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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

WCLK-ABDQHD

FACILITY NAME Valleyhaven		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # ROLE-7STPTQ
FACILITY ADDRESS 45450 Menholm Rd			FACILITY PHONE (604) 792-0037
CITY Chilliwack	POSTAL CODE V2P 1M2		MANAGER Cheryl Conroy

INSPECTION DATE June 24, 2016	ADDITIONAL INSP. DATE (multi-day) June 29, 2016		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 9.5
ARRIVAL 11:00 AM	DEPARTURE 02:30 PM	ARRIVAL 09:10 AM	DEPARTURE 03:00 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 Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). This inspection was completed over 2 days. The first day an inspection of the physical facility and review of policies and procedures was completed. 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 this routine inspection, and a 3 year “historical” review of the facility’s compliance and operation. A random audit was completed for the following areas utilizing A Licensing Officer’s Guide to Residential Care Database Coding (October 2, 2015): 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/ccfl for additional resources and links to legislation (CCALA and RCR)

Contraventions

Previous Inspection - Contraventions observed on FIR #WCLK-9WHTLL have been corrected.

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: 31190 - RCR s.19(2)(c) - A licensee must provide communication devices and other means of communication that (c) enable employees to communicate with each other in respect of the needs of persons in care. Observation: A random audit was completed for 5 person in care's, care plans and it was determined that directions in 1 care plan, specific to oral care were inconsistent with information documented on the activity of daily living (ADL) form that guides staff in the care to be provided.. Corrective Action(s): Please review and update communication tools used by staff to ensure consistent care is provided. Date to be Corrected: June 29, 2016 PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31300 - RCR s.22(1)(c) - A licensee must ensure that all rooms and common areas are (c) maintained in a safe and clean condition. Observation: Three hair brushes that had not been cleaned of loose hair were observed together on a cart in one tub room, each brush potentially belonged to different persons in care. Corrective Action(s): Please ensure personal items used by persons in care are maintained in a clean condition and stored separetly to avoid cross contamination. The brushes have been removed from the bathing area and stored in each of the persons in care's rooms. Date to be Corrected: June 29, 2016 STAFFING: 32010 - RCR s.37(1)(a) - A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: (a) a criminal record check for the person. Observation: Random audit of 7 staff files one file had a criminal record check (CRC) that was overdue (March 16, 2011) by three months in meeting the requirement of being renewed every 5 years. Corrective Action(s): During the inspection the Manager confirmed the CRC forms were completed by the staff and the forms would be mailed June 30, 2016. In addition the Manager stated all staff hire dates will be audited and a system developed to alert when CRC's are needing to be renewed. Date to be Corrected: June 29, 2016 CARE AND/OR SUPERVISION: 34900 - RCR s.83(5)(a) - If a person in care refuses or is unable to be weighed, the licensee must (a) record in the nutrition plan of the person in care the reason why the person in care was not weighed. Observation: Licensing completed a random audit of 5 persons in care's weight records and 1 of the 5 was missing monthly weights for February and April, 2016 and the other was missing for April, 2016. The staff informed the scale was not working properly in April which could have accounted for the missing information. Corrective Action(s): Please ensure staff document the reasons for not obtaining weights. Date to be Corrected: June 29, 2016

Comments

Licensing requests a written response be submitted on or before July 15, 2016 describing how the above noted contraventions have been appropriately addressed please include a compliance plan with a time line for any items that may not be addressed before the requested time frame. Please note a follow-up inspection confirming compliance to the CCALA 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 Licensee/Manager.

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 Jul 15, 2016

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