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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SCLY-AEVUBX
FACILITY NAME
Innervisions Recovery Society Hannah House		SERVICE TYPES
125 Substance Use
FACILITY LICENSE #
ABII-6FZP9K
FACILITY ADDRESS
11982 Laity St		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Joanna Schofield
INSPECTION DATE
October 19, 2016		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
2.15
ARRIVAL
01:45 PM		DEPARTURE
04:00 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# CHILDREN ENROLLED
Introduction

A scheduled follow-up inspection 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:
· Physical Facility
· Staffing
· Medication
· Nutrition and Food Services

Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for:
Additional resources, and
Links to the Legislation (CCALA and RCR)
Contraventions
Previous Inspection - Contraventions observed on FIR #NTJN-A7PQEE have been corrected except for those noted on supplementary pages.
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: Review of 8 Person In Cares' (PIC) Medication Administration Records (MAR) found that 1 medication had been signed for, but the medication was still in the blister pack.
Corrective Action(s): Please ensure that all employees comply with medication safety advisory committees policies and procedures.
Date to be Corrected: October 19, 2016

NUTRITION AND FOOD SERVICES: 37190 - RCR s.66(1) - A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition plan.
Observation: There was one menu audit for the week 1 menu, but none for the other weeks. The audit that was present indicated twice that the nutrition did not meet the daily nutrition requirements on Day 5 and 7 and it was not indicated what action was taken to rectify this. This is a repeat contravention from the previous routine inspection #NTJN-A7PQEE.
Corrective Action(s): Ensure that each person in care receives adequate nutrition to meet there personal nutritional needs based on Canada's Food Guide.
Date to be Corrected: October 31, 2016

RECORDS AND REPORTING: 39580 - RCR s.91(1)(a) - A licensee must ensure that all records referred to in this regulation (a) are current.
Observation: Review of 8 PICs' MARs found the following:
- 1 PIC's MAR stated that ibuprofen was to be given 3 times a day, but that MAR had it marked as a PRN. The medication had been administered 3 times a day except on October 18 and 19. On October 18 acetaminophen, a PRN, was administered for pain management.
- Another PIC's MAR states that they are to receive Zyban once a day, but the blister pack sates 2 times a day. The medication was not given in the evening of October 18, but was the other evenings and mornings.
Corrective Action(s): Please ensure that the records (MARs) received from the pharmacy are current and accurate.
Date to be Corrected: October 19, 2016
Comments

It was noted that a fence panel is broken. Although it is not a safety concern, it is recommended that this is fixed.
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
Oct 31, 2016
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.