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Moog and Friends Hospice House

1701 Government St Penticton BC V2A 3G6 · Residential Care - Licensing

8 inspections

  1. Routine Inspection

    2 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): Several Medication Administration Records were reviewed, PRN(as necessary) effectiveness was not documented. Failure to document PRN effectiveness can pose risk of harm to persons in care. If staff are not able to verify whether the PRN medication was effective or not can lead to compromised safety and wellbeing of persons in care. Please submit a corrective action plan by March 5, 2026, advising how current and future medication administration documentation will be completed in accurate and efficient manner.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
    • R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Unlocked cupboard which is accessible to persons in care contains scissors. Unsecured hazardous materials can pose a significant risk of harm and injury to persons in care. Please submit a corrective action plan by March 5, 2026, advising how all areas accessible to persons in care will contain secure and safe storage for hazardous materials.
      • 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)
  2. Routine Inspection

    3 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): Licensing reviewed one month's worth of Medication Administration Records (MAR) for three different persons in care. One MAR did not have three administered PRN medications charted as per policy. Another MAR did not have the PRN effectiveness charted as per policy for 12 of the 25 PRN medications administered. Licensing was informed there was no system to ensure the copy of the Regulation and the Act used for orientation was current.
      • R2.1S - Ensure policies are implemented by employees; 85( 1 )(d)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Licensing Officer observed two packaged food items for persons in care. They were both stored in a freezer without a labelled expiry date.
      • R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 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): Licensing Officer observed there were no recreation and leisure plans for persons in care.
      • R10.3F - Care plans must include a recreation and leisure plan; 81( 3 )(d)
  3. Routine Inspection

    4 infractions

    • R1.1 - Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): It was identified during the routine inspection that there was a change in manager but licensing was not notified.
      • R1.1E - Notify licensing if the manager resigns or expects to be absent for at least 30 consecutive days; 8( 3 )(a)
    • 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): Licensing Officer observed that there was no system for orientating staff to the Residential Care Regulation nor the Community Care and Assisted Living Act. Licensing Officer observed that there was no system for submitting reportable incident reports to Licensing other than expected or unexpected deaths. Licensing Officer observed that the PRN effectiveness was not charted as per facility policy.
      • R2.1P - Provide written policies and procedures for the purposes of guiding employees in all matters related to care and supervision of persons in care; 85( 1 )(a)
      • R2.1T - Ensure there are written policies and procedures for orientation of new managers and employees, including all policies and procedures of the facility, the regulations and the Act; 85( 2 )(b)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Licensing Officer was informed that the Licensee does not retain a photograph for each person in care.
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • 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): Licensing Officer observed two care plans for persons in care, both did not contain an oral care plan.
      • R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
  4. Routine Inspection

    3 infractions

    • R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Most PRN effectiveness records are incomplete.
      • R3.1X - 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): Written consent has not been obtained to call a practitioner or ambulance in the event of an accident or illness. Please ensure that person in care records are complete as this was noted during the last inspection.
      • R4.1I - 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)
    • R4.6 - Are facility records current and complete?
      • Observation(s): Records of concerns and complaints are not consistently documented and/or are incomplete.
      • R4.6F - Retain a record of complaints made and concerns expressed under section 60 (dispute resolution) and the responses to them; 89 ( 1 )
  5. Monitoring

    4 infractions

    • R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): Upon review of medication administration records, it was observed that when PRN medication (as needed) is provided to persons in care, the effectiveness is not documented consistently.
      • R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • R4.1 - Are person in care records current, complete and kept confidential?
      • Observation(s): Upon review of person in care's charts and card-ex documentation, it would appear that many of the requirements set out in the Regulations (with respect to what needs to be on the care plan) were not located at the time. For example, height and weight upon admission, photograph or information that could be used in cases of emergency, written consents, etc.
      • R4.1A - Record the height and weight of each person in care on admission; 49 ( 2 )
      • R4.1F - Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
      • R4.1I - 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): In one person in care's room, it was observed that a cover plate for an electrical outlet box was missing, leaving the wiring exposed. In addition, directly outside this room, a light fixture was missing its glass cover.
    • 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): Upon review of person in care's care plans, one person has an AGG alert on their file, however, the Licensing Officer could not locate a plan for preventing aggressive behaviours, nor a plan should these behaviours become apparent or escalate.
      • R10.3A - Develop a care plan with the participation of the person in care to the extent reasonable practical or the parent or representative and takes into account the unique abilities, physical, social and emotional needs, cultural and spiritual preferences of the person in care; 81( 2 )(a)(i)(ii)(b) (Show More)
      • R10.3C - Care plans must include a plan to address behavioural intervention, if applicable; 81( 3 )(a)(ii)
  6. Monitoring

