Staffing:
The Facility will be developing a checklist confirming that all documentation required by the Residential Care Regulation is in-place. The writer will provide a sample of a checklist which can be used for both staff and volunteers. Systems are in-place to ensure all staff prior to being hired have all the required documentation. The Manager has a tracking tool whereby they have noted / documented the performance appraisals and they are tracking when these need to be completed. The writer also met with the Clinical Nurse Educator who reviews and monitors the education staff take.
Please provide confirmation in - writing that the following items are in-place for all staff where required:
* First aid (someone accessible at all times with valid first aid)
* Criminal Record Check through the Ministry for Public Safety and Solicitor General. Please note: Professionals such as Registered Nurses, Licenced Practical Nurses, etc will have this completed through their professional registration which would meet the intent of the legislation.
* In-services (Reviewed and discussed with the Clinical Nurse Educator).
* References
* Work history (e.g., resume)
* Diplomas/Certificates, etc.
* Tuberculosis / Immunizations
* Performance appraisals (The Manager has a tracking tool regarding this and when staff are to have their appraisal). Please let the writer know the plan as to when performance appraisals will be completed for all the staff.
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Volunteers:
A discussion took place as to the documentation to be in-place for volunteers. Please provide confirmation in - writing that the following items are in-place for all volunteers (In discussion with the Manager they indicated this is in-place by the staff that oversees this aspect)
* Work history (for example, an application for volunteer would suffice).
* References
* Tuberculosis and Immunizations
* Criminal record checks
Nutrition and Food Services:
The Food Services Manager was off-site and was on speaker phone with the writer and Manager. It appears overall there are thorough systems in-place for nutrition and food services after reviewing all the relevant documentation, meeting with the Dietitian and speaking with the Food Services Manager. The Food Services Manager was provided the writer's e-mail address and they will e-mail the resident satisfaction survey results and other audits that were discussed on the phone.
Persons in care charts:
Overall it appears the intent of the Residential Care Regulation is being met. The facility is utilizing a standardized Tuberculosis Assessment form and Immunization form adapted from the Community Care Facilities Licensing Tuberculosis and Immunization Guideline which meets the intent of the Residential Care Regulation. The Manager will be reinforcing with all the staff in the facility (Weatherby and Dr. Al Hogg Pavillons) that these documents must be consistently used. Many of the charts the writer reviewed had for example a chest xray result and immunizations documented such as pneumococcal vaccine and there are standing orders for the influenza vaccine as well.
Summary:
There appears to be thorough systems in-place with reinforcement to be done in some areas by the management as discussed during the routine inspection. For example, some PRN (as needed) medications not noted with the effect/result, however in discussion with the Residential Care Coordinators and Manager they are addressing this issue which appears to be satisfactory.
Thank you for your time to complete today's inspection. If there are any questions regarding this report, please contact your Licensing Officer.
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