This checklist is intended to assist Licensing staff to monitor compliance with the Community Care and Assisted Living Act () and the Residential Care Regulation (RCR). This tool is not intended to be part of the facility inspection report. Licensing recommends that the Licensee/ Manager use this tool as evidence to support selfmonitoring of the premises, program and services for compliance with the legislative requirements. The recommended timeline for self-monitoring is six months, there are two columns to the right of the checklist that will facilitate two reviews annually. KEY: PIC means a person in care, includes a child, youth & adult. CYR means Child & Youth Residential. LTC means Long Term Care. in the means the regulation is not applicable to a transitional facility. in the means the regulation cannot be exempted. in the Section means it is also a regulation under Schedule (Residents Bill of Rights). LICENSING 101/ 502 Access to Residential Care Regulations & Community Care and Assisted Living Act * 7 (1)(b) 101/502 Residents Bill of Rights & Community Care and Assisted Living Act are posted and promoted. * 7 (1)(b) 101 Excluding CYR & Community Living - Licence is displayed, including any terms/conditions, & the name of the manager. 11(1)(a), *7(1)(c) 101 Routine facility inspection reports are posted (excludes CYR & Community Living). 11 (1)(b) (2), 103 Operating as per licence (service type, capacity, only PIC > 19 yrs of age in an adult facility). 2, 46(2); *16(2) 103 / 207 Duty to inform & obtain approval for changes to information or operation (reference Schedule B). 8(1)(2), 9, 102 Duty to inform & obtain approval for any change in Manager status. 8(3) 502 LTC only - Liability insurance for property damage & bodily injury. 10 103 Advertising/offering services to the public includes the type of care provided. 11 (3) 502 Inspection/investigation is not obstructed & relevant records/information are not withheld, concealed or destroyed. 12 (1) 502 A health & safety plan, is provided during an investigation if requested. 12 (2) PHYSICAL FACILITY General Physical Requirements 207 Directional signs for information or assistance meet the PIC s needs. 13 207 Areas intended for use by PICs with mobility aides, are accessible. 14 (1) 207 LTC only - hallways for use by PICs, are > 1.83 m wide. 14 (2) 207 Signaling devices, lights & elevator controls are accessible & can be used without difficulty. 14 (3) 207 Windows, are secured if necessary for health & safety, unless they are an emergency exit. 15 207 Temperature of bedrooms, bathrooms & common areas is safe & comfortable for the activities within. 16 (1) 207 Lighting in bedrooms, bathrooms & common areas is sufficient for the type of activities & protects H&S. 16 (2) 207 Lighting (natural & artificial) & temperature of rooms intended for use by PIC meets preferences & needs. 205 Water, accessible to PICs does not exceed 49 o Celsius. 17 16 (3) Revised: Oct 1 09; Apr 7 10, Jul 21 11 CCFL RES202 Page 1
201 A telephone is provided, exclusive to PIC s that is private, adaptable, accessible & conveniently located. 18 201 Monitoring & signaling devices if required, are appropriate to signal the need for assistance & the location. 201 Communication means & devices are appropriate & enable communication between staff & with PIC. 19 (2) 19(1) 207 Notification of electronic surveillance use is prominently displayed. 19 (3) 206 Emergency equipment required if < 7 persons: interconnected smoke alarms in bedrooms, hallways to bedrooms appropriate to the needs. sprinklers conform to the BC Building. emergency lighting in stairs & hallways leading to bedrooms (for at least 30 minutes). 201/ 202/ 402 Furniture/equipment is appropriate, compatible with health, safety & dignity and is safe, clean & in good repair. 21 202/ 203 All rooms & common areas are well ventilated, safe, clean & in good repair. 22 (1) 205 Emergency exits are not obstructed or secured to hinder emergency exit. 22 (2) 202/ 206 All rooms, common areas, emergency exits & equipment, monitoring & signaling devices are regularly inspected & maintained. 205/ 502 Smoking on the premises only allowed for PICs, who if required, are supervised for safety. 23 (a)(c) 502 Staff do not smoke while supervising PICs. 23 (b) 205 No weapons [as per Criminal s 84(1)] permitted on the premises. (e.g. firearms, switch blades etc.). Bedrooms 207 Each PIC has a separate bedroom. 