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 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: March 16, 2023

Observations: Licensing inspected the medication cabinets. There were several issues noted on the last pharmacist inspection such as: medications with an expiry once opened were not labeled with open/discard dates; daily shift counts were not being completed with two signatures consistently; audit of narcotic and controlled substance practices was not performed monthly; the refrigerated medications were not stored separate from food; outcome and effectiveness of prn medications was not consistently documented;

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: Ensure that each person in care is weighed at least once each month.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 16, 2023

Observations: Licensing reviewed the weight records of persons in care. There were many months without a weight record documented for persons in care.

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:

Corrective Actions Taken By Licensee: Licensing inspected the medication cabinets in House 1 and House 2. There were no expired medications in House 1, and one medication that just passed it's expiry date that was removed for return to pharmacy.

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

To Be Corrected By:

Observations: