Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing received a copy of the policy and procedures list, dated December 2023, on January 23, 2024.

Actions Required By Licensing: No further action required; this contravention has been addressed.

To Be Corrected By:

Observations:

Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure that all policies are implemented by employees.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: December 28, 2023

Observations: Licensing audited five employee files and observed three employee files had a performance review dated March 2023. The facility's policy stated performance reviews had to be conducted quarterly for all employees.

Description: In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74 (1) (b) [when restraints may be used]: the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care

Corrective Actions Required: Ensure that the use of restraint, its type and duration is documented in the care plan for persons in care.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: December 12, 2023

Observations: The Manager stated that one person in care had a lap belt that they could not undo themselves, and there was no restraint noted in the care plan.