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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

MMON-C7BPV4

FACILITY NAME Rosedale		SERVICE TYPES 125 Substance Use	FACILITY LICENSE # LBJE-6HXRCG
FACILITY ADDRESS Removed at operator's request			FACILITY PHONE Removed at operator's request
CITY Chilliwack	POSTAL CODE Removed at operator's request		MANAGER Removed at operator's request

INSPECTION DATE September 27, 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

An unscheduled routine inspection was completed to assess compliance with the Community Care and Assisted Living Act (CCALA) and the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSOP). 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. Care systems reviewed during inspections include the following: Licensing, Physical Facility, Staffing, Policies and Procedures, Care and Supervision, Hygiene and Communicable Disease Control, Medication, Nutrition and Food Services, Program, Records & Reporting. Staffing was not able to be reviewed during this inspection, as all Staffing files are kept offsite, at facilities Head Office and will be reviewed at a later date. 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 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

POLICIES AND PROCEDURES: 33140 - RCR s.68(3)(b)(i) - The medication safety and advisory committee must establish and review as required (b) policies and procedures in respect of (i) the safe and effective storage, handling and administration of the person in care's medications, in compliance with the Pharmacy Operations and Drug Scheduling Act. Observation: A review of two person in care's medication administration records (MAR) showed evidence of no documentation of administration in one person in care's MAR of a medication for the month of September. A review of the facilities PRN medication policy and two person in care's MAR's showed evidence of the facility were not following the written policy for administration of PRN medications. Corrective Action(s): Ensure the medication safety and advisory committee has established and reviewed policies and procedures in respect of safe administration of medications to person's in care. Date to be Corrected: November 5, 2021 HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs. Observation: A review of two person in care's charts found no evidence of tuberculosis or immunization documentation, in one chart. Corrective Action(s): Ensure all persons admitted to a community care facility comply with the Province's immunization and tuberculosis control programs. Date to be Corrected: November 5, 2021 HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled. Observation: One fridge had five plates of prepared food items which were covered in plastic wrap, but had no labels and were not in original packaging. Kitchen cupboard had one bag of a packaged food item left open. Corrective Action(s): Ensure all food is safely stored. Date to be Corrected: October 1, 2021 MEDICATION: 36050 - RCR s.68(2)(b) - A licensee must appoint a supervising pharmacist to (b) inspect the areas of the facility where medications will be stored. Observation: Facility did not provide evidence of current or any other medication room/area inspection documents, since October 2017. Corrective Action(s): Ensure supervising pharmacist inspects medication storage areas and provides documentation to Licensee. Date to be Corrected: November 5, 2021

Comments

Please submit a written response by November 5, 2021 indicating the corrective action taken and/or timeline and plan for compliance with legislative requirements. This inspection report was not signed by management as it was reviewed with management over the telephone and sent via email to the site

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 Nov 05, 2021

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