Northern Health Authority

Inspection Information
Facility type	Residential Care - 100
Service type	103 Long Term Care
Inspection type	Follow-up
Inspection date	June 12, 2020
Follow up required	Yes

Contraventions: A summary of the contraventions found during the inspection are listed below.
No contraventions were found during the inspection.

The following were still in contravention as of June 12, 2020
Code RCR Section 35(1)(c) noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Physical Facility, Equipment and Furnishings: A licensee must provide the following appropriately furnished and equipped areas: secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials. (Insufficient designated work areas.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 42(1)(a) noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Staffing: A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care. (Inadequate staffing coverage.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 74(1)(b)(ii) noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Policies and Procedures: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care. (No written agreement.) CORRECTED LATER: 23-Jul-2020 Code RCR Section 77(2)(c) noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Records and Reporting: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer. (Insufficient notification following reportable incident.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 78(1)(a) noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Records and Reporting: A licensee must keep, for each person in care, a record showing the name, sex, date of birth, medical insurance plan number and immunization status. (Insufficient records..) CORRECTED LATER: 23-Jul-2020 Code RCR Section 78(2)(b) noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Records and Reporting: A licensee must keep, for each person in care, a medication administration record showing the date, amount and time at which the medication was administered. (Insufficient records.) CORRECTED LATER: 23-Jul-2020 Code RCR Section 82 noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Care and Supervision: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan. (Insufficient implementation.) CORRECTED LATER: 23-Jul-2020 Code RCR Section 83(4)(a) noted on Routine inspection # THUL-BFHQJL of Aug-29-2019 Records and Reporting: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month, (Insufficient records.) CORRECTED LATER: 22-Jun-2020 Code CCALA Section 7(1)(b)(ii) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Care and Supervision: A licensee must do all of the following: operate the community care facility in a manner that will promote in the case of adult persons in care, the rights of those persons in care. (Facility did not promote the rights of persons in care.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 19(1)(c) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Physical Facility, Equipment and Furnishings: If a person in care requires monitoring, or a signalling device, to ensure that person's health and safety, a licensee must provide a monitoring system or signalling device that will signal to employees that the person in care needs immediate assistance. (Insufficient monitoring, signalling and communication.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 37(2)(c) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Staffing: 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 has the training and experience and demonstrates the skills necessary to carry out the duties assigned to the manager or employee. (Inadequate character and skills.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 40(1)(a) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Staffing: 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 continues to meet the requirements of this regulation (Insufficient performance evaluation of staff.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 42(1)(a) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Staffing: A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care. (Inadequate staffing coverage.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 42(1)(b) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Staffing: A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to assist persons in care with the activities of daily living, including eating, moving about, dressing and grooming, bathing and other forms of personal hygiene, in a manner consistent with the health, safety and dignity of persons in care. (Inadequate staffing coverage.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 46(1) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Care and Supervision: A licensee may accommodate only those persons who will receive both safe and adequate care in the community care facility. (Prohibited service.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 52(1)(a) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Care and Supervision: A licensee must ensure that a person in care is not, while under the care or supervision of the licensee, subjected to financial abuse, emotional abuse, physical abuse, sexual abuse or neglect as those terms are defined in section 1 of Schedule D. (Harmful actions.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 54(1) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Hygiene and Communicable Disease Control: A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene. (Hygiene program not established.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 68(4) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Policies and Procedures: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee. (Inadequate compliance with medication safety.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 70(3)(a) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Medication: Subject to subsection (4), a licensee must ensure that only employees administer medications to a person in care. (Inappropriate administration.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 76(1) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: If a person in care becomes ill or is injured while under the care or supervision of a licensee, the licensee must immediately notify the parent or representative, or contact person, of the person in care. (Insuffcient notifcation of illness or injury.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 77(2)(c) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer. (Insufficient notification following reportable incident.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 80(1) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: On admitting a person in care to a community care facility, a licensee must ensure that a short term care plan is developed that will guide caregivers in protecting and promoting the health and safety of the person in care. (Insufficient care plan.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 80(2) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: Anything that must be recorded in a care plan under this regulation must be recorded in the short term care plan until a care plan is developed. (Insufficient care plan.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 80(2) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: Anything that must be recorded in a care plan under this regulation must be recorded in the short term care plan until a care plan is developed. (Insufficient care plan.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 81(1) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission. (Insufficient records.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 82 noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Care and Supervision: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan. (Insufficient implementation.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 84(a) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: the type or nature of the restraint used. (Insufficient records.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 84(b) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: the reason for the use of the restraint. (Insufficient records.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 84(c) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care:the alternatives that were considered to the use of the restraint, and which, if any, were implemented or rejected. (Insufficient records.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 84(d) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: the duration of the restraint and the monitoring of the person in care during the restraint. (Insufficient records.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 84(e) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: If a person in care is restrained, a licensee must ensure that the following information is recorded in the care plan of the person in care: the result of any reassessment of the use of the restraint. (Insufficient records.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 85(1)(a) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Policies and Procedures: A licensee must do all of the following: have written policies and procedures for the purposes of guiding staff in all matters relating to the care and supervision of persons in care. (Insufficient policies and procedures.) CORRECTED LATER: 08-Oct-2020 Code RCR Section 89(1) noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: A licensee must keep a record respecting complaints made and concerns expressed to the licensee under section 60 [dispute resolution], and the responses to them. (Insufficient records.) CORRECTED LATER: 22-Jun-2020 Code RCR Section 93 noted on Complaint Intake inspection # THUL-BGZJDP of Aug-27-2019 Records and Reporting: A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential. (Inadequate confidentiality of records.) CORRECTED LATER: 22-Jun-2020