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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
MMAE-AAKS8K

FACILITY NAME
Tall Timbers Residence
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
NNAL-8H9QRY
FACILITY ADDRESS
24156 56th Ave
FACILITY PHONE
(604) 534-8611
CITY
Langley
POSTAL CODE
V2Z 2N9
MANAGER
Tammi Fink

INSPECTION DATE
May 27, 2016
ADDITIONAL INSP. DATE (multi-day)
May 30, 2016
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
02:30 PM
DEPARTURE
03:00 PM
ARRIVAL
01:00 PM
DEPARTURE
04:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# CHILDREN ENROLLED

Introduction

CCFL completed a routine inspection on May 30, 2016 which had been initiated on May 27, 2016 by conducting an unscheduled inspection of the physical premise.

The L.O. guide to data base coding was used for this inspection.

Contraventions
Previous Inspection - Contraventions observed on FIR # have been corrected except for those noted on supplementary pages.
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: 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: Although the care plan has been reviewed/revised within the last year, there are components of the care plan that do not show a review date and have a date in excess of one year. For example the ADL routine, ADL bedtime and meal guidelines do not have a review date which makes it difficult to determine if the plan is current.
Corrective Action(s): Ensure all components of the care plan show a review or revision date.
Date to be Corrected:

MEDICATION: 36100 - RCR s.70(1) - A licensee must ensure that only medications that have been prescribed or ordered by a medical practitioner or nurse practitioner are administered to a person in care.
Observation: In review of the documentation for 1 resident, it appeared that there were 3-4 treatments in which the MAR showed a date that the prescription was valid to. However, these dates have passed by approximately 2 months. Likewise there was a tag/label on the treatment containers that also showed a "good to" date. It therefore appears there is not a current prescription for the medications. At the time of this inspection, the most recent medication review for the resident could not be located to confirm if the prescriptions were current.
Corrective Action(s): Ensure there is an effective system in place that provides clarity as to if there is a current prescription to administer medication/treatments.
Date to be Corrected:


Comments

Medication Administration: The current policy for the administration of all PRN treatments and/or medications requires facility staff to consult with Vinge nursing. However, in review of the MAR’s there are some that do not state to administer/apply "as per Vinge". As discussed, it is recommended that the current policy be reviewed by the MSAC regarding the requirement to contact Vinge for all PRN’s.

The above contraventions were discussed with the Manager at the time of the inspection.


Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into complianceNo action required

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