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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

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FACILITY NAME Bevan Village		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # TBIU-88XMDX
FACILITY ADDRESS 33386 Bevan Avenue			FACILITY PHONE (604) 850-5416
CITY Abbotsford	POSTAL CODE V2S 5G6		MANAGER Denise Bedard

INSPECTION DATE July 20, 2017	ADDITIONAL INSP. DATE (multi-day) July 21, 2017		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 6.5
ARRIVAL 10:30 AM	DEPARTURE 03:15 PM	ARRIVAL 10:30 AM	DEPARTURE 12:45 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CC&ALA) the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). Evidence for this report was based on the Licensing Officer’s(LO) observations, review of facility records and information provided by facility staff at the time of the inspection. As part of the Routine Inspection a 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. A random audit of the following areas were completed; Licensing, Physical Facility, Staffing, Policies & Procedures, Care & Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition & Food Services, Program, Records & Reporting, Resident Bill of Rights. Visit CCFL website at www.fraserhealth.ca/residentialcare for additional resources and links to legislation (CCALA and RCR)

Contraventions

Previous Inspection - Contraventions observed on FIR # have been corrected.

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

Observed Violations

STAFFING: 32010 - RCR s.37(1)(a) - 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: (a) a criminal record check for the person. Observation (CORRECTED DURING INSPECTION): 1 of 7 staff files audited had an expired criminal record check (CRC). The staff had been on an extended leave (2 years) and had just returned to work. The staff was working at the facility on the second day of the inspection, but their job duties did not include working directly with persons in care. Corrective Action(s): During the inspection the CRC was requested through the facility electronic system. Please ensure policy is reviewed and/or revised to reflect an appropriate timeline as to when a CRC may have to be re-submitted if an employee is away on an extended leave. Date to be Corrected: July 21, 2017 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: 7 of 10 staff files reviewed there was no evidence available to confirm performance evaluations had been completed as per facility policy of 3 months upon hire and each 2 years after. The Manager confirmed and was aware that staff evaluations are over due Corrective Action(s): Please ensure a system is developed to ensure evaluations are tracked and completed accordingly. Date to be Corrected: Please submit a compliance plan on or before August 11, 2017 STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee. Observation (CORRECTED DURING INSPECTION): A medicated shampoo for one person in care, to be stored in the medication cart as confirmed by staff, was found in a cart in the shower room. The shower room door was locked and not accessible to persons in care. Corrective Action(s): The shampoo was removed from the cart and stored accordingly. Please ensure medications are stored as per policy. Date to be Corrected: July 20, 2017

Comments

Policies & Procedures During this inspection Licensing reviewed required policies and there were 3 policies with a last review date of 2014. The staff in charge of review of policies explained the new system they have implemented with taking minimum 3-4 policies to the Management meetings for review and feedback. Licensing explained the intent of section 85(b) of the Residential Care Regulations.. Self-Monitoring The Manager explained and reviewed the various auditing and reporting systems being implemented to monitor the care and services provided. There has been a noticeable improvement in the areas of care planning as the 6 person in care files reviewed had strategies and interventions specific to each individual, review/revision dates and ongoing monitoring as demonstrated with flow and monitoring sheets being consistently signed by staff. Licensing also reviewed, with the Manager, the revised compliance plan submitted June 2017 and she explained they are on track for meeting their proposed targets for various goals set since the previous routine inspection was completed in August 2016. Staffing The previous 3 year history of the facility demonstrated there had been continuous change to the Leadership team including the Director of Care responsible to supervise care staff. The current Manager has been in place for approximately 8 months and appears to be working diligently to to have the Management and Care teams work together to ensure continuity in care and a respectful work place. Licensing requests a written response be submitted on or before August 11, 2017 describing how the above noted contraventions have been appropriately addressed. For contraventions where a compliance plan has been requested please include a time for when compliance will be met.A follow-up inspection confirming compliance to the CC&ALA and RCR may be conducted after the compliance plan has been received by Licensing. Licensing wrote the report off site and delivered it on July 21, 2017 from 4:30-5:00. Copies of the inspection report and the Risk Assessment Tool were reviewed, discussed, and provided to the Manager. Please contact your Licensing Officer if you have any questions or concerns regarding this report.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance	No action required
Due Date Aug 11, 2017

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