PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31290 - RCR s.22(1)(b) - A licensee must ensure that all rooms and common areas are (b) maintained in a good state of repair.
Observation: During the inspection of the physical facility, the following was noted:
- exterior paint work was chipped.
- exterior wood work was chipped.
- The dryer vent has blown large amounts of lint onto the roof of the facility and is starting to clog.
- There is a large amount of wasps swarming around a tree that overhangs a path that is regularly used by the PIC's and staff. Licensing was unable to determine if a nest was present.
- The cover for a bedroom heater was cracked.
- The door frame on 1 PIC's bedroom has had the protective wrap removed leaving exposed wood visible.
Corrective Action(s): Please ensure that all rooms and common areas are maintained in a good state of repair.
Date to be Corrected: August 31 2017
STAFFING: 32100 - RCR s.40(1)(a) - 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 (a) continues to meet the requirements of this regulation.
Observation: Facility policy states that staff performance reviews will be completed annually. A review of 3 staffing files found 3 instances of reviews that have not been completed within the last year (Oct 2015 for 1 and June 2016 for the other 2).
Corrective Action(s): Please ensure that all staff receive a performance review annually as per agency policy.
Date to be Corrected: September 15 2017
POLICIES AND PROCEDURES: 33180 - RCR s.74(1)(b)(ii) - Subject to subsection (2), a licensee may restrain a person in care (b) if there is agreement to the use of a restraint given in writing by both (ii) the medical practitioner or nurse practitioner responsible for the health of the person in care.
Observation: Review of 1 PIC's restraint guidelines found that it had been signed off on by the PIC's mother but not by a medical practitioner.
Corrective Action(s): Please ensure that any restraints in use have been agreed upon, in writing, by the medical practitioner.
Date to be Corrected: August 15 2017
CARE AND/OR SUPERVISION: 34110 - RCR s.50(2)(b) - A licensee must not (b) transfer a person in care, other than a person in care who is on leave under the Mental Health Act, to another community care facility without the consent of the person in care or that person's parent or representative.
Observation: A review of 3 PIC's care plan's found 1 that did not have consent for hospital transfer on file.
Corrective Action(s): Please ensure that all PIC's or their representative's have given their consent for hospital transfer. This is a repeat contravention from the 2016 routine inspection.
Date to be Corrected: August 15 2017
CARE AND/OR SUPERVISION: 34760 - RCR s.81(4)(b)(ii) - A licensee must ensure that (b) each care plan is reviewed and, if necessary, modified (ii) if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Observation (CORRECTED DURING INSPECTION): 3 PIC's oral care plans were reviewed. All 3 were written in 2015 by the Fraser Health community dental hygienist. None had evidence of being reviewed by the facility since then.
Corrective Action(s): Please ensure that all care plans are reviewed at least once each year.
Date to be Corrected: August 15 2017
HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled.
Observation: At the time of the inspection the facility fridges and freezers were within recommended temperature ranges. However no documentation was being kept to show that this being monitored regularly to ensure the safe storage of food.
Corrective Action(s): As per the Meals and More guidelines, please ensure fridge and freezer temperatures are being regularly monitored and documented to ensure the safe storage of food.
Date to be Corrected: July 31 2017
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