Victorian Community Health Centre of Kaslo
673 A Ave Kaslo BC V0G 1M0 · Residential Care - Licensing
8 inspections
- Routine Inspection
0 infractions
- Routine Inspection
2 infractions
- R4.1 - Are person in care records current, complete and kept confidential?
- Observation(s): The system to ensure that persons in care are weighed monthly appeared to be ineffective. Upon a random audit of resident records, the Licensing Officer noted four residents who had missed at least one monthly weight in the past year. The absence of documented monthly weights increases the risk of inaccurate nutritional monitoring of persons in care. Submit a plan by April 24, 2025, outlining your system to ensure all persons in care have a monthly weight recorded in their chart. The plan must include your process for ongoing monitoring of the updated system.
- 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)
- 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): The system for ensuring all care plans are current appeared to be ineffective. Upon a random audit of persons in care's My Day care plans, the Licensing Officer noted two plans did not contain dates indicating when they were developed or last reviewed. The absence of dates on care plans can increase the risk of the plan not reflecting a person in care's current status or needs. Submit a plan by April 24, 2025 outlining the system that will be put into place to ensure all persons in care's My Days contain a date, and the plan for ongoing monitoring of the my days to ensure dates are recorded.
- 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)
- R4.1 - Are person in care records current, complete and kept confidential?
- Routine Inspection
2 infractions
- R8.2 - Does the program of activities support individualized care plan requirements?
- Observation(s): Although there is planned recreation at the facility, the program in place does not appear to be meeting the objectives noted in some persons care plans.
- R8.2A - Provide without charge an ongoing planned program of activities designed to meet the objectives of the persons care plan (Does not apply to Hospice); 55( 1 )(a)(ii)
- RB1.13 - Is there a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan?
- Observation(s): See R8.2 above.
- RB1.13A - Ensure a suitable ongoing planned program of physical, social and recreational activities that meets the objectives of the care plan.
- R8.2 - Does the program of activities support individualized care plan requirements?
- Routine Inspection
3 infractions
- R4.3 - Is documentation concerning restraints adequate?
- Observation(s): The system for ensuring that persons in care who require restraints have the reason for the restraint clearly documented in the care plan appeared ineffective. Of the care plans reviewed, licensing officer noted two care plans that did not have a clear reason for the use of the restraints.
- R4.3B - Record the reason for the use of restraint in the person's care plan; 84(b)
- R4.5 - Are incidents and notifications reported and records retained as required?
- Observation(s): The system for ensuring that all incidents are reported to licensing as required appeared ineffective. In a review of the incidents reported in the past year, it was determined that two reports for Unexpected Illness were not submitted.
- 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)
- 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): The system for ensuring that the care plans for oral care include direction as to what care is required appeared ineffective. Of the care plans reviewed, only one contained clear direction for the type of oral care needed for the person in care.
- R10.3D - Care plans must includes an oral health care plan; 81( 3 )(b)
- R4.3 - Is documentation concerning restraints adequate?
- Routine Inspection
5 infractions
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Observation(s): The process for monitoring a person in care while a restraint is in use appears to be effective. However, the process for ensuring that there is a written agreement in place for the use of the restraint appeared ineffective.
- R2.2A - A restraint may be applied in an emergency or when there is written agreement to the use of a restraint by both the person in care or their representatives, medical practitioner or nurse practitioner; 74( 1 )(a)(b)(i)(ii)
- R10.4 - Are restraint and fall prevention plans appropriate?
- Observation(s): The system for ensuring care plans include the required information appeared to be ineffective. In a review of residents' records, it was noted that a restraint was in use, but the type of restraint and the reason for the restraint was not in the resident's care plan.
- R10.4G - Document in the care plan the use of the restraint, its type and the duration for which it is used ; 73( 2 )c
- R3.1 - Do the manager and employees meet the employment requirements and are they assessed regularly for performance?
- Observation(s): Fire drills are not consistently being practiced as per policy.
- R3.1W - Employees must be trained in the implementation of emergency plans and the use of any equipment noted in the plan; 51 ( 3 )
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Some medicated creams and ointments were noted be stored on the counters in resident bathrooms.
