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: character references in respect of the person

Corrective Actions Required: Ensure character references are obtained for all employees.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 24, 2024

Observations: Licensing audited three employee files. Two of the employee files did not contain character references.

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: 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: March 24, 2024

Observations: Licensing audited three employee files and all three files did not have a recent performance evaluation.

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: March 24, 2024

Observations: Licensing audited the medication administration records of two persons in care. One person in care had a medication that was not signed for or coded by staff on February 20, 2024.

Description: A care plan must include all of the following: if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan to prevent the person in care from leaving

Corrective Actions Required: Ensure the care plan includes a plan for preventing persons from leaving the facility without notifying an employee if that person in care was determined to be a risk for leaving.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 24, 2024

Observations: Licensing audited the care plans of two persons in care. One person in care who was determined to be a risk for leaving the facility without notification of an employee, did not have a plan for prevent the person in care from leaving.

Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan

Corrective Actions Required: Ensure each care plan is reviewed at least once a year if there is no substantial change in the circumstances of the person in care.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 24, 2024

Observations: Licensing audited the care plans of two persons in care and both persons in care's oral care plan had not been reviewed in the last year.