LICENSING: 30240 - RCR s.61 - A licensee must regularly monitor the physical environment of the community care facility, and the care and services provided by it, to ensure that the requirements of the Act and this regulation are being met.
Observation: Of concern is that there is no specific monitoring of the care and care services provided. For example, there is no documentation to evidence that daily care is being provided and some documentation is not current or complete. For example, a one week incontinence record was not always completed by the evening or night shift; there is no record of the care provided to persons in care; the care plan and ADL care plan for two persons with agreements for the use of restraints did not indicate the use of restraints and no reassessment of the restraints was observed; a fall risk assessment or fall risk was not indicated in a care plan subsequent to 3 falls by that person with no plan for prevention; and the wounds assessment and wound care flow sheet were missing for the one person with a wound.
Corrective Action(s): Submit your self-monitoring plan to ensure compliance with legislation on an on-going basis in all aspects of the operation. The plan shall focus on ensuring consistency of care and that auditing and monitoring of care systems and the physical environment is conducted on a regular basis. The audits should demonstrate that staff are being held accountable to meet the expectations as outlined in their job duties. The self-monitoring plan should include the frequency of audits, timelines for completion, and who is responsible to conduct the audits and other formal self-monitoring/ quality improvements initiatives.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31550 - RCR s.29(1)(a) - A licensee must provide, at no cost to the person in care, each person in care with bedroom furnishings, including (a) a safe, secure place in which the person in care may store valuable property.
Observation: This section was previously found in non-compliance. Now, upon request, a lockbox is offered for persons in care who wish to store valuable property; even though they are advised against bringing any. Of concern is that the box could easily be removed since it is not secure. CCFL recognizes that compliance with this section will need to recognize that persons in care bring their own furniture.
Corrective Action(s): Ensure all persons in care are provided with a safe, secure place in which they may store valuables in their bedroom.
Date to be Corrected:
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31640 - RCR s.32(a) - A licensee who provides a type of care described as Long Term Care must provide (a) for the number of persons in care on a floor and in the same wing indicated in column 1 of the following table, the number of bathing facilities indicated in column 2 opposite the number of persons in care.
Observation: A room approved by CCFL for use as a bathing facility (shower room) is now being used as a storage room. The Manager advised that this has been used in this way for many years because there is little storage space in the facility and because there is a shower in the west wing bathing facility (tub and shower room) that is used.
Corrective Action(s): Restore the shower room for use by persons who reside in the east wing. Please note that there is a continuing duty to inform CCFL if changes are made to the information submitted while applying for a licence (RCR 8). You may apply for an exemption as outlined in RCR 4 if there will be no increased risk to health and safety.
Date to be Corrected:
STAFFING: 32080 - RCR s.37(2)(c) - A licensee must not employ a person in a community care facility unless the licensee is satisfied, based on the information available to the licensee under subsection (1), that the person (c) has the training and experience and demonstrates the skills necessary to carry out the duties assigned to the manager or employee.
Observation: The Information Handbook states that ‘Volunteers are not allowed to feed residents unless the family takes full responsibility for volunteer’s actions’. Given that volunteers are by CCALA definition employees, it is the Licensee who is responsible to ensure that if ‘care’ is provided by a volunteer that they meet the character and skill requirements of RCR 37.
Corrective Action(s): Please confirm your plan for volunteers including what training and experience you would require for a volunteer to provide care including assisting persons in care with eating. Please revise and submit any revisions to the Information Handbook.
Date to be Corrected:
POLICIES AND PROCEDURES: 33030 - RCR s.48(1)(c)(i) - Before admitting a person to a community care facility, a licensee must advise the person, or the person's parent or representative, of (c) how the person, or the person's parent or representative, may express concerns or make complaints to (i) a medical health officer.
Observation: The Information Handbook and admission information does not specify how a person or their representative may express concerns or complaints to the Medical Health Officer (CCFL).
Corrective Action(s): Please ensure that persons in care, families, and staff are aware that contact may be made through the CCFL Central Intake Line at 604 587 3936 to express concerns or make complaints.
Date to be Corrected:
POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: The emergency plan has food supplies that include condiments like peanut butter and jam with no food to spread them on. There also was no equipment to heat food like soup or modify textures.
Corrective Action(s): Please review the plan to ensure that it may be implemented in an emergency.
Date to be Corrected:
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: The Manager advised that policy is in process of being revised and the goal is for it to be available electronically; which will ensure that when revised the current version is accessible to staff. Having said that, it was observed that even though policy was reviewed in Feb 2019, some required policy does not include information for compliance with legislation like definitions of abuse, aggression between persons in care, incident reporting instructions, etc.
Corrective Action(s): Review all required policy to ensure it meets legislative requirements as per the information I will e-mail to you.
Date to be Corrected:
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: The restraint policy requires a 30 day reassessment for the continued use of a restraint including approval by the physician. The progress notes and care plan for the two persons in care who have a restraint do not indicate that the physician has not been contacted for approval of for the continued use of restraints.
Corrective Action(s): Ensure that all policy is implemented by employees.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34470 - RCR s.73(2)(c) - In addition to the requirements under subsection (1), the following conditions apply to the use of a restraint under section 74(1)(b) [when restraints may be used]: (c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care.
Observation: Restraint use and reassessment is not documented in the care plan of the two persons with restraints in use.
Corrective Action(s): Document the use of any restraints and reassessments in the care plans of persons in care.
Date to be Corrected:
CARE AND/OR SUPERVISION: 34920 - DOLSOP Advanced Directives & Care Plans [3] - A resident (or someone with the legal authority to make health care decisions on the resident's behalf) must not be required, either as a condition of admission (or as an ongoing requirement to reside in a community care facility) to sign advance directives or level of intervention documents.
Observation: The Information Handbook advises ‘Each resident has a signed ‘MOST’ …that is completed and signed by the doctor and followed in the event of an emergency. The Director of Licensing Standard of Practice (DOLSOP) is clear that this is not required as a condition for admission or continued residency. It is indicated that issues related to end of life planning and advance directives may be discussed and documented.
Corrective Action(s): Ensure that residents and their family or support persons are not required to sign such documents.
Date to be Corrected:
RECORDS AND REPORTING: 39460 - RCR s.87(b) - A licensee must keep a record of the following matters respecting food services: (b) menus and menu substitutions.
Observation: The cook advised that menu substitutions are few and that when a food is substituted it is from the same food group. No substitution records are not kept.
Corrective Action(s): Ensure that a record of any menu substitutions are kept.
Date to be Corrected:
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: There are no records of results of food services/nutrition care monitoring except one Meal Service Audit.
Corrective Action(s): Utilize the audit program in Audits & More or develop audit forms and checklists to confirm that nutrition and foodservice requirements are met.
Date to be Corrected:
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