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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KDHL-AQ5TNG

FACILITY NAME
Hylan Home
SERVICE TYPES
150 Acquired Injury
FACILITY LICENSE #
0782552
FACILITY ADDRESS
32223 Hylan Ave
FACILITY PHONE
(604) 850-8122
CITY
Abbotsford
POSTAL CODE
V2T 1S8
MANAGER
Lydia Valle Nguyen

INSPECTION DATE
August 10, 2017
ADDITIONAL INSP. DATE (multi-day)
August 11, 2017
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9
ARRIVAL
12:30 PM
DEPARTURE
04:00 PM
ARRIVAL
11:00 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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.

The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and 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 - Not Applicable
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: 2 PRNs and 2 contingency medications were not signed on the back of the blister pack when administered.
Corrective Action(s): Ensure staff comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: September 15, 2017

POLICIES AND PROCEDURES: 33010 - RCR s.48(1)(a) - Before admitting a person to a community care facility, a licensee must advise the person, or the person's parent or representative, of (a) all charges, fees or other payments that the person in care may have to pay in return for accommodation and other services offered by the community care facility.
Observation: Their is no information/ form of documentation of persons in care being advised of all charges. Presently, a person in care is charged for staff's portion of expense during an outing. Policy relating to charges, the welcome package, discussion with the manager, and 3 persons in care financial records were reviewed to assess compliance. The manager was unable to produce documentation to confirm compliance with this regulation.
Corrective Action(s): Ensure persons in care, or their representatives are advised of all charges, fees and/or other payments that the person in care may have to pay in return for services offered by the community care facility.
Date to be Corrected: September 15, 2017

POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Although the manager reviews policy on an ongoing basis, review of fire safety plan and policy relating to fire drills has not been revised to reflect practice with fire drills.
Corrective Action(s): Ensure policy is revised if necessary.
Date to be Corrected: September 15, 2017


Comments

Licensing would like to acknowledge the following:
Physical Facility:
Licensee has discussed potential renovations. Please ensure approval from Licensing for any structural changes prior to changes occurring.

Care and Supervision:
Ensure preferences are reviewed with all persons in care with regards to family pet visitors.

Program:
The licensee to ensure opportunity for resident and family council to discuss items regarding the facility on a collective platform.

Medications:
Medication Safety and Advisory Committee meetings and medication reviews occur every three months. The manager will ensure documentation to confirm meetings and reviews is provided by the pharmacy in a timely manner.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Sep 15, 2017

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