LICENSING: 30060 - RCR s 8(3)(b) - If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must (b) replace the manager, either by hiring a person who, or using a hiring process that, is approved in writing by the medical health officer.
Observation: Current Manager of Care has been in place since September 2017. No application for change of manager including confirmation of qualifications has been received by CCFL despite requests to do so.
Corrective Action(s): Ensure that a change of manager form is completed and submitted to CCFL
Date to be Corrected: December 22, 2017
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31260 - RCR s.21(c) - A licensee must ensure that all furniture and equipment for use by persons in care (c) are maintained in a good state of repair.
Observation: On inspection the LO observed:
- paint peeling on a dresser in a PIC bedroom
- surface worn on the fireplace in a PIC bedroom
- exercise bike seat with tears and tape covering it (corrected on inspection)
Corrective Action(s): Ensure all equipment and furnishings are maintained in a good state of repair
Date to be Corrected: January 31st 2018
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 (CORRECTED DURING INSPECTION): On inspection the LO observed:
- downstairs a mattress and frame in the hallway against a wall
- clogged bathroom sink upstairs
- underneath the stairs outside, foam mattress pieces
- clutter observed in several areas around the house
Corrective Action(s): Ensure that all areas are maintained in a safe and clean condition
Date to be Corrected: January 31, 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: 2/3 employee files reviewed did not include a Criminal Record Check.
Corrective Action(s): Ensure all employees have a current criminal record or confirmation of current registration with regulatory professional body (eg. RN, RPN).
Date to be Corrected: December 31, 2017
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: Review of the information in the policy binder, on "when to call the coroner" for a death in the facility, includes if it was an unexpected death. There is no evidence the coroner was called for the unexpected death documented on 02/27/2017.
Corrective Action(s): Ensure that staff are aware of and follow policies.
Date to be Corrected: January 15, 2017
POLICIES AND PROCEDURES: 33320 - RCR s.85(2)(b) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (b) the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Observation: Review of the orientation policy found that it does not include an orientation outline or plan for new managers.
Corrective Action(s): Ensure that there is a policy that outlines an orientation plan for new managers
Date to be Corrected: March 1, 2018
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: Review of 3 care plans found that 3/3 did not include an assessment of nutritional status. This is a repeat contravention from the 2016 routine inspection.
Corrective Action(s): Ensure that all PIC's have evidence of an assessment of nutritional status.
Date to be Corrected: January 31, 2018
CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of weight charts showed several PIC's that had significant weight changes in a short period of time. One PIC went from 145lbs to 152 lbs in one month, one PIC went from 145lbs to 153 lbs in one month, and one PIC went from 180lbs, was not weighed for 2 months, then the next time weighed was 162 lbs. No information regarding these significant weight changes could be found. All PIC's are regularly seen by medical professionals but no details regarding weight changes being brought up or addressed could be found.
Corrective Action(s): Ensure that evidence is available that documents consultation for any significant weight changes.
Date to be Corrected: December 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 3 PIC records found 2/3 did not have any immunization or TB records. This is a repeat contravention from the 2015 and 2016 routine inspections.
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: February 15, 2018
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: Foods such as meats and bread in several storage freezers do not have any labelling with contents or date to ensure freshness on use. This is a repeat contravention from the 2015 routine inspection.
Corrective Action(s): Ensure that all freezer items are dated.
Date to be Corrected: January 31, 2018
RECORDS AND REPORTING: 39090 - RCR s.77(2)(c) - Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify (c) a medical health officer, in the form and in the manner required by the medical health officer.
Observation: Review of the reportable incident binder found that several reportable incidents were documented, but copies not sent to licensing. 3 unexpected illnesses, 1 missing/wandering, 1 fall, and 1 unexpected death. These appear to have occurred when an interim MOC was in place, prior to the current MOC. The unexpected death report on file at the facility does not include conformation that the coroner was called.
Corrective Action(s): Ensure that all reportable incidents are sent to CCFL as required.
Date to be Corrected: December 5, 2017
RECORDS AND REPORTING: 39310 - RCR s.81(1) - If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Observation: Review of 3 care plans found that 1/3 did not have a comprehensive care plan and has been in the facility since June 2017. Intake information including emergency information, medications, diagnosis and progress notes are available to support care of the PIC. No nutritional assessment or nutritional care plan, oral care plan or recreational care plan are available.
Corrective Action(s): Ensure that a comprehensive care plan is completed for every PIC within 30 days.
Date to be Corrected: December 31, 2017
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: No menu audit was available for the current or new menu. This is a repeat contravention from the 2016 inspection.
Corrective Action(s): Ensure that every month of a menu used at the facility has evidence of being audited to meet the required nutritional needs of the PIC's.
Date to be Corrected: February 15, 2018
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