STAFFING: 32270 - RCR s.44(2) - A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is (a) a nutrition manager with membership in the Canadian Society of Nutrition Management, (b) a person who is eligible to be a member of the Canadian Society of Nutrition Management, or (c) a dietitian.
Observation: An exemption to the above noted legislation was submitted to CCFL and approved on October 24, 2014 with an expiry date of September 30, 2015. The expiry date was based on information provided within the exemption request. At the time of this inspection, CCFL spoke with the staff member who has been in the process of obtaining the education to qualify for membership in the CSNM. The staff member explained that initially it was a 2 year program which has been modified resulting in a lengthier time frame to complete the program.
Corrective Action(s): An exempption request is required to be submitted to CCCFL regarding the extended time frame, etc.
Date to be Corrected:
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: In review of the MARS for 7 residents, it is noted that the effect of PRN's are not consistently documented.
Corrective Action(s): Ensure staff document the effects of PRN's
Date to be Corrected:
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: In review of the documentation/records for 6 residents, it is noted that the nutritional assessment for 1 resident could not be located. It was agreed at the time of the inspection that the current system utilized by the former RD is cumbersome and time consuming to locate the assessments.
Corrective Action(s): Ensure nutritional assessments are completed and a record is available for review.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34740 - RCR s.81(4)(a) - A licensee must ensure that (a) the implementation of each care plan is monitored on a regular basis to ensure proper implementation.
Observation: In review of the documentation for 6 residents, it is noted that the diet for one resident was not consistent with the care plan/nutritional assessment.
Corrective Action(s): Ensure care plans are monitored to ensure there is proper implementation.
Date to be Corrected:
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: In review of the food services audits/meals and more, not all audits have been completed within the last year,
Corrective Action(s): Ensure all audits are completed in a timely manner and that there is a record available for review..
Date to be Corrected:
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