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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY

WCLK-AFHSJ2

FACILITY NAME Primrose Centre for Community Living		SERVICE TYPES 140 Community Living	FACILITY LICENSE # PNEL-8A2PKD
FACILITY ADDRESS 4807 Georgia St			FACILITY PHONE (604) 946-0401
CITY Delta	POSTAL CODE V4K 2T1		MANAGER Kevin Reid

INSPECTION DATE November 08, 2016	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 4.25
ARRIVAL 09:40 AM	DEPARTURE 02:00 PM	ARRIVAL	DEPARTURE	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 #WCLK-A2TTSB 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

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31270 - RCR s.21(d) - A licensee must ensure that all furniture and equipment for use by persons in care (d) are maintained in a safe and clean condition.
Observation: One room in one person in care's apartment, had 1 tall cabinet that was not secured and could pose a falling hazard.
Corrective Action(s): Please ensure furniture and/or equipment is secured in a manner that prevents potential injury.
Date to be Corrected: Nov. 10, 2015

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - 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.
Observation: A random audit of 3 persons in care's medication administration record (MAR) was conducted. Upon review of the MAR from August - October 2016, for one of the three, there were 15 dates missing staff signatures for a prescribed cream to be applied daily. In discussion with the Manager he explained that staff may only be applying the cream as needed and that a new prescription may be required.
Corrective Action(s): The Manager stated he would follow-up with staff and the pharmacist accordingly to confirm if the prescription requires adjusting.
Date to be Corrected: Nov.10, 2016

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 (CORRECTED DURING INSPECTION): A random audit of 3 persons in care's medication storage baskets was completed and 1 person's basket contained 1 medication that had expired in May 2015. There was a new order for the same medication and no medication had been removed from the expired package.
Corrective Action(s): The Manager explained the system for removal of expired medications and stated he would follow up with staff accordingly and the expired medication was removed from the basket.
Date to be Corrected: Nov.8, 2016

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: A random of audit of 3 persons in care's weight records was completed and 2 of the three were missing months of weight not being taken. The Manager confirmed the weights were not taken and there was also no documentation as to the reason why they were not taken.
Corrective Action(s): There is a system in place requiring staff to take weights at the beginning and the middle of each month and reminders are given to staff. Please ensure weights are taken at a minimum once per month to be in compliance with the above noted regulation.
Date to be Corrected: Nov.15, 2016

Comments

During this inspection the LO discussed the following with the Manager and Assistant Manager:
There were some pieces of documentation that were missing review dates (ie. service plan) however there were quarterly reviews in each person in care's file demonstrating the plan was reviewed. Licensing recommends the files be reviewed to ensure that all relevant documentation reflects current dates.
In reviewing recent reportable incident (RI) information submitted to Licensing, the way the information is documented (ie. earning, reward) it could interpreted that recreation activities and some food items (pop,treats) are potentially being withheld in relation to behaviour management. The LO confirmed this was not the case, however, it was recommended that additional documentation be included to further clarify the incidents and action of staff when submitting the RI.

Licensing requests a written response be submitted describing how the above noted contraventions have been appropriately addressed. For contraventions where a compliance plan may be required 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 written response has been received by Licensing.

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 questions or concerns regarding this inspection report.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Nov 25, 2016

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