25 (1) 207/ 201 If no separate bedroom -number of double occupancy bedrooms does not exceeds 5% of max. capacity: privacy screening is provided. health, safety, personal comfort & dignity are protected. separate bedroom relocation plan is in place if requested. child/youth > 6yrs of age do not share a bedroom with the opposite gender. 207 Bedroom meets needs of PIC & ensures health, safety & dignity. 26 (1) 207 Bedrooms are directly accessible from a hallway. 26 (2) 20 22 (3) 24 25 (2)(a) 25 (2)(b)(c)(d) 25 (3) 201/ 207 Interior bedroom door locks, if safe, that can be opened in an emergency, are provided if requested. 26 (3)(4) 207 Single or double occupancy bedrooms meet the space requirements. 27 207 Bedrooms have windows that provide natural light & have coverings to block light & protect privacy. 28 (1) 207 Bedroom windows can be opened, if there is no A/C or mechanical ventilation & no risk to health, safety or dignity of PIC. 28 (2) 207 If PIC is non-ambulatory - a window for outside visibility from a sitting position is available. 28 (3) 207 Bedroom furnishings are provided at no cost & include a closet/wardrobe & a safe/secure place for valuables. 207 PIC s are permitted to bring personal possessions and furnishings in their bedroom if safe & appropriate. 29 (2) 29 (1) Bathroom Facilities 207/ 201 Bathrooms have a lock, that can be opened from the outside & slip resistant material on tub/shower bottom, conveniently located grab bars & hand rails at the toilet/tub/shower to meet the needs & preferences of PICs & any other equipment necessary to protect the health, safety & dignity. 30 207 Excluding LTC - Bathrooms have, 1 washbasin & 1 toilet/3 persons, & 1 bathtub or shower/4 persons. 31 207 LTC only - Bathrooms: bathing facilities meet the requirements for the number of persons on a floor or in the same wing. have appropriate washbasins & toilet facilities next to each dining/lounge/recreational areas. have a washbasin & toilet in each bedroom for the exclusive use of the occupants. 32 CCFL RES 202 Page 2
Common Areas and Work Areas 207/ 201 Dining space meets requirements & has appropriate & sufficient tables & seating for all PICs. 33 (b) 33 (a)(c) 207/ 201 Excluding LTC - Lounge space meets requirements & is comfortably furnished. 34 (1) 207/ 201 LTC only - recreational & lounge space meets space requirement, & is suitably equipped & furnished. 34 (2) 207 Recreational & lounge space is accessible to all PIC s except during cleaning & maintenance. 34 (3) 207/ 204 Appropriate areas are available for staff, administrative work, medications, PIC records, chemical/hazardous materials, clean & soiled laundry/articles. 207 Laundry facilities secure if not used by PICs; if used by PICs it has a slip resistant floor. 35 (2) 207/ 201 Outdoor space meets requirements, has a surfaced patio, shelter & comfortable seating & if required, is secured or fenced. STAFFING General Staffing Requirements 302 Staff records meet requirements e.g. CRC 37 (1) CCFL RES 202 Page 3 35 (1) 36 (1)(a)(b) 36 (1)(c)(2) 302 Staff are of good character & possess the necessary personality, ability & temperament. 37 (2)(a)(b) 302 Manager & staff possess the training, experience & demonstrate the skills to carry out assigned duties. 37 (2)(c) 302 Persons >12 yrs (not in care) & ordinarily present, are of good character & have a CRC. 38 302 Record of continued compliance with the provincial Tb & immunization program is on file. 39 (1) 302 Medical certificate, if requested by Licensing is provided. 39 (2) 302/ 502 Performance reviews occur regularly & as directed by Licensing to ensure competence & compliance. 40 (1)(2) 301 Staff only perform duties for which they have the necessary training/experience & competence. 40 (3) 301 Charge person designated if Manager is temporarily absent. 41 (1) 301 A qualified staff is designated to supervise employees, coordinate & monitor care & manage unusual situations & emergencies. 301 Sufficient number & pattern of suitably qualified staff available at all times to meet PICs needs. 42 (1) 301 Supervision when outside the facility, is provided if required. 42 (2) 301 Staff are accessible at all times, that can effectively communicate with PICs. 42 (3) 301/302 Staff with current First Aid & CPR per Schedule B, is accessible at all times & knowledgeable of PICs 43 (1) medical conditions & can communicate effectively with emergency personnel. 