Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
29-May-2023
Subject
["Health and Safety","Staffing (Includes issues such as suitability, insufficient levels, etc.)","Neglect","Reporting (Includes issues such as not reporting, insufficient reporting, etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
If a person in care becomes ill or is injured while under the care or supervision of a licensee, the licensee must immediately notify the parent or representative, or contact person, of the person in care
Observation: Through the investigation process, Licensing determined that the Licensee did not immediately notify the parent or representative, or contact person, of the person in care when they became injured while under the care or supervision of the Licensee.
Corrective action: Ensure that if a person in care becomes ill or is injured while under the care or supervision of a licensee, the licensee must immediately notify the parent or representative, or contact person, of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On August 18, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included updating the policy to include reporting any injury, as well as informing the representatives of persons in care immediately and that staff would be trained on the policy and were to sign off on training. The corrective action plan was reviewed and accepted by Licensing. On September 8, 2023, Licensing was informed that the the policy for reporting illness was updated on September 7, 2023 and additions made for informing representatives and that staff training was implemented on August 1, 2023 with the coordinator to ensure staff sign off of completion.
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 meet the needs of the persons in care,
Observation: Through the investigation process, Licensing determined that the employees on duty were not sufficient in numbers, training, and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care.
Corrective action: Ensure that at all times, the employees on duty are sufficient in numbers, training, and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On August 18, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that the Licensee was to ensure that there was always trained staff sufficient in numbers on site and safe ratio information was added to all call out books. The corrective action plan was reviewed and accepted by Licensing. On September 8, 2023, Licensing was informed that training had commenced for all current employees in a 1:1 format with the Manager, the Scheduler was made aware on August 24, 2023 that no untrained employees would be scheduled until all site specific orientation had been completed and the Manager had signed off on completion, and a person in care no longer resided at the facility as of June 16, 2023.