Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee demonstrates the competence required for the duties to which the employee is assigned.

Corrective Actions Required: Ensure that the performance of each employee is reviewed regularly.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 30, 2023

Observations: Licensing audited four employee files and observed one employee had a performance review last completed in 2019. The Manager stated performance reviews were to be conducted every two years as per the policy.

Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 30, 2023

Observations: Licensing audited three person in care's medication administration records and the facility's narcotic count record. Two person in care's medications were not signed for or coded by staff on multiple dates and the narcotic count record was missing a second staff signature on multiple dates.

Description: A licensee must keep the following records in respect of each employee: character references

Corrective Actions Required: Ensure that character references are kept in respect of each employee.

Corrective Actions Taken By Licensee:

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

To Be Corrected By:

Observations: Licensing audited four employee records and observed one employee had only one reference, in respect of the employee.

Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.

Corrective Actions Required: Ensure that all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: June 30, 2023

Observations: Licensing audited three person in care's records and observed one person in care did not have a record of tuberculosis screening.