Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
20-Sep-2024
Subject
["Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","Neglect"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
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 Licensee did not operate the community care facility in a manner that will promote the health, safety and dignity of persons in care, specifically, in relation to documentation.
Corrective action: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On December 3, 2024 and January 15, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan, implemented before the concern raised on September 20, 2024, Staff completed education module covering the task documentation process on August 15, 2024. An audit of the monthly compliance report was conducted to ensure at least 95% of documentation was completed. Additionally, a random audit of the daily compliance report was performed by leadership to assess documentation accuracy. If the compliance report fell below 95%, management notified care staff to improve the percentage. New staff received documentation training during their orientation. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On December 9, 2024, Licensing received a compliance report for all persons in care, which indicated that 95 to 97.24 percent of the total documentation had been completed.
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 Licensee did not operate the community care facility in a manner that will promote the health, safety and dignity of persons in care, specifically, related to documentation.
Corrective action: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of 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 December 3, 2024 and January 15, 2025, Licensee submitted a corrective action plan to Licensing. The corrective action plan included on September 20, 2024, staff completed an education module covering the task documentation process on August 15, 2024, an audit of the monthly compliance report was conducted to ensure at least 95% of documentation was completed, a random audit of the daily compliance report was performed by leadership to assess documentation accuracy, if the compliance report fell below 95%, leadership notified care staff to improve the percentage and new staff received documentation training during their scheduled orientation. This corrective action plan was reviewed and accepted by Licensing. On December 9, 2024, Licensing received a compliance report for all persons in care, which indicated that documentation had been completed.