206 First aid supplies are accessible at all times, including when care is provided off-site. 43 (2) 302 Staff responsible for food preparation & service are experienced, competent & trained to meet needs. 44 (1)(a) 302 Food service staff receive ongoing education re: food service & if required, assisted eating techniques. 44 (1)(b) 302 If >50 PICs, there is a qualified food services manager, or a dietitian. 44 (2) 301/302 Excluding Hospice: there is a designated & qualified staff to organize/supervise the physical, social & recreational activities, and who has sufficient time away from other duties to carry out the activities, and sufficient time is provided for PICs to participate in activities. OPERATIONS Admission and Continuing Accommodation 502 Only persons for whom safe & adequate care can be provided are accommodated. 46(1) 502/ 603 Admission Screening occurs that ensures safe & adequate care & considers, training & experience of staff, staffing levels & patterns of coverage, facility design, construction, the facilities & equipment, needs of the PIC & other PICs, & any funding criteria, advice or information. 41 (2) 45 47
502 Pre-admission, the person, parent or representative are appropriately advised of all charges, fees or payments for accommodation/services; refund agreement; the policy & procedure for expressing concerns/complaints (includes Licensing & if applicable, the Patient Care Quality Review Board) & resolving disputes. 603 Compliance with Tb screening & immunizations is on file. 49 (1) 603 Height & weight on admission is recorded. 49 (2) 603 Risk of leaving without notification / wandering is assessed on admission. 49 (3) 502 Health & safety are regularly monitored to ensure PIC s needs can continue to be met. 50 (1) 48, *19 601 PIC sent to hospital only as an emergency or under order by a Dr. or nurse practitioner. 50 (2)(a)(3) 601 PIC transferred to another CCF only in an emergency, or on leave under the Mental Health Act, or with consent of the PIC, parent or representative. General Care Requirements 502 Emergency plan is current, prominently displayed, & includes procedures for preparation, mitigation, response, evacuation & recovery from an emergency. 50 (2)(b)(3) 51(1)(a)(2)(4) 502 Emergency plan provides for the continuous delivery of care during an emergency. 51 (1)(b) 502/ 301 Staff is trained & practice implementing the emergency plan & equipment. 51 (3) 201/ 502 Communication equipment is accessible & reliable in an emergency. 51 (5) 502 No PIC is subject to any type of abuse or neglect, & food or fluids is not used as a punishment, or reward. 601 Personal privacy, bedroom, belongings & storage area are respected while health & safety is maintained. 53 401/402/ 601 A health & hygiene program is implemented, instruction & assistance is provided as necessary. 54(1) 601 Assistance is provided to obtain health services & a medical/nurse practitioner is accessible in an emergency. 52 54(2) 601 Professional dental exams are encouraged annually & assistance is provided to obtain dental services. 54(3)(b)(i)(ii)(4) 601 Assistance is provided with maintaining daily oral health & recommended or ordered dental treatments. 54(3)(b)(iii) 601 Excluding Hospice: An ongoing & planned activity program: is provided at no charge that meets the care plan & needs of the PICs. may provide events beyond the regular program, with or without charge (e.g. dinners out, trips). encourages PICs to participate & takes advantage of community opportunities. provides at no charge sufficient quantity & variety of safe, accessible supplies/materials & equip. 55 603/ 502 Excludes PIC in CYR if able to identify self - written documentation/identification accompanies PIC who temporarily leave the facility. 602/ 502 Known wanderers & elopement risk (who cannot identify themselves) carry appropriate identification. 56 (3) 601 Reasonable access is provided to parent or representative. 57 (1) 601 Visitation at any time if safe & appropriate, privacy is provided. 57 (2) 601/ 602 Court orders/orders under another enactment to prohibit or restrict access are complied with. 57 (3) 56 (1)(2) 601/ 502 No release or removal of a PIC unless indicated in care plan or by written authorization. 58 601 Opportunities for family or resident councils, to meet with the licensee is provided. 59 502 Dispute resolution process in place that is prompt & effective, fair & ensures no retaliation. 