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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-C9WUSD

FACILITY NAME
Harmony Court Care Centre
SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
GLAE-5RPUZ9
FACILITY ADDRESS
7195 Canada Way
FACILITY PHONE
(604) 527-3300
CITY
Burnaby
POSTAL CODE
V5E 3R7
MANAGER
Cindy Kahlon

INSPECTION DATE
December 21, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.5
ARRIVAL
09:30 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

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 https://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
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: Upon inspection of the facility narcotic count book, it was observed that the dosage count and the wasted narcotic was not signed off on.
Corrective Action(s): Ensure that employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: December 31, 2021

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Upon review of facility post falls assessment, it was determined that one was in complete. The neuro-vital assessments were not conducted at the required intervals for the required duration of time.
Corrective Action(s): Please ensure that post falls assessments are conducted as per the policy in place.
Date to be Corrected: December 31, 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: Upon inspection of the facility spa room, there were observed a hairbrush and hair tie that had been used, as evidenced by the presence of hair. Of concern is the implements were not labelled specifically for use with one person in care (PIC). These items are not for shared use.
Corrective Action(s): Assist PIC's with maintaining health and hygiene
Date to be Corrected: December 31, 2021


Comments

Thank you to the staff for their time and support with this inspection.
An email copy of this report and the accompanying risk assessment was provided by email to facility leadership.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Dec 31, 2021

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