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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

JSAT-BLNN78

FACILITY NAME Ferguson Home		SERVICE TYPES 140 Community Living	FACILITY LICENSE # TBIU-8F8MS5
FACILITY ADDRESS 32375 George Ferguson Way			FACILITY PHONE (604) 850-1055
CITY Abbotsford	POSTAL CODE V2T 2L2		MANAGER Karin Olsen

INSPECTION DATE February 10, 2020	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4
ARRIVAL 09:30 AM	DEPARTURE 01:30 PM	ARRIVAL	DEPARTURE	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 and investigations include the following: 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

CARE AND/OR SUPERVISION: 34550 - RCR s.75(3)(a)(i) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (a) reassess the need for the restraint on the earlier of (i) the time specified in the care plan of the person in care. Observation: On review of 2 care plans, 1 person in care's care plan was last reassessed and signed off by the Physician and legal guardian, for restraint use in March of 2018. Corrective Action(s): Ensure restraint care plan is reassessed and signed off by both legal guardian and Physician as per facility policy. Date to be Corrected: CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan. Observation: On review of 2 care plans and discussion with manager, it was found that 1 care plan had a seizure protocol that last showed evidence of review in March of 2018. Corrective Action(s): Ensure that each care plan is reviewed and if necessary modified at least once each year. Date to be Corrected:

Comments

Copies of the inspection report and the Facility Risk Assessment Tool were reviewed, discussed, and provided to the Licensee/Manager.

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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