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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

CJOS-CV8TRV

FACILITY NAME Crossroads Inlet Centre Hospice		SERVICE TYPES 110 Hospice	FACILITY LICENSE # KSER-5RBRRL
FACILITY ADDRESS 101 Noons Creek Dr			FACILITY PHONE (604) 949-2270
CITY Port Moody	POSTAL CODE V3H 5J1		MANAGER Sylvie Jensen

INSPECTION DATE August 31, 2023	ADDITIONAL INSP. DATE (multi-day)		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 1
ARRIVAL 02:30 PM	DEPARTURE 03:30 PM	ARRIVAL	DEPARTURE	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care & Assisted Living Act (CCALA), the Residential Care Regulation (RCR) and the relevant Director of Licensing Standards of Practice (DOLSP). This report was based on the Licensing Officer’s observations, review of the facility records and information provided by the facility staff at the time of inspection. The following areas were reviewed: · Licensing · Physical Facility · Staffing · Polices & Procedures · Care & Supervision · Hygiene and Communicable Disease Control · Medication · Nutrition and Food Services · Program · Records and Reporting As part of the routine inspection, a Facility Risk Assessment Tool is completed and a copy is provided. The Risk Assessment includes non-compliance identified during the routine inspection and a 3-year “historical” review of the facility’s compliance and operation. Visit the CCFL website at https://www.fraserhealth.ca/health-topics-a-to-z/residential-care-licensing#.W2NubJioupo for: · Additional resources and · Links to the Legislation (CCALA & RCR)

Contraventions

Previous Inspection -

Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations

CARE AND/OR SUPERVISION: 34630 - RCR s.81(3)(b) - A care plan must include all of the following: (b) an oral health care plan. Observation: Review of persons in care's (PIC) care plan (kardex) found there is not an oral care plan in place to guide the staff in what the PIC's oral care needs are. In discussion with staff it was determined that they are providing oral care as per the PIC's needs and they are documenting that care is being provided, however it is not found in the care plan. Corrective Action(s): Ensure that the care plan includes an oral care plan. Date to be Corrected: September 15, 2023

Comments

Thank you to the staff for their assistance in completing this inspection. The inspection report and risk assessment were discussed with team members and a copy of both were provided by email.

Action Required by Licensee/Manager	Action Required by Licensing Staff
No action required	No action required

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