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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SCLY-ATCQFV

FACILITY NAME
Holmberg House Hospice
SERVICE TYPES
110 Hospice
FACILITY LICENSE #
TBIU-9UAPLB
FACILITY ADDRESS
32780 Marshall Road
FACILITY PHONE
(604) 613-4201
CITY
Abbotsford
POSTAL CODE
V2S 1J7
MANAGER
Teresa Armstrong

INSPECTION DATE
November 20, 2017
ADDITIONAL INSP. DATE (multi-day)
November 22, 2017
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.75
ARRIVAL
02:00 PM
DEPARTURE
04:00 PM
ARRIVAL
09:00 AM
DEPARTURE
11:45 AM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

An unscheduled routine was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · Records and Reporting

As part of this 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 http://www.fraserhealth.ca/health-info/health-topics/residential-care-licensing/ for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected.
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: The medication safety and advisory committee (MSAC) policies and procedures states that staff are to record the effectiveness of an administered PRN.
A review of persons in care (PIC) MAR records found that 3 PICs had at least 5 PRNs administered that did not have the effectiveness indicated along with the staff's initials.
Corrective Action(s): Please ensure that employees comply with the MSAC's policies and procedures for administering and recording PRNs.
Date to be Corrected: November 22, 2017


Comments


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 01, 2017

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