Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
20-Sep-2022
Subject
["Staffing (Includes issues such as suitability, insufficient levels, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must do all of the following: ensure that policies are implemented by employees.
Observation: Through the investigation process, Licensing determined that staff did not implement policies. Specifically, staff did not follow the policy related to cell phone use.
Corrective action: Ensure that all policies are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 7, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the facility would adopt a new policy that allowed team members to carry personal cell phones while on duty and the new policy would be signed and reviewed by staff by January 31, 2023. This corrective action plan was reviewed and accepted by Licensing. On January 31, 2023, Licensing received a copy of the new cell phone policy which had been signed by the staff team.
A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Observation: Through the investigation process, Licensing determined that the staff did not demonstrate the skills and abilities to carry out the duties as assigned.
Corrective action: Ensure the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that all staff have the character and skills necessary to carry out the duties assigned. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 7, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the staff member had met with management and a letter of discipline was placed on the employee file on December 7, 2022 and the staff member was to complete education and policy review by December 13, 2022. This corrective action plan was reviewed and accepted by Licensing. On January 4, 2023, Licensing received confirmation that a staff completed the required education and policy review.
A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Observation: Through the investigation process, Licensing determined that the staff did not demonstrate the skills and abilities to carry out the duties as assigned.
Corrective action: Ensure the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that all staff have the character and skills necessary to carry out the duties assigned. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 7, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the staff member had met with management and a letter of discipline was placed on the employee file on December 7, 2022 and the staff member was to complete education and policy review by December 13, 2022. This corrective action plan was reviewed and accepted by Licensing. On January 4, 2023, Licensing received confirmation that a staff completed the required education and policy review.
Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Observation: Through the investigation process, Licensing determined that a person in care was involved in a reportable incident and the medical health officer was not immediately notified.
Corrective action: Ensure if a person in care is involved in a reportable incident to immediately notify a medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 7, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the staff team was sent an email on December 7, 2022 outlining the responsibility and requirements of reportable incidents to Licensing. This corrective action plan was reviewed and accepted by Licensing. On December 7, 2022, Licensing received an email that was sent to the staff team outlining reportable incident requirements.