- R7.1AR - Ensure all medications are safely and securely stored; 69( 3 )(a)
- 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): Although all residents' "My Day" care plans were noted to be current, there were some specialized care plans (i.e. behavioural) which had not been reviewed within the past year. Medication care plans were not dated and therefore Licensing Officer could not ascertain if they had been reviewed/revised within the past year.
- 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)
- R2.2 - Are written policies and procedures in place to guide staff in fall prevention?
- Monitoring
2 infractions
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): The current system in place for monitoring water temperature is ineffective. Licensing officer noted the water temperature to be 51.5 and 51.4 in two separate resident rooms. Please inform licensing of the corrective action you have taken and the system you will use moving forward to ensure water temperature does not exceed 49 degrees Celsius.
- R7.1C - Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- 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): The system for ensuring care plans are reviewed/revised, at minimum annually, is not effective. Licensing officer noted that numerous oral care plans were dated 2014. One resident had a consult from a hygienist in 2016 but this information was not reflected in the oral care plan. Although there are medication care plans in place for all residents, the system for ensuring that they are current/reviewed is not effective as none of them were dated. Please inform licensing by the above date of the system you will implement to ensure all care plans are reviewed/revised, at minimum annually or if there is a change in resident status.
- 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)
- R7.1 - Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Monitoring
4 infractions
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): Licensing observed on a couple of PIC's care plans, an incomplete falls prevention plan. There is an ineffective process in place to monitor care plans for completed falls prevention plan.
- 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)
- 18 - Is the facility operated in a manner that promotes the health, safety and dignity of persons in care, and their rights?
- Observation(s): Licensing observed and measured the water tap temperature in PIC rooms @ 51.2-51.8 degrees celsius which is a potential hazard for PIC. There is an ineffective process in place to monitor the water temperatures. Licensing observed on a housekeeping cart hazardous cleaning agents accessible to persons in care (PIC) which is not secure, safe and adequately stored. There is an ineffective process in place to monitor the safety of PIC from hazardous cleaning agents and ensure adequate storage of cleaning agents, chemical products and other hazardous materials. (CDI)
- Operate the facility in a manner that promotes the health, safety and dignity of persons in care and their rights.
- 25 - Are care plans developed within 30 days of admission for admissions of 30 days or more?
- Observation(s): Licensing observed on two of PIC's care plans, an incomplete falls prevention plan. There is an ineffective process in place to monitor care plans for completed falls prevention plan.
- Ensure care plans include all required elements.
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Licensing observed and measured the water tap temperature in PIC rooms @ 51.2-51.8 degrees celsius which is a potential hazard for PIC. There is an ineffective process in place to monitor the water temperatures. Licensing observed on a housekeeping cart hazardous cleaning agents accessible to persons in care (PIC) which is not secure, safe and adequately stored. There is an ineffective process in place to monitor the safety of PIC from hazardous cleaning agents and ensure adequate storage of cleaning agents, chemical products and other hazardous materials. (CDI)
- Ensure water accessible to a person in care does not exceed 49 degrees Celsius; 17
- Maintain all rooms and common areas in a safe and clean condition; 22( 1 )(c)
- Provide appropriately furnished and equipped areas for secure, safe and adequate storage of cleaning agents, chemical products and other hazardous materials; 35( 1 )(c)
- 10.4 Are restraint and fall prevention plans appropriate?
- Monitoring
3 infractions
- 10.4 Are restraint and fall prevention plans appropriate?
- Observation(s): One resident did not have a completed fall prevention plan in place.
- 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)
- 7.1 Are the physical facility, equipment and furnishings maintained, sanitary, accessible and appropriate for persons in care?
- Observation(s): Two small holes and numerous chips and scrapes were noted on the wall in the lounge. In one room, there was notable damage to the wall around the vent.
- Maintain all rooms and common areas in a good state of repair; 22(1)(b)
- 10.3 Do care plans include the required elements and are they developed with the participation of the person in care, parent or representative?
- Observation(s): The medication care plans are not consistently dated, and therefore LO is unable to ascertain if they are current. LO was able to find pins in a bulletin board and on the wall in the lounge - this contravenes a care plan that is in place for a resident. This was corrected during the inspection.
- 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)
- Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person's care plan; 82
- 10.4 Are restraint and fall prevention plans appropriate?