PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: A random review of the hot water temperature measured at the sink in the bathroom next to Room 5 measured at 59.1 degrees Celsius and was still slowly increasing. The Manager had a staff contact the company that was on-site to address the hot water before the Licensing Officer arrived for the inspection to adjust the hot water temperature to 49 degrees Celsius.
Corrective Action(s): Please ensure that water accessible to a person in care from any source is not heated to more than 49 degrees Celsius.
Date to be Corrected: October 29, 2021.
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: The Manager has self identified physical plant items that need to be addressed with BC Housing.
A random review of the physical plant indicated the following:
- Room 7 the inside of the closet door handle fell off during the inspection. The blinds on the left side are bent.
- Room 5 to the right of the room window with white patches that have not been painted yet.
- Outside the "den" is a corner wall before leading down a hallway. There is a chip in the corner wall as shown to the Manager at the time of the inspection.
- In the hallway outside for example Room 5, the floor appears to start peeling up in various locations. Please note: If issues arise, please ensure measures are implemented to ensure the health and safety of all persons in care until the floor where required is fully addressed.
Corrective Action(s): Please ensure all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: November 30, 2021.
STAFFING: 32020 - RCR s.37(1)(b) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (b) character references in respect of the person.
Observation: In review of the staff checklist, one staff did not have references documented.
Corrective Action(s): Please ensure references are documented on the staff checklist as required.
Date to be Corrected: November 30, 2021.
STAFFING: 32030 - RCR s.37(1)(c) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (c) a record of the person's work history.
Observation: In review of the staff checklist, it was noted four staff did not have work history (e.g., resume) documented.
Corrective Action(s): Please ensure work history is documented on the staff checklist for staff where required.
Date to be Corrected: November 30, 2021.
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 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: In review of the staff checklist, performance appraisals are not documented for any of the staff.
Corrective Action(s): Please ensure that the performance of each staff is reviewed regularly and is documented on the staff checklist.
Date to be Corrected: November 30, 2021.
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: Currently there is no emergency menu in-place. On October 29, 2021, the Licensing Officer e-mailed a sample emergency menu to the Manager to guide the facility in developing their own.
Corrective Action(s): Please ensure you have an emergency menu plan in-place as to how persons in care will continue to be cared for in the event of an emergency.
Date to be Corrected: November 30, 2021.
POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act.
Observation: In review of the Medication Safety and Advisory Committee (MSAC) minutes from February 2021, the Pharmacist had completed an inspection of the medication systems. It is recommended that review of the medication policies and procedures be added to the MSAC meetings as a "standing agenda" item and that the minutes are documented and kept on file. Please also refer to section 68 (3)(a) and 68 (3)(b)(ii) of the Residential Care Regulation as to other items that should be reviewed by the MSAC.
Corrective Action(s): Please ensure the MSAC reviewed the medication policies and procedures and this is documented accordingly.
Date to be Corrected: November 30, 2021.
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: In review of the policies and procedures binder, the review and/or revision dates are not current. For example, Restraints/Acting Out Policy revised on February 27, 2008; "AWOL" (Elopement) Policy revised January 2014; Nutrition Assessment Policy revised October 28, 2011.
Corrective Action(s): Please ensure all the policies and procedures required by Section 85 of the Residential Care Regulation are reviewed and/or revised once a year and this is documented accordingly. For the remainder of the policies and procedures, please ensure there is a system for review and/or revision and there is a system for documenting the review/revision.
Date to be Corrected: November 30, 2021.
RECORDS AND REPORTING: 39470 - RCR s.87(c) - A licensee must keep a record of the following matters respecting food services: (c) the results of monitoring, by the licensee, of food services and nutrition care.
Observation: A nutrition satisfaction survey is being completed and no other audits seen, for example, the menu audit. The Licensing Officer e-mailed the Meals and More Manual and 1 accompanying document that goes with the Meal and More Manual to the Manager on October 29, 2021 to review and determine the other audits that need to be put in-place for the facility.
Corrective Action(s): Please ensure nutrition audits specific for the facility are being completed and are documented accordingly.
Date to be Corrected: November 30, 2021.
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