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: Policies regarding PIC finances had not been implemented in the past seven months. This included storage of PIC monies and review of financial records.
Corrective Action(s): Ensure polices and procedures are implemented by staff.
Date to be Corrected: May 31, 2023
CARE AND/OR SUPERVISION: 34120 - RCR s.52(1)(a) - A licensee must ensure that a person in care is not, while under the care or supervision of the licensee, subjected to (a) financial abuse, emotional abuse, physical abuse, sexual abuse or neglect as those terms are defined in section 1 of Schedule D.
Observation: Financial abuse is defined as the misuse of a person in care’s funds and assets by a person not in care. The Licensee used a PICs' funds to purchase items required for care including shared equipment.
Corrective Action(s): Ensure PICs are not subject to financial abuse.
Date to be Corrected: May 31, 2023
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: Recreation and restraint plans of care had not been reviewed in greater than one year for three out three persons in care. Recreation activities had greater than one aspect change for all persons in care..
Corrective Action(s): Ensure care plans are reviewed at least annually.
Date to be Corrected: June 14, 2023
MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored.
Observation: Evidence of the pharmacist’s last inspection of the medication storage area was not available. Medications belonging to a former PIC and medications discontinued eight months ago continued to be stored.
Corrective Action(s): Ensure a supervising pharmacist inspects the medication storage.
Date to be Corrected: June 14, 2023
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: Evidence was not available to demonstrate PIC nutritional needs were met as per the Canada Food guide. Menu reviews and nutritional audits were not available. Record of menu substitutions had not been completed in two months as per RCR s. 87(a).
Corrective Action(s): Ensure records of matters respecting food services including monitoring are kept.
Date to be Corrected: June 14, 203
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