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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
SCLY-BGTRTU

FACILITY NAME
The Cascades
SERVICE TYPES
110 Hospice
130 Long Term Care
FACILITY LICENSE #
TBIU-9KSNHS
FACILITY ADDRESS
45586 McIntosh Dr
FACILITY PHONE
(604) 795-2500
CITY
Chilliwack
POSTAL CODE
V2P 7W8
MANAGER
Robert White

INSPECTION DATE
October 08, 2019
ADDITIONAL INSP. DATE (multi-day)
October 10, 2019
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7.5
ARRIVAL
10:45 AM
DEPARTURE
02:30 PM
ARRIVAL
10:15 AM
DEPARTURE
02:00 PM
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

An unscheduled routine 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 · Hygiene and Communicable Disease Control
· Physical Facility · Medication
· Staffing · Nutrition and Food Services
· Policies and Procedures · Program
· Care and Supervision · 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 operation.
Visit the CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XXbB7myos2w for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)

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

Observed Violations
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: 6 out of 8 employee files that were reviewed did not have evidence of current performance appraisals.
Corrective Action(s): Please ensure that employees received regular reviews in accordance with the regulation and your policy.
Date to be Corrected: Oct 24, 2019

STAFFING: 32210 - RCR s.43(1)(a) - A licensee must ensure that persons in care have at all times immediate access to an employee who (a) holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C.
Observation: 4 out of 4 LPN and RN files reviewed found that none of them had valid first aid in their files and the facility has not validated their registration with the college of nursing to ensure that their first aid has been renewed.
Corrective Action(s): Please ensure that there is an employee available at all times who holds a valid first aid and CPR certificate.
Date to be Corrected: Oct 24, 2019

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: Review of 3 medication carts found that all three were left unlocked and unattended and 1 had personal information of a resident in care viewable on the screen. The DOC stated they are required to lock them and block out the screens.
Corrective Action(s): Please ensure that employees comply with all policies and procedures.
Date to be Corrected: Oct 10, 2019


Comments

The fire extinguishers expired at the beginning of October and the facility has a scheduled review of them for the end of October.

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
Oct 24, 2019

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