60 601 Physical environment, care & services are regularly monitored for compliance with the legislation. 61 Nutrition 802 4 week menu used, weekly menu may be if accommodation is for < 6 weeks. 62 (1) 802 The menu provides for each day: 3 nutritious meals with min. 3 food groups from the Canada Food Guide (CFG) & snacks with min. 2 food groups from the CFG. a variety, that considers nutritional care plans, age, gender, & activity level; food preferences, cultural background; seasonal variation; texture, color, food safety, taste & visual appeal. for substitution from the same food group & similar nutritional value. CCFL RES 202 Page 4 62 (2)
802 Menu is followed within reason & if unable to follow, meets the nutritional needs as per section 62(2). 62 (3) 802 LTC only - weekly menus are posted in the dining area. 62 (4) 802 Food is safely prepared, stored, served & handled. 63 (1) 802 Food is prepared & served to the extent possible to meet personal preferences & cultural background. 63 (2) 802 Meals are provided in: a dining area, or by temporary tray service (if temporarily unable to attend the dining area), or by ongoing room tray service, not for the convenience of the staff but as per the care plan & ordered by a medical or nurse practitioner & is reassessed minimum every 30 days. 802 PICs have sufficient time & assistance to eat safely & comfortably. 63 (5) 802 Excluding CYR- meals & snacks are available at times specified by the regulations. 64 (1) 802 CYR only- meals & snacks are provided at times that meet the needs. 64 (2) 802 Brunch, if preferred, is available on weekends and holidays (combines morning & noon meal). 64 (3) 802 A packed meal or snack is provided without charge if absent for a snack or meal. 64 (4) 802 Participation is encouraged in menu planning, meal prep, food service & activities if practical & in care plan. 802 PICs participating in food preparation are appropriately supervised. 65 (2) 801 Individual nutritional needs, based on Canada s Food Guide and nutritional care plan are met. 66 (1) 801/ 802 Fluids are provided in sufficient quantity & variation to meet PICs needs & preferences. 66 (2) 801/ 802 Required & ordered supplements & tube feeds, eating aids, assistance or supervision are provided. 67 (1) 804 Children are not fed by means of a propped bottle. 67 (2) 63 (3)(4) 65 (1) Medication 704 Medication Safety & Advisory Committee (MSAC) is established & includes the required persons. 68 (1) 704 Pharmacist, inspects the medication storage area & consults with staff re: medication interactions & other med. Issues. 704 MSAC establishes & reviews as required: staff training & orientation programs related to medication system. the policies & procedures for the safe & effective storage, handling & administration of medications, immediate response to & reporting of medication errors & adverse reactions. 702 Staff comply with the policies & procedures of the MSAC. 68 (4) 704 Medications are packaged & recorded on the medication administration record (MAR) by the pharmacist. 69 (1) 702 Medications remain in original container or package until administered, unless authorized by the MSAC. 69 (2) 701 Medications are at all times safely & securely stored, (includes self administration medication). 69 (3) 702 Only medications prescribed by a medical or nurse practitioner are administered by trained staff (19+ yrs). 70 (1)(2)(3)(a) 702 If absent from the facility (e.g. LOA, day program) arrangements made for administration of medication. 70 (3)(b) 704 Self-medication permitted if approved by MSAC & prescribing medical/ nurse practitioner & in the care plan. 702 A staff is immediately available for adverse reactions to document on the MAR & notify the medical/nurse practitioner & pharmacist. 703 No handwritten changes are made on the medication container or package & changes are promptly recorded on the MAR & the pharmacist notified. 702 Discontinued & expired medications are returned to the pharmacy. 72 68 (2) 68 (3) 70 (4) 70 (5) 71 Use of Restraints 601 Restraint used only if it meets the requirements for use, (i.e. minimal as possible, safety & dignity monitored during & after use, staff are trained in all aspects & follow instructions for use, alternative considered). 73 (1)(2) CCFL RES 202 Page 5
