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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-C9ZRMA

FACILITY NAME
Irene Thomas Hospice
SERVICE TYPES
110 Hospice
FACILITY LICENSE #
MLAO-BZEV66
FACILITY ADDRESS
4635 Clarence Taylor Cres
FACILITY PHONE
(604) 946-1121
CITY
Delta
POSTAL CODE
V4K 4L8
MANAGER
Jo-Anne Kirk

INSPECTION DATE
December 20, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
10:00 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
POLICIES AND PROCEDURES: 33020 - RCR s.48(1)(b) - Before admitting a person to a community care facility, a licensee must advise the person, or the person's parent or representative, of (b) the policies of the community care facility respecting expressing concerns, making complaints and resolving disputes under section 60 [dispute resolution].
Observation: In review of the 'new resident information booklet', there was no information provided regarding how a person can make a complaint or resolve a dispute.
Corrective Action(s): Please ensure that persons are provided at the time of admission with a summary of how to express concerns or make a complaint.
Date to be Corrected: January 29, 2022

POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: In review of the Medication Administration Records (MAR's), it was observed for 1 person in care that the result/effectiveness for 9 administered PRN's was not documented. As per the Clinical Practice Guideline for Medication Administration, staff are directed to document the client's response to treatment. The PRN Administration Record provides a column for the result/effectiveness to be documented.
Corrective Action(s): Please ensure that policies are implemented by employees re: the documentation of PRN medications.
Date to be Corrected: January 14, 2022

CARE AND/OR SUPERVISION: 34680 - RCR s.81(3)(e)(ii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (ii) a plan for preventing the person in care from falling.
Observation: In review of a care plan for a person in care, it was noted that this person was assessed at the time of admission as being a 'high falls risk'. An interdisplinary care plan to address the risk of falls was not completed.
Corrective Action(s): Please ensure that a care plan is developed for a person in care who may be prone to falling.
Date to be Corrected: January 14, 2022


Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection.

Please provide a response to Licensing by January 26, 2021 as to how the identified items in this report will be addressed.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was written off-site and forwarded to the Licensee)

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
Jan 26, 2022

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