Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
20-Mar-2023
Subject
["Neglect","Physical Plant/Equipment (Includes issues such as cleanliness, state of repair, insufficient quantity of supplies, smoking/vaping etc.)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: neglect
Observation: Through the Licensing investigation process, Licensing determined that a person in care was subjected to neglect while under the care or supervision of the licensee.
Corrective action: Ensure that a person in care is not subjected to neglect, while under the care or supervision of the licensee. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On June 12, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All person in care's individual care needs, including safety checks, were uploaded to Point of Care (POC), care staff sign off on care tasks once completed; this was an ongoing practice, POC compliance audit reports were to be monitored by the Leadership team weekly; this was an ongoing practice, policies related to Resident's Rights and Wishes, Prevention of Resident Abuse and Neglect and Bill of Rights education was provided to all staff on April 25, July 18, July 20, and August 10, 2023. This corrective action plan was reviewed and accepted by Licensing. On September 15, 2023, Licensing received a copy of the attendance records which indicated staff reviewed the requried policies.
A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Observation: Through the investigation process, Licensing determined that the care and supervision for a person in care had not been consistent with the care plan.
Corrective action: Ensure that the care and supervision for persons in care is consistent with the terms and conditions of the person in care's 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 September 12, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All person in care's individual care needs, including safety checks, were uploaded to Point of Care (POC), care staff sign off on care tasks once completed; this was an ongoing practice, POC compliance audit reports were to be monitored by the Leadership team weekly ongoing, the POC manual was reviewed with Residential Care Aides (RCAs) regarding expectations related to documentation, and POC documentation was to be reviewed with all staff upon hire. The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.
To be corrected by: 31-Mar-2024
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 safety checks were not documented for person in care. Corrective Actions Required: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care, specifically regarding safety checks for persons in care. Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On September 12, 2023 Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All person in care's individual care needs, including safety checks, were uploaded to Point of Care (POC). Care staff sign off on care tasks once completed; this was ongoing. •POC compliance audit reports were to be monitored by the Leadership team weekly; this was ongoing. •The POC manual was reviewed with Residential Care Aides (RCAs) regarding expectations related to documentation. •POC documentation was to be reviewed with all staff upon hire. Policies related to Resident's Rights and Wishes, Prevention of Resident Abuse and Neglect and Bill of Rights education was provided to all staff on April 25, July 18, July 20, and August 10, 2023 •On September 15, 2023, Licensing received a copy of the attendance records which indicated staff reviewed the above policies. The corrective action plan was reviewed and accepted by Licensing.. Licensing to review and monitor this corrective action plan
Corrective action:
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 safety checks were not documented for person in care.
Corrective action: Ensure that the facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that documentation is completed. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On September 12, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All person in care's individual care needs, including safety checks, were uploaded to Point of Care (POC), care staff sign off on care tasks once completed was ongoing, POC compliance audit reports were to be monitored by the Leadership team weekly ongoing, the POC manual was reviewed with Residential Care Aides (RCAs) regarding expectations related to documentation and POC documentation was to be reviewed with all staff upon hire. The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.
To be corrected by: 31-Mar-2024