601/ 603 After an emergency restraint, the PIC, witnesses, & staff involved in the implementation of the restraint are provided information & advice regarding use of the restraint & document this in the care plan. 502/ 601 Restraint used only in an emergency, or by written agreement of persons identified in the regulation, & is not used for punishment, discipline or the convenience of staff. 601 The need for the restraint is assessed within 24 hours of first use & if required beyond 24 hrs, required consents obtained & use complies with Section 73(2). 601 Following written agreement for use of a restraint for > 24hrs., reassessment occurs on the earlier of either the time specified in the care plan or as specified by the persons who authorized it & where practical are included in the reassessment. 73 (3) 74 (1) 74 (2) 75 (1)(2) 75 (3) Matters That Must Be Reported 601/ 402 Illness or injury while in care is immediately reported to the parent/representative or contact person. 76 (1) 402 Notification within 24 hours to the MHO of a reportable communicable disease (as listed in the Health Act Communicable Disease Regulation - Schedule A). 503 Parent/ representative/ contact person/ medical or nurse practitioner/ funding & licensing receive immediate notification of a reportable incident. 503 Hospice only- expected deaths are immediately reported to the parent/ representative/ contact person/ medical / nurse practitioner,& Licensing & funding program if applicable are notified within 30 days. RECORDS Records for Each Person in Care 603 PIC records contain the required documentation (e.g. persons who are restricted access or pose risk etc.) 78 76 (2) 77 (1)(2) 77 (3) 703 Medication administration records are maintained, & include information re: administered meds. 78 (2) 603 Written consent from authorized person identifying to whom a child can be released, & to call medical/nurse practitioner or ambulance, etc. are maintained. 603 Records & receipts of all money, valuables & other things, held in trust, all disbursements & use of a PIC s money, any fees charged to manage the valuables or money, & returns upon discharge or death are maintained. 602 Short term care plan, developed upon admission, meets requirements. 80, 81(3) 602 If admitted for >30 days, a care plan that meets the requirements of section 81 is developed within 30 days. 602 PIC, or parent / representative participate in development of the care plan. 81 (2) 602 Care plans are regularly monitored for implementation & reviewed at least 1x/yr, & when a substantial change in circumstance to ensure needs & preferences are met & it is compatible with PIC s abilities. 78 (3) 79 81 (1) (3) 81 (4)(a)(b) 602 Review & modification of the care plan, where reasonably practical., includes the PIC. 81 (4)(c) 602 Care & supervision is consistent with the terms & conditions of the care plan. 82 801 If < 24 persons in care: a nutrition plan (NP) must be developed: If no dietitian input - reasonable steps taken to assess specific needs & nutritional risk based on relevant factors identified in s. 83(1)(b). 801 If > 24 persons in care NP must be developed with the assistance of a dietitian. 83 (2) 801 NPs are regularly reviewed with a dietitian & at the request of a health care provider, Licensing or funder. 83 (3) 83 (1) 801 Excludes Hospice - weight is monitored monthly & recorded in the NP, reason for refusal or inability to weigh is documented in the NP, & advice sought immediately if significant, unintentional weight loss. 602 Restraint use is documented in care plan & includes, type & nature of restraint, reason for use, alternatives tried, duration & monitoring during use, results of reassessments, staff compliance with (s.73-75). Additional Records 502 Written policies & procedures in place & implemented, to guide staff in all matters relating to care & supervision, & are reviewed & revised (if required) at least 1x/yr & are available to employees, Licensing, parent or representative. 83 (4)(5) 84 85 (1) CCFL RES 202 Page 6
