Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
29-Sep-2022
Subject
["Neglect","Physical Plant/Equipment (Includes issues such as cleanliness, state of repair, insufficient quantity of supplies, smoking/vaping etc.)","Reporting (Includes issues such as not reporting, insufficient reporting, etc.)","Confidentiality/Privacy","Dispute Resolution"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A care plan must include all of the following: a plan to address behavioural intervention, if applicable
Observation: Through the investigation process, Licensing determined that a care plan for a person in care did not address behavioral intervention.
Corrective action: Ensure that a plan to address behavioural intervention is included in the care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On November 15, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: an updated care plan which included a plan to address behavioural intervention. This corrective action plan was reviewed and accepted by Licensing. On November 15, 2023, Licensing received the updated care plan which addressed behaviour.
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 the licensee did not immediately notify the medical health officer of a reportable incident.
Corrective action: Ensure that if a person in care is involved in a reportable incident, immediately notify a medical health officer, in the form and in the manner required by the 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 November 15, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: all wellness nurses received training related to reportable incidents. This corrective action plan was reviewed and accepted by Licensing. On November 28, 2022, Licensing received confirmation that the wellness nurses received the training.
A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Observation: Through the investigation process, Licensing determined that the care plan of a person in care did not included a plan to locate the person in care if the person in care leaves without notification.
Corrective action: Ensure if a person in care leaves without notification, there is a plan to locate the person in care included in the care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On November 15, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: an updated care plan which included a plan to locate the person in care if they eloped from the facility. This corrective action plan was reviewed and accepted by Licensing. On November 15, 2023, Licensing received the updated care plan for the person in care which included a plan to locate the person in care if they were missing.
A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential.
Observation: Through the investigation process, Licensing determined that the licensee did not keep the records and personal information of persons in care confidential.
Corrective action: Ensure to the greatest extent possible while maintaining the health, safety and dignity of a persons in care, keep the records and personal information of persons in care confidential. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On November 15, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: staff were provided education on the facility's policy related to confidentiality. This corrective action plan was reviewed and accepted by Licensing. On November 28, 2022, Licensing received confirmation that the staff received education on confidentiality.
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.
Corrective action: Ensure that 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 November 15, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a new process was established regarding complaints and concerns feedback management system and management would review complaints and concerns during management meetings. This corrective action plan was reviewed and accepted by Licensing. On November 15, 2022, Licensing received a copy of the new process for recording complaints and concerns.