LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: A review of the audits binder for nutrition/food services, it was noted the following was not completed, for example:
* Meal Service Audit dated February 28, 2019 there is score/calculation documented at the bottom of the form.
* Nutrition Care Plan (Snack implementation) dated May 9, 2019 Part B not completed with the score/calculation
Corrective Action(s): Please ensure the Licensee regularly monitors the care and services provided by it to ensure that the requirements of the Act and Residential Care Regulation are being met.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of four staff files indicated for one staff file there were no references on the personnel file.
Corrective Action(s): Please ensure character references are noted on staff files where required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: A random review of four staff files indicated for one staff file there is no work history noted in the personnel file.
Corrective Action(s): Please ensure a record of work history is noted in the staff files where required.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: A random review of four staff files indicated for one staff file there is no performance appraisal completed. The Manager/Director of Care acknowledged that a performance appraisal needs to be completed.
Corrective Action(s): Please ensure the performance of each employee is reviewed regularly.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
HYGIENE AND COMMUNICABLE DISEASE: 35010 - RCR s.39(1) - A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province's immunization and tuberculosis control programs.
Observation: A random review of four staff files indicated that for one staff file there are is no tuberculosis clearance or immunizations documented.
Corrective Action(s): Please ensure tuberculosis and immunizations are noted on personnel files (The Community Care Facilities Licensing Tuberculosis and Immunization Guideline for staff has standardized forms for both tuberculosis and immunizations that can be utilized).
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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: As per the summary of audits to be completed (kept at the front of the nutrition/food services binder), the resident satisfaction survey is to be completed and there is no survey(s) completed for example for the year 2019. During the inspection, the Manager/Director of Care started to address this and the writer saw an example of a completed satisfaction survey. Please complete the satisfaction surveys and all other audits as noted/documented and by the date(s) noted on the summary of audits form.
Corrective Action(s): Please ensure a record is kept of the results of monitoring by the licensee of food services and nutrition care specific to the facility and care needs of the persons in care. There is a Audits and More Manual that has standardized audit forms included that can be utilized and adapted to any particular setting.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
RECORDS AND REPORTING: 39480 - RCR s.87(d) - A licensee must keep a record of the following matters respecting food services: (d) food services and nutrition care education and training programs attended by food services employees.
Observation: In-services are occuring and participation records documented, however there is no set schedule for nutrition/food services education/training attended by food services employees. The writer will email a sample nutrition/food services education calendar to the Manager/Director of care to assist/guide in developing your own.
Corrective Action(s): Please ensure as per section 87 (d) of the Residential Care Regulation that a record is kept of the food services/nutrition care education and training programs attended by food services employees.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
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