    3 infractions

    • R10.4 - Are restraint and fall prevention plans appropriate?
      • Observation(s): Upon review of person in care's card-ex, it was indicated that the person in care was a "high fall risk"; however, the Licensing Officer was unable to locate a plan for prevention or strategies the facility staff will use to mitigate the risk of falling for this person.
      • R10.4P - Ensure there is a fall prevention plan for those in Long Term Care or those prone to falling, which must address an assessment of the nature of the risk of falling presented by the person in care, a plan for preventing the person in care from falling, and a plan for following up on any falls suffered by a person in care; 81( 3 )(e)(i)(ii)(iii) (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?
      • Observation(s): The facility has a fire evacuation plan in place at this time. However, the emergency plan in place is more specific to acute care and not specific to this facility overall. The Care Coordinator indicated she has been working on this plan and projects to have it completed by no later than June 30, 2017. She will provide the Licensing Officer with confirmation of completion prior to this date.
      • 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 speaking with the Care Coordinator and Manager, they have indicated the performance appraisals for staff have not been completed regularly. The Manager agreed to work with the Care Coordinator to come up with a plan on how these appraisals will be regularly completed and will report this plan to Licensing by the indicated date.
      • 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)
  7. Monitoring

    4 infractions

    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Upon discussing this with the Care Coordinator during this inspection visit, it is apparent that the infraction as noted on the inspection dated May 28, 2015 is still considered not completely resolved at this time.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Although there are some self-monitoring processes in place (as discussed with the Care Coordinator during this inspection visit), the infraction as noted on the inspection dated May 28, 2015 is still considered not completely resolved at this time.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 6.3 Does the facility demonstrate appropriate outbreak prevention and control measures?
      • Observation(s): Temperature logs for the medication and kitchen fridges not being done at this time.
      • Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): The temperature of the hot water was tested and read as 53 degrees Celsius.
      • Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
  8. Monitoring

    7 infractions

    • 4.2 Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
      • Observation(s): PRN documentation of reason and result of medication is charted inconsistently, many instances reviewed in which result of PRN is not charted. This item was noted on the last licensing inspection and found unresolved during this inspection.
      • Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
    • 4.5 Are incidents and notifications reported and records retained as required?
      • Observation(s): Facility has a procedure to notify licensing of expected deaths in hospice, facility requires an incident reporting procedure to notify licensing of reportable incidents identified in Schedule D and section 77 of the Residential Care Regulation.
      • Immediately notify licensing in the form and manner required, if a person in care is involved in a reportable incident; 77( 2 )(c)
    • 1.1 Does the Licensee operate in accordance with their license and inform Licensing of any significant changes?
      • Observation(s): Please develop a self monitoring procedure to review on a regular basis the facility physical environment and the care and services provided.
      • Regularly monitor the physical environment and the care and services provided; 61
    • 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): Emergency procedures discussed during this inspection, staff unsure as to where alternate location would be if facility needed to be evacuated and PIC's could not return. Ensure all staff are aware of facility emergency evacuation procedures.
      • Emergency plans must set out procedures to prepare for, mitigate, respond to and recover from any emergency including evacuation procedures; 51( 1 )(a)
    • 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
      • Observation(s): Facility policy is to conduct staff performance evaluations every three years, staff performance evaluations are not up to date. Inform Licensing on how/when performance evaluations will be completed for care staff. Current staff documentation process does not include dates for expiry of staff first aid/CPR certificates. Please ensure expiry dates are known to ensure facility has a staff with valid first aid/CPR at all times. Staff qualification checklist submitted to Licensing does not include dates of Criminal Record Clearance checks.
      • 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)
      • Ensure that persons in care have immediate access at all times to an employee who holds a valid first aid and CPR certificate from a course that meets requirements of Schedule C, is knowledgeable about each person in care's medical condition, and is capable of effectively communicating with emergency personnel; 43( 1 )(a)(b)(c) (Show More)
      • Keep in the case of employees, all records required under section 37 ( 1 )[character and skill requirements] for the entire time that the subject of the records is an employee; 92( 3 )(a)
    • 4.1 Are person in care records current, complete and kept confidential?
      • Observation(s): Ensure each PIC has a detailed description available with admission documentation by which they may be described in an emergency.
      • Keep for each person a record showing information by which the person in care may be described or identified in an emergency, including a photograph; 78( 1 )(d)
    • 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
      • Observation(s): Medication fridge accessible at time of inspection as the door to room was left open, resolved at the time of inspection. Cleaners accessible at the time of inspection in the dirty service room and in some PIC rooms in an unlabelled bottle. Ensure all hazardous products are stored in a manner that keeps them inaccessible to PIC's. This item noted on the last licensing routine inspection and found unresolved during this visit.
      • Provide appropriately furnished and equipped areas for the safe and secure location of medications and the records of persons in care; 35( 1 )(b)
      • Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)