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: 6 employee files were reviewed and 1 employee had no evidence to confirm they had been provided training and orientation upon hire and 2 employees had orientation checklists that were incomplete. There was no evidence that monitoring of the orientation program had occurred or that follow up on the missing and incomplete training had occurred.
Corrective Action(s): Please ensure monitoring of the orientation and training program occurs regularly.
Date to be Corrected: September 12, 2022
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation: Rooms that contain potential hazards such as housekeeping carts with chemical cleaners and unused equipment in storage were found to be unlocked and accessible to persons in care.
Corrective Action(s): Please ensure that doors are locked and secure, preventing PICs from accessing areas with potential hazards.
Date to be Corrected: September 12, 2022
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: 6 employee files were reviewed and it was confirmed that 2 staff were employed prior to the application to obtain their criminal record check (CRC) had been submitted and the results received.
Corrective Action(s): Please ensure the CRC is obtained before hiring a person.
Date to be Corrected: September 12, 2022
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: 6 employee files were reviewed and only 1 references was obtained for 1 employee.
Corrective Action(s): Please ensure that at least two references are obtained before hiring a person.
Date to be Corrected: September 12, 2022
STAFFING: 32050 - RCR s.37(1)(e) - 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: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: 6 employee files were reviewed and 4 had insufficient or incomplete evidence confirming their compliance with the provinces immunization and tuberculosis control program.
Corrective Action(s): Please ensure compliance with the provinces program is obtained before hiring a person and all required forms are complete.
Date to be Corrected: September 12, 2022
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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: 6 employee files were reviewed and it was determined that 3 did not have evidence that their performance had been reviewed since their start of employment.
Corrective Action(s): Please ensure that each employee's performance is reviewed regularly.
Date to be Corrected: September 12, 2022
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: One person recently admitted into care had not been screened on admission to determine if they were at risk of elopement from the facility.
Corrective Action(s): Please ensure that all persons in care are screened on their admission to determined their elopement risk.
Date to be Corrected: September 12, 2022
CARE AND/OR SUPERVISION: 34670 - RCR s.81(3)(e)(i) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (i) an assessment of the nature of the risk of falling presented by the person in care.
Observation: Care plans of 4 persons in care (PIC) were reviewed and it was determined that for 2 PICs, their care plans did not include a fall prevention plan, not including the 1 PIC with no care plan.
Corrective Action(s): Please ensure all PICs have care plans for fall prevention.
Date to be Corrected: September 12, 2022
NUTRITION AND FOOD SERVICES: 37105 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation: Menus for each of the four weeks is posted in the dining room, however they do not include the two snacks required to be included in the menu for each day. Each snack must contain at least two food groups.
Corrective Action(s): Please ensure menus are displayed prominently and include the required meals and snacks.
Date to be Corrected: September 12, 2022
RECORDS AND REPORTING: 39290 - RCR s.80(1) - On admitting a person in care to a community care facility, a licensee must ensure that a short term care plan is developed that will guide caregivers in protecting and promoting the health and safety of the person in care.
Observation: A person recently admitted into care had no short term care plan developed to guide staff in the delivery of their care or to ensure the safety of the person in care.
Corrective Action(s): Please ensure that a person in care has a care plan developed on their admission into care.
Date to be Corrected: September 12, 2022
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