Click here for FAQ About Inspections. Click here for a description of each "Category" of violation displayed.

Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

JSAT-CHKUPB

FACILITY NAME Eleanor House		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0782340
FACILITY ADDRESS 2052 Eleanor Ave			FACILITY PHONE (604) 859-2907
CITY Abbotsford	POSTAL CODE V2S 4L6		MANAGER Kristie Osen

INSPECTION DATE August 23, 2022	ADDITIONAL INSP. DATE (multi-day) August 25, 2022		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 01:00 PM	DEPARTURE 03:00 PM	ARRIVAL 02:00 PM	DEPARTURE 04:00 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). Evidence for this report was based on the Licensing Officer’s observations, review of the facility records, and information provided by the facility staff at the time of inspection. Care systems reviewed during inspections include: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & Reporting. As part of the routine inspection a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3 year “historical” review of the facility’s compliance and operation. Visit the CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to the legislation (CCALA & RCR).

Contraventions

Previous Inspection -

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

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: 1 of 2 medication administration records reviewed, did not document the effectiveness of the PRN medications as required by the MSAC policies. Two months of PRN medication administration was reviewed and the effectiveness was missing approximately 50% of the time. Corrective Action(s): Ensure all employees comply with the policies and procedures of the MSAC. Date to be Corrected: September 9, 2022 POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) 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. Observation: One person in care did not have written agreement from the parent or representative, to the use of a restraint. Corrective Action(s): Ensure each person in care has written agreement from the parent of representative, for the use of a restraint. Date to be Corrected: September 9, 2022 POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection 74(2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care. Observation: one person in care who had a safety plan in place, did not have written agreement to the use of the restraint given by the physician responsible for the person in care. Corrective Action(s): Ensure there is written agreement to the use of a restraint given in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care. Date to be Corrected: Sept 9, 2022 HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs. Observation: One person in care did not have a record of immunization on file. Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Province's immunization program. Date to be Corrected: September 9, 2022

Comments

Discussed during inspection: -completion plan for staff performance reviews -MSAC meeting minutes and medication room inspections -secured doors on one side of the home It is requested that a written response be submitted on or before September 9th, describing how the above noted contraventions have been appropriately addressed and/or the plan for compliance with legislated requirements. The plan shall include a time line for any items that have not already been addressed. Please note that a follow-up inspection may be conducted to confirm compliance after the written response has been received by Licensing. Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager. (Please note: due to infection control practices related to COVID-19 prevention, this inspection report was reviewed with the Manager, written off-site and forwarded to the Licensee. Therefore no signature was obtained.)

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Sep 09, 2022

Click here for FAQ About Inspections. Click here for a description of each "Category" of violation displayed.