Resources for Community Care Providers

• A licensee must develop and complete an individualized care plan for each resident within 30 days of their admission to a community care facility
• As part of the development of a comprehensive care plan, issues related to end-of-life planning and advance directives may be discussed with a resident and their family or support persons, and documented
• A resident (or someone with the legal authority to make health-care decisions on the resident’s behalf) must not be required, either as a condition of admission (or as an ongoing requirement to reside in a community care facility) to sign advance directives or level of intervention documents
• To require a resident to sign such documents is in contravention of section 7(1)(b) of the Community Care and Assisted Living Act, which requires a licensee to operate a community care facility in a manner that will promote the health, safety, dignity and rights of persons in care.

Food
The resources below will help you provide quality food and nutrition care for the people living your care facility. They also meet the requirements set out in the regulations for community care homes under the Community Care and Assisted Living Act.

• Fight Back! Food Safety Training
• BC Centre for Disease Control – Food Safety (BCCDC)
• Caring About Food Safety
• Food Safety for Fresh Fruits and Vegetables (HealthLinkBC)
• Foods to Avoid for People at Risk of Food-Borne Illness (HealthLinkBC)
• Food Safety: Easy Ways to Make Food Safer (HealthLinkBC)
• FOODSAFE (BCCDC)

 
Drinking water

Persons with reduced immunity due to age (very young or elderly), congenital immune deficiencies or acquired diseases, and those taking certain medications, may be at greater risk of contracting waterborne diseases. Review and monitoring of water supplies is necessary to ensure safe water is available for all persons in your care.

The following resources will help you learn about safe drinking water, determine if your drinking water is under an advisory and what to do if it is:

• Drinking Water for Everyone

Prevention of illness and injury

The following resources provide information on a range of topics relating to communicable illnesses and injury prevention:

• Immunization of Adult Persons in Residential Care (residential care is a term sometimes used for community care homes)
• COVID-19 Guidelines For Long-term Care Facilities (BCCDC)
• Preventing Opioid Overdose Deaths
• Wildfire Smoke and COVID-19 in Long-Term Care and Assisted Living Facilities

Emergency planning

During an emergency, Interior Health is responsible for:

• Making sure critical health-care services are resumed as quickly as possible
• Working with the Province during an emergency
• Cooperating with and providing assistance to other health authorities where an emergency event requires sharing resources

During emergency events, Environmental Public Health focuses primarily on addressing the needs of regulated facilities, local governments, the media and, indirectly, the public.
The resources below will help to provide information in case of an emergency:

• Call an Environmental Health Officer
• How Health Legislation Applies in Licensed Care Facilities
• Prepared BC
• Fire Safety Planning for a Seniors Residential Care Facility (residential care is a term sometimes used for community care homes) 
• COVID-19 Outbreak In This Facility poster

Healthy eating is fundamental to overall health. Community care home operators are responsible for supporting healthy eating habits in their care facilities.

The following resources will support you in delivering healthy eating options and encouraging healthy habits for people in your care:

• Canada Food Guide (Health Canada)
• Audits and More: A Nutrition and Food Service Audit Manual for Adult Residential Care Facilities with 25 or more Persons in Care (residential care is a term sometimes used for community care homes)
• Meals and More: A Foods and Nutrition Manual for Homes of Adults and Children with 24 Persons or Fewer in Care

Access our webpages listed below with natural emergency information for community care providers:

    • Wildfires
    • Floods/Landslides
    • Power Loss
    • Extreme Heat 
    • Emergency Preparedness 

Licensees are required to notify a medical health officer immediately if a person in care is involved in, or may have been involved in, a reportable incident.

A reportable incident is an event where a person in care has been injured, been adversely affected, or gone missing while under the care and supervision of the licensee. 

