PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis.
Observation: The following were observed to be needing maintenance:
-the florescent lighting in room 2 was missing a lens cover for florescent tubes. Ceiling is low and the fixture is within reach for accidental damage.
-curtains over window, ground floor, room 2, right hand panel does not provide privacy as it no longer is attached to curtain rod
-closet door is off the roller and does not open or close properly, room 2
-room 7, door is off a freestanding closet
-the caulked edge of 2 bathroom tubs were observed to be black, implying mold growth
-one closet in a shared room was observed to be overstuffed with the clothing of 2 residents being mixed
-room 11 tall armoire, pull handle of 2nd drawer from the bottom is displaced.
-dresser room 1 appears scratched and worn
-upstairs bedroom, a section upper left inside door molding held in place with duct tape
Corrective Action(s): Please provide a plan of action, with a timeline, that will ensure there is a system for regular monitoring and maintenance of the entire facility. These contraventions were remediated by Jan. 16, 2019 inspection.
Date to be Corrected: January 31, 2019
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31750 - RCR s.35(1)(b) - A licensee must provide the following appropriately furnished and equipped areas: (b) safe and secure locations for medications and the records of persons in care.
Observation: Over the counter medications (Tums), as well as prescription creams and drops were observed in 3 rooms. The medications were not securely stored, nor was there a plan for self-medication in place. It was also observed that expired and discontinued medications were not securely stored while waiting pick-up by the pharmacy staff.
Corrective Action(s): Please provide a plan to licensing that will ensure that all medications including those approved for self-administration with documented evidence are securely stored.
Date to be Corrected: Jan. 31, 2019
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: Three staff files were reviewed, and there were no current performance reviews. This is a repeat contravention from the previous inspection. The manager stated he was new to the facility at last Routine Inspection and was not in a position to evaluate the staff until recently. The Policy and Procedures were reviewed for direction for intervals of time between performance assessments. The information was not found in the P&P.
Corrective Action(s): Please provide a plan and timeline that will ensure completion of the performance reviews in a timely manner, and please ensure that the policy relating to performance reviews of staff reflects the interval of time the performance reviews will be conducted in the future
Date to be Corrected: Jan. 31, 2019
STAFFING: 32310 - RCR s.51(3) - A licensee must ensure that each employee is trained in the implementation of the plans described in subsection (1), including in the use of any equipment noted in the plan.
Observation: The manager states that the fire drills occur every month, this was supported by documentation, with the exception of one month. Discussion took place with relation to adding different disaster scenario preparation to the fire drill training, . The BC Emergency Preparation site on the internet was also discussed as a useful tool for planning purposes.
There was no evidence of training for other disasters such as earthquake, gas leak, aggressive behaviors, prolonged electrical outage, etc. The emergency supplies were reviewed and explained by the manager. Packs have been purchased with extended expiry dates for all resident, enough food for 3 days.
There were large carboys of water, that did not show an expiry date. One of the carboys had a broken seal and cap
There was no accommodation for communication in the event of an emergency shut down of communications such as cell phone. There was no radio to allow residents and staff to keep in touch with regional rescue status in the event of a lengthy response time.
The house is vintage, although it seems sturdy, there was no arrangement for an alternate setting if the house was deemed unsafe to inhabit until rescue. Alternate settings can be other facilities, a church or community center.
Corrective Action(s): Please provide a plan that will: -ensure there is an easily identifiable expiry date for water supplies and a means to determine if the seal has not been damaged.
- there is planning and training of staff for different disaster scenarios, this can be combined with fire drills
- please describe the planning surrounding communications during a disaster
- please provide information for an alternative situation/place in the event the house structure was deemed unsafe after a disaster event.
Date to be Corrected: Jan. 31, 2019
POLICIES AND PROCEDURES: 33100 - RCR s.60(a) - A licensee must (a) establish a fair, prompt and effective process for persons in care and their parents or representatives, family members and contact persons to express a concern, make a complaint or resolve a dispute.
Observation: A policy describing a complaint/dispute resolution process was not found and the manager was not able to describe the complaint resolution process.
Corrective Action(s): Please provide a plan that will ensure that the PIC's, their families and representatives are made aware of the facility complaint/dispute resolution process, and that there is policy in place to support the process.
Date to be Corrected: Jan. 31, 2019
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: Mandatory policies were reviewed and found to have not been reviewed in the past 2 years.
Corrective Action(s): Please provide a plan that will ensure that policies meant to direct staff in matters of care and supervision are reviewed and if necessary revised yearly
Date to be Corrected: Jan. 31, 2019
POLICIES AND PROCEDURES: 33320 - RCR s.85(2)(b) - Without limiting subsection (1)(a), a licensee must have written policies and procedures in respect of all of the following: (b) the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Observation: There was no policy identified, nor orientation material for orientation of the manager to the requirements of licensing,( i.e. CCALA and RCR) of the facility observed at inspection. this was a concern identified in the previous inspection.
Corrective Action(s): Please ensure there is a policy and orientation process available for inspection to ensure managers and employees are oriented to the legislation and the regulations.
Date to be Corrected: Jan. 31, 2019
POLICIES AND PROCEDURES: 33370 - RCR s.85(2)(f)(i) - Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: (f) release of children, youths and vulnerable adults from the community care facility, including (i) if a person who is authorized to remove the person in care from the community care facility appears to be incapable of providing safe care to the person in care.
Observation: A policy directing staff for managing an approved visitor who wishes to remove a PIC from the facility but appears incapable of providing safe care was not observed in the policy manual.
Corrective Action(s): Please provide evidence that a policy is in place regarding the above mandatory policy requirement.
Date to be Corrected: Jan. 31, 2019
CARE AND/OR SUPERVISION: 34600 - RCR s.81(3)(a)(i) - A care plan must include all of the following: (a) a plan to address (i) medication, including self-administered medication if approved under section 70 (4) [administration of medication].
Observation: Three PIC rooms were observed to contain medicated ointment. these products were not securely stored, and there was no approved plan found in their care plan.
Corrective Action(s): Please provide a plan that will address the issue of self-administration of medications and secure storage of medications that are being self-administered.
Date to be Corrected: Jan 31, 2019
RECORDS AND REPORTING: 39490 - RCR s.88(a) - A licensee must keep a record of all of the following: (a) minor accidents, illnesses and medication errors involving persons in care that do not require medical attention and are not reportable incidents.
Observation: A system of keeping records of non-reportable, minor incidents, illnesses, medication errors not requiring medical attention was not found.
Corrective Action(s): Please provide a plan that will demonstrate a system of recording non-reportable and minor incidents.
Date to be Corrected: Jan. 31, 2019
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