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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
JMEA-CE4TPR

FACILITY NAME
The Madison
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-95YUG4
FACILITY ADDRESS
1399 Foster Av
FACILITY PHONE
(604) 936-9231
CITY
Coquitlam
POSTAL CODE
V3J 2N1
MANAGER
Annie Kinamore

INSPECTION DATE
May 04, 2022
ADDITIONAL INSP. DATE (multi-day)
May 06, 2022
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
10.5
ARRIVAL
09:00 AM
DEPARTURE
02:00 PM
ARRIVAL
09:15 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE
130

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 at https://www.fraserhealth.ca/residentialcare 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: 31860 - RCR s.69(3)(a) - A licensee must ensure that (a) all medications in the community care facility are safely and securely stored.
Observation (CORRECTED DURING INSPECTION): Two medications for persons in care were found on the desk located at the nursing station not properly stored or secured.
Corrective Action(s): Ensure that all medications in the facility are safely stored and secured.
Date to be Corrected: June 4, 2022

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: A review of the medication room found the following:
- A review of the narcotic drug count sheets had inconsistencies whereby, the second nurse signature/initials was not documented. A review of their narcotic drug count policy confirmed that two signatures/initials are required on the record.
- An unopened blister pack containing medications was dated May 4, 2022 for a person in care and was found in the medication cart. However, a review of the EMAR system indicated that the medications in this blister pack had been administered to the PIC and confirmed sign off by the nurse.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: June 4, 2022

HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: A review of the servery refrigerator found that the temperature monitoring sheets had inconsistencies as temperatures were not taken twice daily as required.
Corrective Action(s): Ensure that all food is safely prepare, stored, served and handled.
Date to be Corrected: June 4, 2022


Comments

I would like to thank the team at The Madison for their time and assistance in the completing this inspection.
Please submit a written response by June 4, 2022 indicating the corrective action taken and/or timeline and plan for compliance with the legislative requirements.
If you have any questions related to this report please feel free to contact me.
Due to infection control practices in place related to COVID-19 prevention, this report was written off-site and is therefore unsigned. The report was reviewed with facility leadership and an email copy was provided.

Action Required by Licensee/ManagerAction Required by Licensing Staff
Provide a written response to LicensingNo action required
Due Date
Jun 04, 2022

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