Examples of reportable incidents include, but are not limited to, the following:

• Aggression between persons in care: by a person in care towards another person in care that causes an injury that requires first aid, emergency care by a medical practitioner or nurse practitioner, or transfer to a hospital
• Disease outbreak or occurrence: above the incident level that is normally expected
• Emergency restraint: any use of a restraint that is necessary to protect the person in care or others from imminent serious physical harm and is not agreed to under section 74 (when restraints may be used)
• Fall: a fall of such seriousness, experienced by a person in care, as to require emergency care by a medical practitioner or nurse practitioner, or transfer to a hospital
• Missing or wandering person: a person in care who is missing
• Service delivery problem: any condition or event that could reasonably be expected to impair the ability of the licensee or his or her employees to provide care, or that affects the health, safety or dignity of persons in care

For a complete list of reportable incidents, please refer to Schedule D of the Residential Care Regulation (which governs community care homes).

The staff who are involved in or who witnessed an incident should complete a report so that the details are reported first hand. The facility manager can review the report and provide additional details and follow-up actions prior to signing the report. If the manager completes the report, it is helpful to include staff notes regarding the incident to ensure all relevant details and contributing factors are included.

Include the following information on the incident report, to ensure that it provides the details needed for proper assessment.

• A description of the incident with as much descriptive detail as possible (who, what, when, where, how, why)
• Noting of the sequence of events that led to the incident and identify any factors that may have contributed
• A description of the strategies that were implemented to lessen the circumstances.
• A description of the immediate response steps that were taken as well as the safety measures, corrective and preventative actions that were put into place as a result
• Who you notified besides licensing
• The current status of the person(s) in care and what, if any, changes were made to their care plan

Licensees can submit incident reports to Licensing Direct using our direct reporting portal. The following tips will ensure your successful submission:

• Use Google Chrome or Internet Explorer.
• If the form doesn’t submit, all areas of the form with a red asterisk are not complete. Even if there is data in the field, it may not have been entered in the correct format such as the date/time fields.
• Complete the form from top to bottom. Certain data elements towards the bottom of the form rely on mandatory information entered at the top of the form.
• Printing and saving reports will not work well directly from the editable form. If you need to print or save copies, we recommend that you use Google Chrome. Set the print setting to “print to PDF” rather than sending the form to a printer, which allows you to save or print a PDF copy of the submission. 

Contact Licensing Direct if you have any questions. We are here to help.

A licensing officer investigates the incident report to assess the factors that led to the incident, as well as the appropriateness of the licensee’s response and corrective actions. The goal of this process is to review the licensee’s actions to determine whether there is a recurring pattern, and to prevent a similar occurrence in the future, if possible.

Licensees must also keep a log of minor, unexpected accidents and illnesses that do not require medical attention and are not reportable incidents. Section 88(a) of the Residential Care Regulation (which governs community care homes) requires this information to be kept on record and made available during inspections.

To be a licensed community care home operator, you must ensure that your facility conforms to all relevant laws, regulations and standards. By making sure you are fully informed about the following legislation and resources, you will have the knowledge you need to meet all of your legal obligations, operate a healthy and safe facility and programs, and keep your licence in good standing.

• Community Care and Assisted Living Act: The legislation that governs all aspects of licensing for community care facilities that offer care to vulnerable people in child day care, child and youth long-term and adult long-term settings
• Residential Care Regulation: Aligned with the Community Care and Assisted Living Act, this regulation, which governs community care homes, includes all aspects of licensing; operations and facility requirements; staffing requirements; record keeping; and the minimum health and safety requirements for provision of care
• Health Care Consent Regulation: The legislation that governs care facilities in regards to consent to admission; consent to care; assessments of incapability; and the use of restraints
• Health Care (Consent) and Care Facility (Admission) Act: The legislation that governs care facilities in regards to consent rights around health care, advance directives for future health care, admission to a care facility and provider liability
• Patients’ Bill of Rights Regulation: Aligned with the Hospital Act, regulation outlining the display and promotion of patients’ rights  
• Guide to Community Care Licensing in BC: A description of the system of legislation and policy that governs licensed community care facilities, including community care homes (e.g., long-term care, child and youth care, etc.) and child care, and an overview of the licensing process
• Continuing Care Act: The legislation governing community care facilities in the care of individuals with a frailty or an acute or chronic illness or disability that do not require admission to a hospital

