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

FACILITY NAME
Bethesda Matsqui Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0720048
FACILITY ADDRESS
32768 Bevan Ave
FACILITY PHONE
(604) 850-3499
CITY
Abbotsford
POSTAL CODE
V2S 1T1
MANAGER
Marian VanderBos

INSPECTION DATE
November 18, 2016
ADDITIONAL INSP. DATE (multi-day)
November 21, 2016
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6
ARRIVAL
01:00 PM
DEPARTURE
03:15 PM
ARRIVAL
01:30 PM
DEPARTURE
03:00 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 -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
POLICIES AND PROCEDURES: 33130 - RCR s.68(3)(a) - The medication safety and advisory committee must establish and review as required (a) training and orientation programs for employees who store, handle or administer medications to persons in care.
Observation: No documentation since 2015 to evidence that MSAC has:
- Reviewed training/ orientation programs for employees who store / handle/administer medications.
- Reviewed policies and procedures for safe, effective storage, handling and administration of medications
- Reviewed the response and reporting of medication errors and adverse reactions
Corrective Action(s): Ensure MSAC committee has established and reviewed as required training/ orientation programs for employees, policies and procedures for safe, effective storage, handling and administration of medications, as well as response and reporting of medication errors.
Date to be Corrected: December 23, 2016

POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: Please refer to 33 130 for reference.
Corrective Action(s):
Date to be Corrected:

POLICIES AND PROCEDURES: 33150 - RCR s.68(3(b)(ii) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (ii) the immediate response to and reporting of medication errors and adverse reactions to medications.
Observation: Please refer to 33 130 for reference.
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34640 - RCR s.81(3)(c)(i) - A care plan must include all of the following: (c) a nutrition plan that (i) assesses a person in care's nutrition status.
Observation: Screening Forms to assess dietician involvement and Food and Nutrition Information forms were not completed. The manager stated there is not an alternative form of assessment used to assist the licensee to assess the nutritional status for all persons in care.
Corrective Action(s): Ensure assessment forms are completed to assist in creating a Nutrition Care plan for each person in care.
Date to be Corrected: December 23, 2016


Comments

The manager is working on a fall/ winter menu which will be incorporated by the first week of December 2016. The menu audit for each week will be completed to ensure the requirements for the Canada Food Guide are met.

A new manager has started as of October 1, 2016. The licensee will submit an amendment for the change of manager by December 5, 2016. Licensing has provided The Amendment Form and Licensee Declaration Form to the manager, as well as the Licensed Residential Care bulletin for Change of Facility Manager requirements.

The manager is in the process of completing performance reviews for the staff of Bethesda Matsqui Home.

Due to technical problems, the manager has not been able to update contact information in the resident profiles. These areas were identified by the manager. This will be completed at the first opportunity.

Emergency supply rotation is due November 25, 2016 and will be completed by the end of November 2016. The manager will ensure documentation will reflect all updates.

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
Dec 23, 2016

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