Hilltop House
470 Hilltop Ave Kamloops BC V2B 2S3 · Residential Care - Licensing
10 inspections
- Routine Inspection
6 infractions
- R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
- Observation(s): At the Licensing Officer’s arrival to the facility, there was one support worker on-site. The approved staffing levels are one support worker 24 hours/day and one nurse 17 hours/day (0800 to 2000 and 0300 to 0800). In a person in care’s progress notes, it was noted that the nurse was not present on another day when a nurse would regularly be to complete a task, which was not completed. When staffing levels are not maintained as per the accepted staffing plan, this increases risk of persons in care needs not being met appropriately. Submit a corrective plan which will outline how staffing levels will be maintained to the currently accepted levels and an alternative staffing plan in case of emergency no later than November 12, 2025.
- R3.2A - There must be sufficient numbers of trained and experienced employees on duty at all times. Staffing patterns must meet the needs of persons in care and assist persons in care with activities of daily living, including eating, mobility, dressing, grooming and hygiene in a manner consistent with the health, safety and dignity of persons in care; 42( 1 )(a)(b) (Show More)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Persons in care medication administration records (MAR) were reviewed and there were 14 missed or incomplete effects documented in the as needed (PRN) MAR. In the daily MAR, there were 34 missing initials on MARs for regularly scheduled medications. *This is a repeated contravention. When staff have not documented when medications have been administered, or a reason they were not administered, this increases risk of double dose of medications being administered to persons in care. Submit a corrective plan which will outline the systems that will be put into place to ensure all staff who administer medications document appropriately no later than November 12, 2025.
- R3.1AA - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): Monthly weights were not recorded for 3 of the last 9 months in a person in care’s chart. The facility is in process of transferring their “hard copy” information into a digital program. It was reported that there is not a documentation system in place during the transition to ensure compliance with the requirement of monthly weights. In a person in care’s progress notes, it was noted that the nurse was not present on the appointed day weights were to be taken by the nurse. Monthly weights not being documented increases the risk of some health issues not being assessed and/or recognized due to the information not being gathered. Submit a corrective plan which will outline systems that will be put into place to ensure monthly weights are documented no later than November 12, 2025.
- R4.1U - Weigh each person in care monthly and record their weight in their nutritional plan (Does not apply to Hospice); 83( 4 )(a)(c)
- R4.6 - Are facility records current and complete?
- Observation(s): The fridge temperature daily record had 6 missing entries in the month of October. When staff do not follow Licensee’s policies related to food temperature tracking, this increases the risk of food poisoning or other food borne illness. Submit a corrective plan which will outline the systems that will be put into place to ensure all staff follow the policies no later than November 12, 2025.
- R4.6D - Retain the results of monitoring of food services and nutrition care; 87(c)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): Person in care’s MAR had multiple handwritten entries present, one of the entries was incomplete and did not include frequency, dosage or other required information per medication safety advisory committee policies. There is no current exemption in place for handwritten medication administration records to be used in the facility. *This is a repeated contravention, and previous compliance plans included applying for an exemption. Handwritten MARs increase risk of missing information in administration instructions, which increases the risk of medications not being administered safely and correctly. Submit a corrective plan which will outline how the facility will come back into compliance regarding MARs and use of handwritten medication orders no later than November 12, 2025.
- R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
- R10.3 - Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): One person in care had a specific assessment last completed in 2022 in their chart. It was confirmed by staff that an updated assessment had not been completed since that original date. When ongoing assessment of persons in care is not done, this increases the risk of appropriate care not being provided. Submit a corrective plan which will outline the systems of ensuring ongoing assessment practices are put into place to come back into compliance no later than November 12, 2025.
- R10.3K - Review and, if necessary, modify each care plan if there is a substantial change in the circumstances of the person in care, or at least once a year, to ensure it continues to meet the needs, preferences, and is compatible with the abilities of the person in care; 81( 4 )(b)(i)(ii)
- R3.2 - Are staffing patterns sufficient and appropriate to maintain the health, safety and dignity of persons in care?
- Routine Inspection
5 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): The manager spoke of two incidents which had not been reported to Licensing, and fall within the definition of reportable. The incidents were "Service Delivery Problems" – Replacement of hot water heaters, and a flood in the facility resulting in relocating persons in care for “several weeks” to another location outside the facility. When incidents defined as "reportable" are not reported, oversight for compliance and collaboration to ensure the health, safety and dignity of persons in care does not occur. The Licensee is to create a plan to ensure incidents are being reported and review the last six months of internal incident logs to identify any incidents which meet the definition of reportable and submit the incidents to Licensing. The plan is to be submitted no later than April 24, 2025.