The following resources outline standards of practice that identify key requirements for safe and healthy operation of community care homes:

• Advance Directives: An outline of policies and standards relating to a licensee’s obligation to develop care plans for the provision of services and support of individuals, and discuss with residents and their family end-of-life planning and written instruction around consent to health care in the event that the resident is incapacitated 
• Agreement in Writing to the Use of Restraints: An outline of the regulation around why and when a licensee may restrain a person in care  
• Consent to Care Facility Admission: Information around acquiring consent for an individual’s admission to a facility, including incapability to consent, assessment and relevant legislation 
• Immunization of Adult Persons in Community Care Homes: An outline of legislation around information, recordkeeping, care plans and policies relating to immunization and disease 
• Incident Reporting of Aggressive or Unusual Behaviour in Adult Community Care Homes: A definition of reportable incidents, and an outline of regulations and policies around how and when to report and record incidents, and to whom  
• Preventing Overdose Deaths: An outline of regulations around and resources for the care for individuals who are at risk of an opioid drug overdose

Licensing officers carry out the following types of inspections:

• Initial inspection: an inspection after an application for licence along with all applicable documentation has been received
• Routine inspection: a comprehensive inspection, typically unannounced
• Complaint inspection: an inspection in response to a complaint or concern about a facility
• Reportable incident inspection: an inspection in response to a reportable incident 
• Follow-up inspection: any inspection that follows up on a previous inspection to ensure the licensee/manager has resolved issues of non-compliance 
• Unlicensed inspection: an on-site inspection to determine if a facility is operating without a valid community care facility licence

When licensing officers conduct an inspection, they are assessing the site for compliance with all legislated requirements. If an area of non-compliance is identified, a recorded observation is made. Observations are discussed with the site operator and, depending on the level of risk associated with the issue, they will work together on an action plan to resolve the matter. 

During an inspection, the following aspects of care are assessed:

• Care and supervision: licensees are required to ensure adequate care and supervision of individuals, including by creating, maintaining and following care plans for each individual
• Hygiene and communicable disease control: acceptable levels of hygiene must be maintained, including handwashing and hygienic practices, which prevent the spread of communicable diseases
• Licensing: licensees must meet a number of administrative requirements around the operation of a facility
• Medication: licensees are required to store, administer and record the medications of individuals
• Nutrition and food services: licensees must ensure safe food preparation and appropriate nutritional content of meals, and provide texture modifications and assistance with feeding as needed
• Physical facility, equipment and furnishings: licensees must maintain the facility, equipment, furnishings in clean and good repair, safe and free from hazards
• Policies and procedures: licensees must have written policies and procedures to guide staff in all matters regarding the care and supervision of individuals 
• Program: licensees must provide individuals with access to indoor and outdoor recreational areas, and an ongoing program of physical, social and recreational activities without charge
• Records and reporting: licensees must maintain a variety of records and documentation in the operation of the care facility 
• Staffing: licensees must ensure that there are adequate numbers of staff with the necessary training and experience to provide for the care, supervision and activity needs of the individuals

How frequently your facility is inspected depends on the results of previous inspections and whether or not your facility is in compliance with legislated requirements. In each inspection of a facility, a licensing officer uses the Risk Assessment Tool to measure compliance and assign a level of risk to the facility. Based on this, the licensing officer determines when the next inspection will take place. 

The Risk Assessment Tool is used for licensed facilities during routine inspections.
 
In general, a risk assessment will be completed at least once every 12 to 18 months; however, there may be situations where a new risk assessment is required sooner. 

