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 continues to meet the requirements of this regulation,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing reviewed one staff performance review, dated August 2021.

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

To Be Corrected By:

Observations:

Description: A licensee must keep a copy of each policy and procedure of the medication safety and advisory committee.

Corrective Actions Required:

Corrective Actions Taken By Licensee:

Actions Required By Licensing:

To Be Corrected By:

Observations:

Description: Clear and up to date records of immunization status kept for each person in care

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care’s records and both records included a record of immunization history.

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

To Be Corrected By:

Observations:

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:

Corrective Actions Taken By Licensee: Licensing audited two person in care’s records and both records included evidence of a tuberculosis screening.

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

To Be Corrected By:

Observations:

Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care’s records and two person in care’s records included consent in writing to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.

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

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: a plan to address behavioural intervention, if applicable

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care’s care plans and both care plans included a behavioural intervention plan, as applicable.

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

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: an oral health care plan

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care’s care plans and both care plans included an oral care plan.

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

To Be Corrected By:

Observations:

Description: A care plan must include all of the following: a nutrition plan that assesses a person in care’s nutrition status,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care’s care plans and both care plan included a nutritional care plan.

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

To Be Corrected By:

Observations:

Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited two person in care’s record and two persons in care had weights recorded for March 2022.

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

To Be Corrected By:

Observations:

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

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited three staff files and all three staff files had a record of references in respect of the employee.

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

To Be Corrected By:

Observations:

Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited three staff files and all thee staff files had a record of immunization history in respect of the employee.

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

To Be Corrected By:

Observations:

Description: A licensee must display the rights of adult persons in care in a prominent place in the community care facility

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing observed the Rights of Adult Persons in Care posted in the living room and hallway.

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

To Be Corrected By:

Observations:

Description: A licensee must ensure that, except as authorized by the medication safety and advisory committee, a person in care’s medications remain in the original labelled container or package provided by the dispensing pharmacy until administered.

Corrective Actions Required:

Corrective Actions Taken By Licensee: Licensing audited the facility's medication cabinet. All medications were secured and no medications had fallen out of the packaging.

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

To Be Corrected By:

Observations: