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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
AROE-B4DLVA

FACILITY NAME
Bethesda West Clearbrook Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0782091
FACILITY ADDRESS
2339 Arbutus St
FACILITY PHONE
(604) 850-7311
CITY
Abbotsford
POSTAL CODE
V2T 2V8
MANAGER
Lorraine Derksen

INSPECTION DATE
September 06, 2018
ADDITIONAL INSP. DATE (multi-day)
September 07, 2018
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.25
ARRIVAL
10:15 AM
DEPARTURE
03:30 PM
ARRIVAL
11:00 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An scheduled 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 (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.
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 https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo for:

· Additional resources and
· Links to the Legislation (CCALA & RCR)


Contraventions
Previous Inspection - Contraventions observed on FIR #KDHL-ANYRSM have been corrected.
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): During the routine inspection it was noted that there was open and unlabeled medication belonging to a staff in a unsecured location in a kitchen cupboard. Manager explained that this is not regular occurrence and proper storage of personal items would be discussed at the next staff meeting.
Corrective Action(s): The licensee must ensure that all medications in the community care facility are safely and securely stored and only medication of PIC's are to be in the home.
Date to be Corrected: September 10,2018

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: Upon review of the Medication Advisory Committee Meeting minutes it was noted that there is no discussion related to the review of training and orientation programs for employees who store, handle or administer medications to persons in care. It is recommended that this be a standing action item on the MSAC meeting agenda.
Corrective Action(s): The Medication Safety Advisory Committee must establish and review as required the training and orientation programs for employees who store, handle or administer medications to persons in care.
It is recommended that policies and procedures in respect of the safe storage, handling and administration of the persons in care's mediation, in compliance with the Pharmacy Operations and Drug Scheduling Act as well as the immediate response to and reporting of medication errors and adverse reactions to mediations are established and reviewed by the MSAC
Date to be Corrected: The next MSAC meeting date


Comments

Licensing
Licensee confirmed that there is no longer a non-resident attending day program activities during the day at the house and the license will be amended to reflect the maximum capacity of Bethesda - West Clearbrook Home will be 4 Persons in Care.
Physical Facility
It was noted that in the shower room there were 2 light bulbs burnt out, in the hallway near the storage room there were 2 light bulbs burnt out and the kitchen lighting appeared dim. Through discussion with the Manager it was explained that all lights in the building are being replaced with new, brighter ones. Manager showed the Licensing Officer the new lights and explained they are just waiting on Maintenance to install them.
In the shower room the fan appeared to be dusty, Manager said that she would ensure it was cleaned.
It was brought to the attention of the Manager that the carpet under an individuals bed, which is used to prevent the bed from sliding even when the brakes are on, is damaged and not easily cleanable. The Manager said she would consider other options to replace the carpet with.
Records and Reporting
During the inspection the Licensing Officer found that the PIC’s personal wallets were visible and accessible. The wallets were being stored in an unsecured area and although it was explained by the manager that there are no outside persons allowed in the home that would have access the wallets, the manager agreed that in order to keep the personal information and items in the wallets safe they should be stored in a less visible and secure area.
Nutrition and Food Services
Upon review of the emergency supplies it was determined that there is adequate food and water available for 72 hours for all individuals in the home. It was suggested that with the new system in place of using reconstituted food in the emergency kits that it be confirmed how much water would be needed in excess to reconstitute the food packages while still maintaining water supplies for drinking.

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 21, 2018

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