• Facilities with a low risk rating will be inspected once per year, at a minimum. 
• Facilities with a moderate risk rating will be inspected twice per year, at a minimum.
• Facilities with a high risk rating will be inspected three times per year, at a minimum.

Most inspections are unannounced; it is important to assess most aspects of the operation at a time when a facility is in its usual routine. Despite this, it is sometimes appropriate to schedule inspections, such as when it is necessary to spend time with the manager to assess specific aspects of a facility’s operation. 

Learn more about the inspection and risk assessment process

A risk assessment is a careful examination of any issue of non-compliance to identify if it could cause someone harm. Determining risk takes into consideration many variables, including the unique features and physical characteristics and policies and procedures of a facility, preventative measures that may be in place, and the various care and supervision needs of the persons in care. 

A licensing officer will use the information observed during an inspection to determine a risk rating using the Risk Assessment Tool. This tool is based on two components: an “in the moment” review of compliance with the legislation and a review of past operation and compliance of the facility. 

Following an inspection, the licensing officer will discuss their observations with the facility manager and forward them an inspection report. If a facility does not meet the requirements of the Community Care and Assisted Living Act, or the Residential Care Regulation, which governs community care homes, the licensing officer will identify the areas in non-compliance and request that the manager make corrections.
 
Inspection reports are posted on the Interior Health website for five years, and include information about the following: 

• Routine and follow-up inspection reports
• Substantiated complaints about licensed care providers
• Providers found to be operating in contravention of legislation

Find inspection reports

A facility might be investigated for many reasons – the most common being a complaint or a reportable incident – but an investigation doesn’t mean that a licensee has done something wrong. Licensing officers must investigate all complaints to ensure the health and safety of persons in care. As such, it is important for facility staff to work cooperatively with the licensing officer in all investigations.
  
An investigation under the Community Care and Assisted Living Act doesn’t require evidence and facts that prove beyond a reasonable doubt that an event occurred. Instead, the investigation determines the likelihood that an event has occurred.

A community care home will be investigated for a complaint about: 

• Being unlicensed
• Not complying with all legislation and standards, and/or the terms and conditions of its license

Investigations also happen when an incident report is received claiming that abuse, neglect and/or injury has occurred at a facility.

We recognize that investigations are unsettling for everyone involved and can be especially difficult for persons in care and staff. While, in most cases, licensing staff are unable to share the source of complaints with a facility, we are committed to being transparent and fair, and to concluding the investigation as quickly as possible.

Depending on the type of concern or the potential risk to the persons in care, the Licensing department of Interior Health will determine the next steps of the investigation process.
A licensing officer will:

• Assess the nature and severity of the complaint(s) and incident report(s) to determine the extent of the investigation
• Advise the licensee that an investigation is taking place, and request a health and safety plan, if required (see next section for more information)
• Request assistance from services such as local law enforcement, Community Living BC, and/or mental health and substance use or residential and contract services
• Gather all necessary information by:
          ◦ Conducting facility inspections
          ◦ Reviewing facility policies, staff records and records of persons in care
          ◦ Interviewing staff, persons in care and their families
          ◦ Investigating the facility’s operational history

Investigation findings are documented and the licensee is given the opportunity to review and respond to the information. More information, including a compliance plan, may be requested at the conclusion of the investigation, and additional compliance activities may also take place.

Other agencies may be also brought into an investigation as required. For example:

• Allegations involving conduct that is potentially criminal are immediately referred to police
• Other expertise may be consulted, including social workers and dietitians

As a licensee, you’re responsible for the performance of your staff, and you may need to conduct your own investigation to satisfy your obligations as an employer. We encourage licensees to be active participants in an investigation and to show due diligence, which includes discussing your role in an investigation with your licensing officer as soon as possible. However, while we are committed to working with licensees, in some cases a joint investigation may not be appropriate.

