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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-BJZPH6

FACILITY NAME
Holmberg House Hospice
SERVICE TYPES
110 Hospice
FACILITY LICENSE #
TBIU-9UAPLB
FACILITY ADDRESS
32780 Marshall Road
FACILITY PHONE
(604) 852-7070
CITY
Abbotsford
POSTAL CODE
V2S 1J7
MANAGER
Jody Yuzik

INSPECTION DATE
December 17, 2019
ADDITIONAL INSP. DATE (multi-day)
December 19, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
09:30 AM
DEPARTURE
11:30 AM
ARRIVAL
11:36 AM
DEPARTURE
12:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). 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.

The following areas were reviewed:
· Licensing
· Physical Facility
· Staffing
· Polices & Procedures
· Care & Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

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 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
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: While inspecting the physical facility it was observed that the temperature of the water from the bathroom sick in a person in care's (PIC) room was 51.9 degrees Celsius.
Corrective Action(s): Please ensure that hot water that is accessible to PIC does not exceed 49 degrees Celsius.
Date to be Corrected: December 19, 2019

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: A review of 3 person in care (PIC) Medication Administration Records (MAR) found the following:
- 1 PIC was missing 11 responses to PRN medication that was administered
- 1 PIC was missing 6 responses to PRN medication that was administered
- 1 PIC was missing 4 responses to PRN medication that was administered
This is a repeat contravention from routine inspection # SCLY-ATCQFV

In review of the Care Records for 3 PIC, it was noted that 1 PIC did not have complete documented record of care during 1 day shift and 4 night shifts.
Corrective Action(s): Please ensure that policies are implemented by employees
Date to be Corrected: December 19, 2019


Comments

Licensing would like to thank the team at Holmberg House Hospice for their time and cooperation during their routine 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
Jan 06, 2020

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