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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
DCC-006

FACILITY NAME
Dufferin Care Centre
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YTGK
FACILITY ADDRESS
1131 Dufferin St
FACILITY PHONE
(604) 552-1166
CITY
Coquitlam
POSTAL CODE
V3B 7X5
MANAGER
Robert O'Neil (Interim General Manager)

INSPECTION DATE
June 15, 2016
ADDITIONAL INSP. DATE (multi-day)
June 16, 2016
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
0.01
ARRIVAL
09:00 AM
DEPARTURE
04:00 PM
ARRIVAL
09:00 AM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction


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

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31850 - RCR s.62(4) - A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Observation:
Corrective Action(s):
Date to be Corrected:

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:
Corrective Action(s):
Date to be Corrected:

STAFFING: 32110 - RCR s.40(1)(b) - 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 (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation:
Corrective Action(s):
Date to be Corrected:

POLICIES AND PROCEDURES: 33170 - RCR s.74(1)(b)(i) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (i) the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34370 - RCR s.63(3)(c)(iv) - A licensee must ensure that meals are provided (c) by ongoing room tray service, if (iv) reassessed by the person in care's medical practitioner or nurse practitioner at least once every 30 days.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34550 - RCR s.75(3)(a)(i) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (a) reassess the need for the restraint on the earlier of (i) the time specified in the care plan of the person in care.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34560 - RCR s.75(3)(a)(ii) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (a) reassess the need for the restraint on the earlier of (ii) the time specified by the persons who agreed.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34570 - RCR s.75(3)(b) - If a restraint is used under section 74(1)(b) and the use of the restraint continues either continuously or intermittently for more than 24 hours, a licensee must (b) as part of the reassessment, consult, to the extent reasonably practical, with the persons who agreed to the use of the restraint.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34590 - RCR s.81(2)(b) - A care plan must be developed, to the extent reasonably practical, (b) in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care.
Observation:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34620 - RCR s.81(3)(a)(iii) - A care plan must include all of the following: (a) a plan to address (iii) if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment.
Observation:
Corrective Action(s):
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:
Corrective Action(s):
Date to be Corrected:

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation:
Corrective Action(s):
Date to be Corrected:

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39350 - RCR s.84(b) - 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: (b) the reason for the use of the restraint.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39360 - RCR s.84(c) - 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: (c) the alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected.
Observation:
Corrective Action(s):
Date to be Corrected:

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:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39380 - RCR s.84(e) - 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: (e) the result of any reassessment of the use of the restraint.
Observation:
Corrective Action(s):
Date to be Corrected:

RECORDS AND REPORTING: 39440 - RCR s.86(d) - A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Observation:
Corrective Action(s):
Date to be Corrected:

RESIDENT BILL OF RIGHTS: 40020 - CCALA s.7(1)(b)(ii) Schedule 1-1(b) - A care plan developed based on his or her unique abilities, physical, social and emotional needs, and cultural and spiritual preferences.
Observation:
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Comments


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