Sage Health Centre
101 Columbia St W Kamloops BC V2C 2S7 · Residential Care - Licensing
8 inspections
- 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): Please review site dispute resolution processes, to ensure documentation of complaints includes actions taken by the facility to follow-up on the concern. Please keep a record of complaints/follow-up to complaints, for review as needed.
- R2.1J - Establish a fair, prompt and effective process for expression of concerns, complaints and dispute resolution; 60(a)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Daily snacks are provided at facility, however, the menu currently does not include information on the snacks provided. Ensure the posted menu includes daily snacks provided, ensure the snacks include at least two food groups.
- 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)
- 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?
- Routine Inspection
3 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Incident reports received over the last year have been completed well, however several were received late. Incident reporting procedures was also noted during the last routine inspection at this site.
- 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)
- 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): Ensure facility orientation for staff and managers includes orientation to Licensing (Residential Care Regulation including Schedule D - Reportable Incidents).
- 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)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): Handwritten medication labels were observed during this inspection, this facility previously had an exemption in place for RCR 69(1)(a)(b), but the exemption has expired.
- 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
2 infractions
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): Incident reporting to licensing was reviewed during this inspection, please inform licensing on how the procedure has been updated to ensure licensing receives incident reports through the IH online portal immediately after a reportable incident.
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Regular and initial performance reviews are overdue for some staff, please submit a plan on how overdue reviews will be caught up,as well as a plan to ensure reviews are completed on time 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)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Routine Inspection
2 infractions
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Observation(s): A refrigerator in one of the person in care houses contained dairy products, the fridge did not contain a thermometer to ensure food is stored at optimal temperature between 0 and 4 degrees Celsius.
- R6.3B - Ensure that food is safely prepared, stored, served and handled; 63 ( 1 )
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): Facility has not had a recent Medication Safety and Advisory Committee (MSAC) meeting, ensure the MSAC is re-established and a regular schedule of meetings is set.
- 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)
- R6.3 - Does the facility demonstrate appropriate outbreak prevention and control measures?
- Routine Inspection
2 infractions
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Facility is currently behind on their annual staff performance evaluations. Inform Licensing on what systems will be put in place to ensure regular staff performance evaluations are completed annually.
- 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)
- R9.1 - Are medications stored, handled, and administered appropriately?
- Observation(s): Facility medication procedures currently include staff hand writing medications on PIC MAR's, facility plans to apply for an exemption to RCR 69(1)(a)(b) to continue hand writing medications rather than having the pharmacist record the medication on the MAR.
- 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)
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Monitoring
2 infractions
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Observation(s): Staff TB screening information was not available in several staff files at the time of this inspection. Inform Licensing that the required information is obtained for the staff files reviewed, also include in your response what systems and audits are in place to ensure all required information is included in staff files.
- R6.2A - Ensure that all persons admitted comply with the Province’s immunization and tuberculosis control programs; 49 ( 1 )
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Ensure substitutions to the menu are documented and retained to allow for review if required. This infraction was noted during the last licensing inspection of the facility. Include in your response how the substitution charting is audited by the facility to ensure the substitution is documented and has a similar nutritional value as the original menu item.
- R5.1J - Follow the menu or, in unforeseen circumstances, document appropriate substitutions that meet the nutritional requirements of section 62( 2 ); 62 ( 3 )
- R6.2 - Have all persons admitted to the facility complied with the Province’s immunization and tuberculosis control programs?
- Monitoring
5 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): Ensure there is a written procedure regarding how staff are to respond to reportable incidents including how to report an incident to Licensing.
- R2.2F - Ensure there are written policies and procedures regarding responding to reportable incidents; 85( 2 ) (j)
- R4.2 - Are Medication Administration Records accurate, kept on site and are adverse events documented and reported?
- Observation(s): The result of PRN medications was observed as being charted inconsistently during this inspection. Ensure the reason and result of PRN medication is charted, please include medication charting auditing plans in your response to licensing.
- R4.2C - Keep a medication administration record showing all medications administered to the person in care; 78( 2 )(a)
- R7.2 - Is the environment maintained to prevent falls?
- Observation(s): Ensure laundry area utilized by residents has a non slip surface.
- R7.2R - Laundry facilities must have a slip resistant floor surface if used by persons in care; 35( 2 )(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): Facility reviewed emergency procedures in December 2017, some changes were identified, ensure facility emergency policies are updated to reflect changes/updates.
- 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)
- R5.1 - Does the facility provide food services which meet nutritional needs and preferences for persons in care?
- Observation(s): Ensure substitutions to the cycle menu are documented and retained to allow for review if needed.
- R5.1I - Provide substitutions from the same food group and have a similar nutritional value; 62( 2 )(d)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Monitoring
2 infractions
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): One staff file reviewed did not contain a Criminal Record Review clearance, the facility manager indicated some staff are coming up on their renewal dates (5 years) so they plan on getting new clearances for all staff.
- Ensure criminal record checks are obtained for all employed persons; 37( 1 )(a)
- 9.1 Are medications stored, handled, and administered appropriately?
- Observation(s): Facility is overdue for a Medication Safety Advisory Committee meeting, ensure meetings are scheduled regularly at the site and minutes from meeting are available for review.
- 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)
- 3.1 Do the manager and employees meet the employment requirements and are they assessed regularly for performance?