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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

VDAN-B8Q28B

FACILITY NAME Fair Haven Burnaby Lodge		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # 3200045
FACILITY ADDRESS 7557 Sussex Ave			FACILITY PHONE (604) 435-0525
CITY Burnaby	POSTAL CODE V5J 3V6		MANAGER Lynda Ells

INSPECTION DATE January 22, 2019	ADDITIONAL INSP. DATE (multi-day) January 23, 2019		ADDITIONAL INSP. DATE (multi-day) January 24, 2019		TIME SPENT (HRS.) 10
ARRIVAL 12:30 PM	DEPARTURE 04:30 PM	ARRIVAL 09:00 AM	DEPARTURE 12:45 PM	ARRIVAL 09:00 AM	DEPARTURE 10:15 AM
INSPECTION TYPE Routine					# OBSERVED IN CARE

Introduction

A scheduled 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). Evidence for 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 (deferred) · Polices & Procedures (deferred) · 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 www.fraserhealth.ca/residentialcare for: · Additional resources and · Links to the Legislation (CCALA & RCR) If you have any questions regarding this report feel free to contact me at 604 918 7526

Contraventions

Previous Inspection -

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

Observed Violations

PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31320 - RCR s.22(3) - A licensee must ensure that all rooms and common areas, emergency exits, equipment, and monitoring and signalling devices are inspected and maintained on a regular basis. Observation: A small fridge was observed in a PIC room. There were 2 sealed beverage bottles inside. The temperature was warm and there was an unpleasant odor from the interior. No food was present. Corrective Action(s): Please ensure that there is a plan for a system in place for the safe management of fridges brought in by families. Date to be Corrected: Feb. 6, 2019 POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: Review of MAR for PRN's demonstrated one instance in 1 unit where 2 PRNs were not signed for 'effect' in addition to a MAR where Jan. 22, 2019 medication administration was not sined for 0700 and 1200 doses. Corrective Action(s): Please ensure there is a system in place that will ensure that policies are implemented Date to be Corrected: Feb. 6, 2019 HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs. Observation: Of 2 care plans reviewed 1 did not have evidence of status of immunization and TB Corrective Action(s): Please provide a plan that will ensure that all PICs who have been admitted to the facility have evidence of compliance with the provincial TB and immunization program. Date to be Corrected: Feb. 6, 2019

Comments

This is a scheduled inspection for the purpose of meeting the manager and discussing/reviewing the role of licensing in the facility. A routine inspection followed the Licensing review. For this inspection, neither the Staff Records nor the Policy and Procedures were reviewed. This facility has recently completed accreditation and there has been a change in leadership. The preliminary meeting covered the topic of performance reviews for staff and the status of the Policies and Procedures since the Accreditation Canada review. The Staff Records and the Policies and Procedures will be reviewed at a Follow-up inspection. The facility has recently survived a power outage due to electrical storm with mobilization of the Facility Emergency Response Plan. The power outage lasted approx. 8 hours, and staff report that other than needing to waste some food previously thawed, all went well. Based on observations at this inspection it appears that the planning to address contraventions from the previous Routine Inspection have been sustained. All staff were very helpful with the completion of this inspection. I would like to thank the staff and the residents who participated for their assistance.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	Follow-up Inspection Required
Due Date Feb 06, 2019	Approximate Follow Up Date

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