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: Review of the DOC daily rounds audits found that not all sections are filled out as being reviewed. The interim DOC says they are completed, however they are not being documented. Previously the audits were being completed by the RN and once the new DOC was hired they were completed partially by the RN and partially by the DOC.
Discussion with the activity manager found that it is being documented who attends programming, but these are not provided to the manager and were not available to be reviewed.
Corrective Action(s): Please ensure that each department conducts there monthly audits.
Date to be Corrected: Dec 30, 2019
STAFFING: 32170 - RCR s.42(1)(a) - A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to (a) meet the needs of the persons in care.
Observation: Review of the RN, LPN, and RCA schedules found the following:
- 14 days in October and November were reviewed for the RN schedule and found there to be 2 nights shifts were an LPN was used in place of an RN.
- 14 days in October and November were reviewed for the LPN schedule and found there to be 1 day shift where there was no LPN on shift.
- review of 14 days in October, November, and December found there to be 11 shifts that were not filled with RCA's. 3 of the days which were reviewed were during a health and safety plan where there was supposed to be extra RCA's on shift and they were short on 4 of the shifts.
Corrective Action(s): Ensure that the facility has sufficient number and pattern of employees available at all time.
Date to be Corrected: Dec 16, 2019
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 Daily Record of Care for December found the following:
- 1 person in care (PIC) record has 15 signatures not present.
- Another PIC's record has 8 signatures not present.
- Another PIC's record has 9 signatures not present.
- Another PIC's records has 29 signatures not present.
Of concern is that there is no way to determine then if care was provided.
It is the facility's policy that all records are completed.
Corrective Action(s): Ensure that employees are following the policies and procedures of the facility.
Date to be Corrected: Dec 16, 2019
PROGRAM: 38010 - RCR s.55(1)(a)(i) - A licensee, other than a licensee who provides a type of care described as Hospice, must (a) provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities (i) suitable to the needs of the persons in care.
Observation: Review of the activity calendar for November and December and discussion with the activity manager found that not all programs are being offered and it is not recorded which programs are not and for what reason.
Corrective Action(s): Ensure that a program of activities is provided to meet the needs of persons in care.
Date to be Corrected: Dec 16, 2019
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