- R4.5D - Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): The facility has been adjusting their staffing model, however this information was not submitted to Licensing for approval prior to implementation. The facility’s previously approved compliance plan included requesting an exemption for handwritten Medication Administration Records, which was not followed. The facility Medication Safety and Advisory Committee decided to instead have pharmacy provide stickers for the Medication Administration Records, and did not resubmit the new compliance plan. Changes of operations and changes to compliance plans without prior notification to Licensing presents risk to all persons in care, as these changes need to be assessed for regulatory compliance. The Licensee must create a plan to ensure notifications are sent to Licensing prior to implementation. The plan is to be submitted by April 24, 2025.
- R1.1A - Notify licensing immediately of changes to original application; 8 ( 1 )
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance reviews for unregulated care providers were complete as of this inspection. The nursing staff performance reviews were not complete at the time of the inspection. Performance reviews not being completed on a regular basis does not ensure employees are being monitored by the employer. The Licensee is to create a plan of how all performance reviews will be completed on a regular basis and submit the plan to Licensing no later than April 24, 2025. (This is a repeated contravention)
- R3.1N - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): A review of person in care’s charts did not show evidence of the facility obtaining consent from either the person in care or their representative to call the medical practitioner, or an ambulance in case of emergency. Having no written consent to call a physician or other medical practitioner, or an ambulance in cases of emergency could result in a delay of care and increases risk to persons in care. The Licensee is to create a plan of how they will obtain the required consent of current persons in care and all new admissions, and provide this plan to Licensing no later than April 24, 2025.
- R4.1L - Have and keep written consent from the person in care, or a parent or representative to call a medical or nurse practitioner or ambulance in case of accident or illness; 78( 3 )(a)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Water temperatures accessible to persons in care were assessed during the inspection and found to be 51.7 degrees Celsius. When hot water accessible to persons in care is above 49 degrees Celsius, this increases the risk of immersion burns. The Licensee is to ensure the hot water accessible to persons in care does not exceed 49 degrees Celsius and must create a plan to regularly monitor the temperatures for ongoing compliance. The plan is to be submitted no later than April 24, 2025.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
4 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN charting reviewed during this inspection did not meet facility MSAC policies for noting the effectiveness of the medication. *This is a repeated contravention
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Performance reviews are reported as not being completed and up to date, other than a "handful" of employees reviews. *This is a repeated contravention. The narcotic count record was missing several secondary check signatures. The medication safety and advisory committee policy was not followed.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R3.1X - Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee; 68 ( 4 )
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): A review of the facility's menus showed that for snacks offered twice daily, only one food group was being offered.
- R5.1D - Provide for each day, at least 2 nutritious snacks with at least 2 food groups described in Canada's Food Guide; 62( 2 )(b)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): A review of Medication Safety and Advisory Committee Meeting Minutes showed the last recorded meeting having occurred in 2018. The facility had evidence available to show the supervising pharmacist had completed medication storage area audits appropriately to the current date despite of the documentation of meetings not being available. A review of the medication administration records showed evidence of handwritten instructions, which did not include all required information when transcribing a doctors order, had not been recorded by a pharmacist.
- R9.1B - Appoint a supervising pharmacist to serve on the medication safety and advisory committee and inspect medication storage areas; 68( 2 )(a)(b)
- R9.1C - Ensure a pharmacist packages all medications and records all medications on the person in care's medication administration record; 69( 1 )(a)(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
5 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN charting reviewed during this inspection did not meet facility MSAC policies for noting the effectiveness of the medication, as there were several PRN effects which were not documented within Medication Administration Records. This contravention is a repeated contravention from the previous two inspections.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
- Observation(s): A review of documentation of fire drills showed no evidence of a drill having been completed in the month of February in 2023. When asked, the manager and staff had not been aware the month's fire drill had not been documented and could not verify if it had occurred.
- R1.1W - Regularly monitor the physical environment and the care and services provided; 61
- R4.6 - Are facility records current and complete?
- Observation(s): When reviewed, it was observed that there were no entries for any meal substitutions on the substitution list since November 2021. Staff report they had forgotten about using this tool and confirmed substitutions have occurred since November 2021.
- R4.6C - Retain food services records of menus and menu substitutions; 87(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The drawer of knives was found to be unlocked during the inspection of the kitchen, which does not follow the facility policy to ensure all knife storage areas are locked unless staff are supervising persons in care during use. This drawer was locked by staff immediately.
- R7.1AK- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): Two medications with past expiry dates were present in the medication cart for the facility.