501/ 502 /503 Written policies & procedures are required for: LTC only- fall prevention includes, assessment, prevention & response. Orientation of new managers & employees regarding policies & procedures and & RCR. Continuing education of managers & employees. Complaints/Dispute resolution - for PIC, parents & representatives as per section 60. Access to PIC by persons who are not employees of the facility. Release of children/youth/vulnerable adults -includes authorized, incapable & not authorized. Monitoring of the nutrition of a PIC. Monitoring of the medication of a PIC. The use of restraints in an emergency. Responding to reportable incidents. Steps to be taken if person in care leaves or may have left without notification to an employee. The appropriate manner & schedule for record keeping. 502/ 704 A copy of the medication policies & procedures developed by the MSAC is available. 85 (3) 302 Employee records contain the required documentation. 86 803 Food service records are complete (i.e. food purchases, menu & substitutions, staff training, etc). 87 503 Unexpected events & minor accidents/illnesses deemed not reportable & not requiring medical attention and all reportable incidents are recorded. 603 Record maintained re: complaints/ concerns & responses under Section 60. 89 (1) 603 Records maintained re: compliance with: LTC only -liability insurance - Section 10. Family & resident council - Section 59. Individual nutrition needs - Section 66. Administration of medication - Section 70. 603 Separate financial records maintained for each facility in accordance with generally acceptable accounting practices, audited financial records available upon request of Director of Licensing. General Requirement Respecting Records 85 (2) 88 89 (2) 603 All required records are current & if more than one facility operated, kept separate for each facility. 91 (1) 603 All records required under Sections 78-81, 85, 88 & 89 are kept in a single place (i.e. Records for: PIC, policies & procedures, minor & reportable incidents, complaints & compliance) all other records are maintained in a place for easy & timely retrieval upon request. 603 PIC records are stored in a manner to prevent unauthorized access. 91 (3) 603 All records must be maintained for at least one year unless directed otherwise under s. 92 (2) thru(5). 92 (1) 302 All signed, original consent forms for CRC must be maintained for at least 5 years. 92 (2) 302 to staff - maintains all records regarding character & skill requirements - Section 37 while employed at the facility, All others- maintains all CRC results & references for the time the subject is ordinarily present on the premises. 302 Character references are returned or destroyed when subject is no longer an employee or ordinarily present. 603 All PIC records, as per Section 78 are maintained for at least 2 years from date of discharge. 92 (5) 603 All records of complaints / disputes as per Section 89 (1) maintained for at least 2 years. 92 (6) 603 Confidentiality of PIC records & personal information is maintained to the greatest extent possible. 93 207 Structural changes, additions or new construction of a transitioned facility (licensed on or before August 94 1, 2000) complies with the requirements of Section 94 (2). 207/ 502 PICs heath & safety is maintained, standard of care is acceptable in a transitioned facility. 95 302 Criminal Record Checks are completed in accordance with the Criminal Records Review Act. 96 90 91 (2) 92 (3)(a)(b) 92 (4) Available resources www.health.gov.ca/ccf for access to the Ministry of Health, Community Care Licensing Branch for information & resources e.g. Director of Licensing, Standards of Practice, the Community Care and Assisted Living Act and/or Residential Care Regulation. www.fraserhealth.ca/your_environment/ccfl to access information and resources regarding licensed residential care in Fraser Health. CCFL RES 202 Page 7
REMEMBER Licensees must notify Licensing and obtain written approval when there is a change in the licence application information (refer to Schedule B) any structural change, renovation with a plan to ensure health and safety of persons in care is a request from Licensing for a health & safety plan (Investigation) is a change in manager status (absence > 30 days or resignation) is a request for a written compliance plan to a facility inspection report Refer to Schedules for requirements to specific sections.... Schedule A- Exemptions - lists the sections of the regulations that can and cannot be exempted Schedule B - Applying for a Licence - sets out the application requirements for a community care facility licence. Schedule C - First Aid - sets out the criteria for determining if the requirement for First Aid & CPR training has been met Schedule D - Reportable Incidents - identifies and defines reportable incidents Comments: CCFL RES 202 Page 8
CCFL RES 202 Page 9