Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
17-Nov-2023
Subject
["Emotional Abuse","Reporting (Includes issues such as not reporting, insufficient reporting, etc.)","Sexual Abuse","Physical Abuse","Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)","Rights of Adult Persons in Care"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Observation: Through the investigation process, Licensing determined that care plans were not reviewed and modified when there was a substantial change in the circumstances of a person in care.
Corrective action: Ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances 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 December 18, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the care plan for a person in care was updated to include a guideline for the video monitoring device. This corrective action plan was reviewed and accepted by Licensing. On January 9, 2024 Licensing received a copy of the revised care plan which addressed the use of a non recording video monitor.
A licensee must do all of the following: operate the community care facility in a manner that will promote in the case of adult persons in care, the rights of those persons in care;
Observation: Through the investigation process, Licensing determined that staff did not promote the rights of persons in care. Specifically, persons in care lifestyle choices related to choice in TV programs were not respected.
Corrective action: Ensure the community care facility is operated in a manner to promote the health, safety and dignity of persons in care. Specifically, in the case of adults persons in care, the rights of those 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 18, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a staff had been removed from working at the facility and was on leave, if they returned, the staff was to received education and re-training on care plans, rights of person in care, Mandt, trauma informed delivery of support, and be placed on a three month probation where management would provide weekly supervision and, a TV watching guideline was implemented and staff were trained on the guideline. This corrective action plan was reviewed and accepted by Licensing. On January 9, 2024 Licensing received evidence the training had been completed with staff. As of May 7, 2024, the staff involved remained on leave from the facility.
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 a medical health officer, in the form and in the manner required by the medical health officer, about a reportable incident.
Corrective action: Ensure that 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. 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 18, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: All staff were trained on the incident report policy. This corrective action plan was reviewed and accepted by Licensing. On January 9, 2024 Licensing received evidence training had been completed by staff.
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 of a person in care was not consistent with the terms and conditions of the person in care's care plan.
Corrective action: 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. 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 18, 2023, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: Upon return to work from a leave, a staff would receive education and re-training on care plans. This corrective action plan was reviewed and accepted by Licensing. As of May 7, 2024 the staff remained on leave from the facility.
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 staff did not demonstrate the skills and abilities necessary to carry out the duties as assigned.
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 18, 2023 Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a staff had been removed from working at the facility and was on a leave of absence, if they returned the staff was to received education and re-training on care plans, rights of person in care, Mandt, trauma informed delivery of support, and be placed on a three month probation where management would provide weekly supervision. This corrective action plan was reviewed and accepted by Licensing. As of May 7, 2024, the staff remained on leave from the facility.
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: emotional abuse
Observation: Through the investigation process, Licensing determined that persons in care were subjected to emotional abuse.
Corrective action: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to emotional abuse. 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 18, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a staff had been removed from working at the facility and was on a leave of absence, if they returned the staff was to received education and re-training on rights of person in care, Mandt, trauma informed delivery of support, and be placed on a three month probation where management would provide weekly supervision, another staff had received a letter of expectation, and received education on emotional abuse and rights of person in care. This corrective action plan was reviewed and accepted by Licensing. On January 9, 2024, Licensing received confirmation that education was provided to a staff and that staff received a letter of expectation. As of May 7, 2024, the other staff involved remained on a medical leave.
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 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 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 18, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a staff had been removed from working at the facility and was on a medical leave of absence. However, if they returned the staff was to received education and re-training on care plans, rights of person in care, Mandt, trauma informed delivery of support, and be placed on a three month probation where management would provide weekly supervision. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. As of May 7, 2024, the staff was still on a medical leave.