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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-B97N7C

FACILITY NAME
Bethesda Chilcotin Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
SSTN-98LVEZ
FACILITY ADDRESS
32704 Chilcotin Dr.
FACILITY PHONE
(604) 744-5274
CITY
Abbotsford
POSTAL CODE
V2T 5S5
MANAGER
Lorraine Derksen

INSPECTION DATE
February 06, 2019
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
6.5
ARRIVAL
12:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
3

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 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
Resident Bill of Rights
Additional CCALA Sections

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
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: Three persons in care's records were reviewed and it was observed that one person in care was using a restraint. The use of this restraint had not been reviewed since May 2017.
Corrective Action(s): Ensure that the use of the restraint is reviewed yearly as indicated in the care plan, or as necessary.
Date to be Corrected: 15 Feb 2019

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: Three person in care's records were reviewed and two were observed to have mealtime guidelines that had not been reviewed since October 2017.
Corrective Action(s): Ensure that all care plans are reviewed annually or as necessary.
Date to be Corrected: 15 Feb 2019

MEDICATION: 36170 - RCR s.72(b) - A licensee must ensure that a person in care's medication is returned to the dispensing pharmacy if (b) the expiry date on the medication has passed.
Observation: Inspection of the medication cupboard found there to be an expired prescription cream. Of concern was the expiry date was handwritten on the container.
Corrective Action(s): Ensure that all expired medication is returned to the pharmacy and ensure that all information pertaining to the medication is on a label provided by the pharmacist.
Date to be Corrected: This was corrected at the time of the inspection.


Comments

This LO wishes to thank the staff for their assistance with this inspection.

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
Feb 15, 2019

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.