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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

JSAT-BLHPCM

FACILITY NAME Grant St. East		SERVICE TYPES 140 Community Living	FACILITY LICENSE # 0782160
FACILITY ADDRESS 2364 Grant St			FACILITY PHONE (604) 864-2205
CITY Abbotsford	POSTAL CODE V2T 2M7		MANAGER Adam Waine

INSPECTION DATE February 05, 2020	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4.5
ARRIVAL 10:30 AM	DEPARTURE 03:00 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

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 during inspections and investigations 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. 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 -

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

POLICIES AND PROCEDURES: 33070 - RCR s.51(1)(b) - A licensee must have (b) a plan that sets out how persons in care will continue to be cared for in the event of an emergency. Observation: On review of emergency supplies and discussion with manager, it was determined that the emergency supplies do not contain personal items and incontinence supplies for each person in care. Corrective Action(s): Ensure the plan sets out how persons in care will continue to be cared for in the event of an emergency. Date to be Corrected: 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: on review of care plan and discussion with manager, it was determined that one person in care's care plan has had a substantial change and has not been update (No longer requires/ has 1:1.) Corrective Action(s): Ensure each care plan is reviewed and if necessary modified if there is a substantial change. Date to be Corrected: CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan. Observation: On review of 2 person in care's care plans, it was noted that 1 person in care's care plan last shows evidence of being reviewed in August 2018. Corrective Action(s): Ensure each care plan is reviewed and if necessary modified at least once each year. Date to be Corrected: MEDICATION: 36080 - RCR s.69(1)(b) - A licensee must ensure that a pharmacist (b) records all medications on the person in care's medication administration record. Observation: On review of the MAR for 2 persons in care, it was noted that 1 person in care had two medications hand written on the MAR. Corrective Action(s): Ensure the pharmacist records all medications on the person in care's MAR. Date to be Corrected:

Comments

Licensing officer (LO) and manager discussed in detail a proposed update to one person in care's care plan. As requested: Required Policies and Procedures reviewed for compliance with RCR 85 includes the following: Access to Persons in Care Concern, Complaint & Dispute Process Continuing Education of Manager & Employees Documentation/Record Keeping Emergency Plan Emergency Restraint Use Medication System Missing/Wandering Nutrition Monitoring Orientation of New Manager & Employees Release of Vulnerable Adults Reportable Incident Response (including Abuse and Neglect) Repayment Agreement

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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