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: Ensure that each employee has a record in compliance 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: December 12, 2023

Observations: Licensing audited five employee files. One employee file did not have a record of tuberculosis screening on file.

Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure that all policies and procedures are reviewed, and if necessary revised, at least once each year.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 28, 2023

Observations: Licensing audited the policies and procedures and found all policies and procedures had a review date of February 2022.

Description: A licensee must do all of the following: ensure that policies are implemented by employees.

Corrective Actions Required: Ensure that policies are implemented by employees.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: December 28, 2023

Observations: Licensing audited five employee files. All five files had a performance review dated June 2023. Facility policy indicated performance reviews had to be conducted quarterly.