PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: (REPEAT CONTRAVENTION) The hot water was measured to be 50.0°C and 51°C in the two bathrooms and 52°C at the kitchen sink.
Corrective Action(s): Ensure water accessible to a person in care, from any source, is not heated to more than 49°C.
Date to be Corrected: May 7, 2021
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition.
Observation: Upon inspection of the physical facility, the following was observed:
- Cleaning supplies were stored in an unlocked cupboard under the kitchen sink and in the laundry room. (CORRECTED DURING INSPECTION).
- 2 outlets on the right and left side of the kitchen sink were within 1.5 meters of a water source and were not GFCI. Management indicated BC Housing is aware and will be correcting this.
- A door panel in the door of a PICs armoire/shelf had fallen out of the frame.
- The chest freezer in the outdoor storage area had 0.5cm of frost build-up covering all interior sides of the freezer and the top of one food item.
- The exterior of the home was observed to have one side of corner beading coming away from the vinyl siding; 4 soffits on the south side of the home were falling out; and a fence panel located beside the south side of the home was braced up with a 2 x 4 piece of wood. Management indicated BC Housing is aware and a work order was submitted March 16, 2021 to correct these items.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a safe and clean condition.
Date to be Corrected: May 7, 2021
STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person.
Observation: A sample of 6 employee files were reviewed. The criminal record check for 1 employee had expired in March 2021 and results of a new criminal record check have not been submitted.
Corrective Action(s): Ensure current criminal record checks are obtained for all employees and are maintained on file.
Date to be Corrected: April 30, 2021
STAFFING: 32050 - RCR s.37(1)(e) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (e) evidence that the person has complied with the Province's immunization and tuberculosis control programs.
Observation: (REPEAT CONTRAVENTION) A sample of 6 employee files were reviewed. 2 employee files contained no record of immunization and 2 employee files contained no record of tuberculosis screening.
Corrective Action(s): Ensure that staff have provided evidence on hire of compliance to BC's immunization and tuberculosis programs.
Date to be Corrected: May 7, 2021
STAFFING: 32250 - RCR s.44(1)(a) - A licensee must ensure that employees responsible for the preparation and delivery of food (a) have the experience, competence and training necessary to ensure that food is safely prepared and handled and meets the nutrition needs of the persons in care.
Observation: Staff prepare meals for persons in care. Upon review of employee files, it was observed that 3 of 6 staff had FoodSafe certificates that were no longer valid. FoodSafe certificates must be recertified every 5 years in order to be in good standing.
Corrective Action(s): Ensure the preparation of meals and snacks is monitored or completed by a staff with a FoodSafe certificate in good standing.
Date to be Corrected: May 7, 2021
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: Upon review of the facility's emergency supplies and emergency procedures, the following was observed:
- The supply of food was insufficient to support persons in care and staff for a period of 3 days.
- The emergency supply kit was last reviewed in January 2021; however, several canned food items were expired.
- The facility's Emergency Response Plan Policy requires the completion of monthly fire drills. Upon review of the past 12 month period, it was observed that 4 fire drills have been recorded as having been conducted. (REPEAT CONTRAVENTION)
Corrective Action(s): Ensure that emergency supplies are adequate to support persons in care and staff for 3 days and that emergency response training is completed as required.
Date to be Corrected: April 30, 2021
HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Personal hygiene items stored in the shower and on the bathroom counter could not be identified according to PIC.
Corrective Action(s): Ensure personal hygiene items are stored in a manner that clearly identifies the PIC
Date to be Corrected: April 30, 2021
RECORDS AND REPORTING: 39330 - RCR s.83(4)(c) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (c) record the weight in the nutrition plan of the person in care.
Observation: Upon review of nutrition plans, it was observed that 2 of 4 person in care (PIC) nutrition summaries did not have a goal weight range recorded and 1 of 4 PIC nutrition summaries did not have a present weight recorded.
Corrective Action(s): Ensure a record of weight and weight range is recorded in the nutrition plan of each person in care.
Date to be Corrected: May 7, 2021
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