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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBOI-AGDRUZ
FACILITY NAME
Foyer Maillard		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
TBIU-9PRU66
FACILITY ADDRESS
1010 Alderson Ave		FACILITY PHONE
(604) 937-5578
CITY
Coquitlam		POSTAL CODE
V3K 1W1		MANAGER
Doris Brisebois
INSPECTION DATE
November 03, 2016		ADDITIONAL INSP. DATE (multi-day)
November 24, 2016		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
11
ARRIVAL
10:00 AM		DEPARTURE
03:00 PM		ARRIVAL
10:30 AM		DEPARTURE
03:30 PM		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 (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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
· Policies and Procedures
· Care and Supervision
· Hygiene and Communicable Disease Control
· Medication
· Nutrition and Food Services
· Program
· Records and Reporting

As part of this 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 operations.

Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

If you have any questions or concerns regarding this report, please contact me at 604-949-7730, or email, kara.bonkowski@fraserhealth.ca.
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: 34750 - RCR s.81(4)(b)(i) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (i) if there is a substantial change in the circumstances of the person in care.
Observation: A review of 6 PIC's nutrition assessments, nutrition care plans, and ADL's sheet indicated that in 4 files there was inconsistent information with respect to either the diet type and/ or feeding assistance required. This was likely due to changes in condition of the PIC's which may not have been communicated in a timely manner. The Director of Care and RD were made aware and will review the current system.

In one of the PIC rooms inspected, the LO noted that wound care information on the ADL found in the bathroom conflicted with wound care directions on a large sign placed above the PIC's bed
Corrective Action(s): Ensure that all information kept regarding PIC's in all places information is kept - is consistent and updated as required.
Date to be Corrected: December 31, 2016
Comments

Noted during the inspection was a cord that was unsecured - and went across a sink in one of the bathing rooms. This should be secured for sanitary and safety reasons. Also noted is the "employer section" at the bottom of the immunization form was not filled out on any of the 6 staff files reviewed.

The facility is currently using a Spring/Summer menu cycle. The support services contractor stated that the Fall/Winter menu will be implemented by the end of the month.
Policies highlighted from the initial inspection are completed; however, the facility is in the process of reviewing these policies. Please ensure dates of review are documented to demonstrate the annual review and revision of policies as per Section 85(1)(b) of the RCR.
Ongoing staff education pertaining to assisted feeding techniques is required as per Section 44(b) of the RCR. Although there has understandably been no ongoing education to date as the facility has been opened less than 6 months, an in-service schedule has not been established. The RD stated she will liaise with the care manager to determine who will be organizing the ongoing education. Please note that there was previously no plan in place for ongoing in service education and this was identified in the initial inspection dated May 27, 2016. The response received from the care manager stated that there was a plan to work directly with the RD to have all staff regularly in-serviced regarding proper feeding techniques. As is unclear to Licensing who would be responsible for the provision of ongoing education, please update licensing once this has been determined to further meet the intent of the legislation.

In reviewing weight records on two floors, it was noted that for 3 PICs there were large discrepancies of over 10 kg between the admission weight and subsequent weights taken after admission. As the admission weight is used by the RD in completing the initial nutrition assessment and is a key indicator of nutritional status, please ensure that as per Section 49(2) the height and weight of each PIC is documented upon admission, if not done so already.
Thank you to the ED, DOC and staff at Foyer Maillard for their assistance during the 2 days of the 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
Dec 30, 2016
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Click here for a description of each "Category" of violation displayed.