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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-B6AMK9

FACILITY NAME
The Cascades
SERVICE TYPES
110 Hospice
130 Long Term Care
FACILITY LICENSE #
TBIU-9KSNHS
FACILITY ADDRESS
45586 McIntosh Dr
FACILITY PHONE
(604) 795-2500
CITY
Chilliwack
POSTAL CODE
V2P 7W8
MANAGER
Robert White

INSPECTION DATE
November 06, 2018
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
12
ARRIVAL
09:15 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

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 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
Resident Bill of Rights
Additional CCALA Sections

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 - Not Applicable
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: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: It was observed in three persons in care rooms that the Activities of Daily Living (ADL) sheet was dated 2017 and did not indicate that it had been reviewed or modified on a monthly basis as per protocol of this facility.
Corrective Action(s): Ensure the ADL sheet is reviewed and modified as necessary as part of the care plan. Ensure this review is documented
Date to be Corrected: 14 Nov 2018

RECORDS AND REPORTING: 39370 - RCR s.84(d) - If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: (d) the duration of the restraint and the monitoring of the person in care during the restraint.
Observation: The care plan did not have a record of monitoring of a restraint for a person in care. The restraint was required to be monitored on an hourly basis and had been completed until 26 Oct 2018. Upon inspection of the electronic care plan, it was discovered that the prompt for monitoring had been cancelled. The person in care still requires the restraint and as such requires the monitoring.
Corrective Action(s): Ensure the monitoring of the restraint is recorded hourly.
Date to be Corrected: 07 Nov 2018.


Comments

This Licensing Officer returned the following day to deliver the Inspection Report. Discussion with the Manager at this time indicates that upon his internal investigation regarding the person in care requiring the restraint, it was discovered that this person no longer requires the restraint. This information was not documented in the Care Plan, nor was it reported in the progress notes.

Copies of the Inspection Report and Risk Assessment Tool were reviewed, discussed, and provided to the Manager. Please contact your Licensing Officer if you have any questions regarding this report.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required
Due Date
Nov 14, 2018

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