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 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 Taken By Licensee:

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

To Be Corrected By: October 25, 2023

Observations: Licensing audited six staff files and observed four staff did not have up to date performance reviews.

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: September 25, 2023

Observations: Licensing audited the medication administration record and observed one medication was not signed or coded for by staff on September 20, 22, and 24, 2023, and two medications were not signed or coded for by staff on September 23, 2023.

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 records are kept in respect to compliance with the Province's tuberculosis control program.

Corrective Actions Taken By Licensee:

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

To Be Corrected By: October 25, 2023

Observations: Licensing audited six staff files and observed that two staff files did not contain records of tuberculosis test results.