PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): On observation, the utility room which had a sign posted to keep the door locked was noted to be left open. No staff were in the vicinity. Please note this is a repeat contravention from the 2018 routine inspection report # KBOI-AYJQL9.
Corrective Action(s): Please ensure the door to the utility room is kept locked at all times.
Date to be Corrected:
STAFFING: 32020 - RCR s.37(1)(b) - 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: (b) character references in respect of the person.
Observation: In 2 out of 6 staff files for support services it was noted that staff did not have evidence of reference checks in the file;
Corrective Action(s): Please ensure that all staff files are complete with pertienet documentation as required by legislation.
Date to be Corrected: June 27, 2019
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: In 3 out of 4 charts reviewed it was noted that there were 1-2 missing signatures per PIC on the MARs for the month of May.
Corrective Action(s): Please ensure that policies pertaining to MSAC committee are followed.
Date to be Corrected: July 31, 2019
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: For one chart there was no effect noted for the administration of prn Tylenoll. The facility's documentation policy states states to note the effectiveness of prn medications.
Corrective Action(s): Please ensure that staff folllow the facilities policy and procedures are implmemented by staff.
Date to be Corrected: July 31,2019
CARE AND/OR SUPERVISION: 34080 - RCR s.49(3) - A licensee must assess each person in care on admission to determine the risk that the person in care may leave the community care facility without notification of an employee.
Observation: Review of 4 PIC admission documents found that 4/4 did not have an elopement risk assessment. Confirmation with staff and management that the site does not complete an elopement risk assessment on admission.
Corrective Action(s): Ensure that each PIC is assessed on admission to determine the risk that the person in care may leave the facility without notification.
Date to be Corrected: July 31, 2019
CARE AND/OR SUPERVISION: 34890 - RCR s.83(4)(b) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (b) immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Observation: Review of 4 care plans noted that 2/4 had significant weight changes and no evidence of follow up or interventions to address weight changes. One PIC's weight was recorded as in kgs: April 81.1, May 74.2 and June 71.4. The second PIC's weight was listed as April 60.6, May 67.0 with no follow up documented or referral to RD noted. .
Corrective Action(s): Ensure that weights are reviewed regularly and that significant changes in weight trigger a referral.
Date to be Corrected: July 7, 2019
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: It was observed that the current menu does not specify what is provided for snacks. The FSM stated that items served for snacks depend on availability and use of surplus items. Please ensure that snacks served are recorded as per RCR 87(b) to provide documentation to ensure the following: - a variety of foods are provided for snacks - snacks served constitute two food groups from the CFG
- snacks served contribute to the total needs of the PICs in terms of the daily servings of food groups required
Corrective Action(s): Please ensure that there is a plan in place to ensure that snacks are planned and documented.
Date to be Corrected: July 17, 2019
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation (CORRECTED DURING INSPECTION): The FSM stated to Licensing that menus are audited by the company which provides the menus. A letter of confirmation was provided to Licensing. However, the letter also states that homes in BC will need to complete the menu audit as per Audits and More manual and that menu changes may be required to comply with the requirements of the Audits and More menu audit.
Corrective Action(s): Please ensure a menu audit that confirms the needs of the PICs are being met is completed by the facility.
Date to be Corrected:
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