PIC files found that 3/3 did not have evidence of compliance with the province's immunization program and 2/3 did not have evidence of compliance with the TB control program
Corrective Action(s): Ensure that all persons admitted have evidence of compliance with the province's immunization and TB control programs
Date to be Corrected: December 15, 2016
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: No weight records for PIC's was found. Staff confirmed that weights are not taken monthly as a focus on weight could be detrimental for the PIC's recovery. Information on applying for an exemption has been provided.
Corrective Action(s): Ensure that PIC's were weighed monthly, or an exemption is submitted to CCFL.
Date to be Corrected: November 15, 2016
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: Menu is available but a menu audit has not been completed.
Corrective Action(s): Ensure a menu audit has been completed to show that food provided meets nutritional requirements
Date to be Corrected: December 15, 2016
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