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 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: April 23, 2024

Observations: Licensing audited three employee files. Two employee files did not contain a performance review.

Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care,

Corrective Actions Required: Ensure there is an agreement in writing for the use of restraints signed by the person in care or their representative.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 23, 2024

Observations: Licensing toured the facility and observed locked doors to the kitchen, dining room and bedrooms. Staff informed Licensing this was due to the behaviours of a person in care. Licensing audited the person in care's chart and there was no agreement signed by the representative regarding the use of restraint.

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 to include in a care plan the use of restraint including the nature and frequency of the restraint.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: March 23, 2024

Observations: Licensing toured the facility and observed locked doors to the dining room, kitchen, and bedrooms. Staff informed Licensing this was due to behaviours of one person in care. Licensing audited the person in care's care plan and it did not include the use of restraints.