You are expected to:

• Implement and maintain an approved health and safety plan
• Ensure the health and safety plan remains in effect until advised
• Work cooperatively with your licensing officer
• Address any findings of the investigation in a timely and appropriate manner

Health and safety plan: As a licensee, you must submit a health and safety plan because, when a complaint is received, licensing officers respond quickly to ensure the health and safety of the persons in care and may request a health and safety plan to address alleged non-compliance and potential risks to persons in care.

If circumstances change, a revised health and safety plan can be submitted for review during an investigation. You will be advised as soon as the health and safety plan is no longer required.

Investigation timelines vary depending on the following:

• The complexity of the investigation
• The number of concerns that need to be investigated
• The need to collaborate with other agencies

• Facility records must be organized and secure, and reviewed regularly to ensure the information is accurate and up to date
• Records must be available and accessible at all times, including when a computer issue, power outage or emergency situation arises

If you have any questions or require clarification regarding the above information, please contact Licensing Direct for assistance.

Records and documentation are necessary for:

• The health and safety of residents
• Being prepared for emergencies
• Supporting good hiring practices 
• Providing the necessary information on persons in care to care providers and substitute care providers 
• Addressing health and safety risks
• Documenting an event in case a conflict or dispute arises  
• Capturing decisions regarding a person in care’s unique care needs and ongoing communications between families and caregivers 
• Complying with the Residential Care Regulation and Standards of Practice

A licensed community care facility is a premises, or part of a premises, where care is provided to three or more individuals, not related by blood or marriage to the caregiver.

The Community Care Licensing program protects and promotes the health, safety and well-being of vulnerable children, youth and adults in licensed care facilities. We do this through education, collaboration and regulation.

The Licensing program is responsible for monitoring compliance of licensed facilities with the Community Care and Assisted Living Act, the Child Care Licensing Regulation and the Residential Care Regulation (which applies to community care homes). The Act and Regulations set forth a standard which all licensed facilities are required to meet.

Licensing officers monitor facilities through an inspection process and perform other duties outlined in the Community Care and Assisted Living Act, including investigating complaints of unlicensed facilities or unsafe, abusive, inappropriate care allegations; reviewing new applications; ensuring that licensees follow-up with corrective action; and considering exemption requests.

The licensee is responsible for ensuring that their facility complies with the Community Care and Assisted Living Act, and Residential Care Regulation (which applies to community care homes) or the Child Care Licensing Regulation. Licensees may delegate this responsibility to a manager who is responsible for the day-to-day operation of the facility.

Licensing staff prioritize work according to the level of risk in a facility. The level is assessed based on investigations, inspections, applications, exemptions, etc. Facilities with a history of non-compliance receive more frequent routine inspections.

Although funding is available, Licensing does not have a role in funding. Please refer to the Ministry of Children and Family Development website for child care information. For community care home funding, contact the agency or department that is responsible for the type of care you wish to provide in the area in which you plan to operate (e.g., Mental Health and Substance Use, and Interior Health Long Term Care and Assisted Living Program, or Community Living BC).

Applicants who are actively pursuing a licence may only provide care to two or fewer individuals, not related by blood or marriage to the caregiver, until a community care facility licence has been issued. A licence is issued after all legislative requirements have been met.

You are not permitted to open or advertise as a licensed care facility until you have received a licence.

Yes. However, it is best to submit a completed application package to Licensing Direct. Incomplete packages may be delayed. If you are struggling with the application process, contact Licensing Direct to discuss the challenges and how you can move forward in the application process.

A number of steps must be completed after an application for a licence has been submitted. The time for completing these steps will vary for each applicant depending on the complexity of the application. The process could take several weeks to months.

No, a community care facility licence is issued for a specific premises (address) and licensee. When there is a change of licensee or facility address, a new application for licence is required.

Notify Licensing Direct immediately if there are changes to the information you provided.

Should a facility manager resign or expect to be absent for at least 30 consecutive days, you must notify your licensing officer.