- R9.1I - Medications must be returned to the dispensing pharmacy if the person in care is no longer taking the medication or if the medication has expired; 72(a)(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN charting reviewed during this inspection did not meet facility MSAC policies for noting the effectiveness of the medication, this contravention was noted during the last inspection, significant progress has been made in this area however some missed charting was observed during this inspection.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): Facility has a dispute policy in place, ensure the policy is updated to include Licensing and Patient Care Quality Office contact information as an option for the complainant.
- R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): A process to ensure staff performance evaluations are completed is not in place, this contravention has been noted on the last several inspections. Please submit a plan to start completing and keeping evaluations up to date moving forward.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Routine Inspection
3 infractions
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): PRN charting observed during this inspection, did not meet facility medication administration policies in regard to the charting of the effectiveness of PRN medications.
- R4.2D - Keep a medication administration record showing the date, amount, and time at which the medication was administered; 78( 2 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Regular staff performance evaluations are behind, this contravention has been noted on the last several inspections. Please submit to licensing a plan on how staff performance evaluations will be completed and kept on schedule moving forward.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R10.2 - Do care and supervision practices ensure health, safety and dignity of persons in care?
- Observation(s): The facility does have ID in place for PIC's who leave independently, but there is no consistent auditing process in place currently to ensure PIC's still have their ID in their possession.
- R10.2L - Ensure there is written documentation (name, facility name, emergency contact information) in possession of persons who temporarily leave the facility (Does not apply to Child and Youth Residential who are capable of self identification); 56( 1 ) ( 2 )
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Monitoring
2 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility is behind on regular performance evaluations of employees, the facility manager has been working on completing all overdue reviews, please submit to Licensing the plan to ensure all overdue reviews are completed.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The floor of the shower in the main facility washroom is stained and in poor condition, inform Licensing on what steps will be taken to repair/replace the shower . The medication fridge thermometer was not functioning properly at the time of this inspection. Inform Licensing on what systems/audits are in place to ensure medications which require refrigeration are always stored at an optimal temperature.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R7.1AJ - Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
4 infractions
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): Facility will be updating their emergency evacuation procedures to include specific details for staff to follow in case of an evacuation. Include in your response how current staff as well as future staff are trained on facility emergency procedures including evacuation to an alternate site, and how this will be audited to ensure all staff are trained on current procedures.
- R2.1F - Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): In discussion with facility manager Shelley Mitchell, some staff performance evaluations or overdue for their regular reviews, Shelley will submit a plan on how the overdue reviews will be completed.
- R3.1K - Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Some lawn furniture in the courtyard area outside of resident rooms requires cleaning to enable residents to use, facility has self-monitoring procedures in place, ensure these items are cleaned and that they are included in the facility self-monitoring checks in the future to ensure they are in good condition for resident use.
- R7.1J - Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): A Medication Safety Advisory Committee meeting has not occurred at the site since May 2016, at this point another meeting has not been scheduled, ensure a MSAC meeting is scheduled to review facility medication administration procedures and storage. Inform Licensing that a meeting has been scheduled and indicate what systems have been put in place to ensure meetings occur on a scheduled basis.
- R9.1A - Appoint a medication safety and advisory committee consisting of the manager or person designated by the manager, the supervising pharmacist and, if employed by the licensee, the health care provider responsible for the immediate supervision of health care services provided in the facility; 68( 1 )(a)(b)(c) (Show More)
- R2.1 - Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Monitoring
1 infraction
- 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Observation(s): Multiple cigarette butts found in the outdoor courtyard in several locations, facilities policy indicates no smoking on the premises. Ensure no one is smoking on facility grounds to comply with the facility policy.
- Ensure policies are implemented by employees; 85( 1 )(d)
- 2.1 Are written policies and procedures in place to guide employees in all matters relating to the care and supervision of persons in care?
- Monitoring
3 infractions
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): MAR's reviewed had some missed charting, ensure every medication is charted. Please use codes available on MAR to explain reasons for missed medication delivery.
- Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Staff performance evaluations have not been completed according to facility policy of at least every three years. Please inform Licensing in writing on how performance evaluations will be completed. This infraction was noted on the last inspection and found unresolved during this inspection.
- Ensure that the performance of each employee is reviewed regularly to ensure that they continue to meet the requirements of this regulation, and demonstrate the competence required for the duties to which they are assigned; 40( 1 )(a)(b)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Medications stored in refrigerator in staff area, a lockbox for medications is available but not in use at time of inspection. This item noted during the last inspection at this site and found unresolved during this inspection. Ensure refrigerator is equipped with a thermometer to maintain appropriate temperature for medications requiring refrigeration.
- Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
- 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?