Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: a criminal record check for the person

Corrective Actions Required: Ensure that all employees have a criminal record check.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 8, 2023

Observations: Licensing audited five employee files. One employee file had a criminal record check that had expired on October 30, 2023.

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: Ensure that policies and procedures are reviewed, and if necessary revised, at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 28, 2023

Observations: Licensing reviewed the policies and procedures and all policies and procedures had a last review date of February 2022.

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.

Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.

Corrective Actions Required: Ensure that a person in care's medication is returned to the pharmacy if the expiry date on the medication has passed.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: November 28, 2023

Observations: Licensing audited the medication cabinet. Licensing observed one medication that had expired October 2023. The Manager immediately disposed of the expired medication.