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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
VDAN-B942S2
FACILITY NAME
The Salvation Army Buchanan Lodge		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
2501002
FACILITY ADDRESS
409 Blair Ave		FACILITY PHONE
(604) 522-7033
CITY
New Westminster		POSTAL CODE
V3L 4A4		MANAGER
Blake Armstrong
INSPECTION DATE
February 04, 2019		ADDITIONAL INSP. DATE (multi-day)
February 07, 2019		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
9
ARRIVAL
09:30 AM		DEPARTURE
03:30 PM		ARRIVAL
11:45 AM		DEPARTURE
01:45 PM		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). 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
· 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 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 or
valerie.dairon@fraserhealth.ca
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: 31100 - RCR s.17 - A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Observation: water temperature in room 200 was noted to be 51 degrees Celsius while water in the south side of the building measured 40 degrees.
Corrective Action(s): Please provide a plan that will ensure that all areas for hot water distribution throughout the building to which PICs access do not exceed 49 Degrees Celsius
Date to be Corrected: Feb. 21, 2019

STAFFING: 32110 - RCR s.40(1)(b) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee (b) demonstrates the competence required for the duties to which the employee is assigned.
Observation: A record of review of the currency of performance reviews for staff in all departments was provided. Food services, dietary and laundry have recorded 0-10 percent staff performance reviews since 2015. Care staff P/A reviews show completion rates of 20-56% with the exception of LPN's who were reviewed at 125%. The facility policy indicates that yearly review is to be conducted at the discretion of the DRC.
Corrective Action(s): Please provide a plan of achievable/sustainable performance review intervals, and a plan to meet the policy objective for this year.
Date to be Corrected: Feb. 21, 2019

HYGIENE AND COMMUNICABLE DISEASE: 35030 - RCR s.54(1) - A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
Observation: Only one SPA/Tub room was inspected. There was a large multi-use pump container for shampoo, there was an unlabelled personal shampoo bottle wedged in the shower railing. Nail clippers though unlabelled were in a small drawer cabinet with the person and room labelled.
Corrective Action(s): Please ensure that personal use products are labelled with the PIC name, and that there is a system for using the multiple use products that will ensure that there is no opportunity for the pump to vector contamination.
Date to be Corrected: Feb. 21, 2019
Comments

There was a review of 3 staff files. Of staff who would normally be involved in assisting feeding residents, 2 did not show Food Safe training. In discussion with the HR staff there was uncertainty as to the direction for food safe training requirements for care staff.
ACTION: Please provide a plan that will determine whose duties require the training offered by food safe training, and respond to Licensing by Feb. 21, 2019.

In response to a question regarding ongoing education for food service staff RCR 87(d) The dietitian indicated that there was internal education taking place in several forms, but there is no good system of documenting staff attendance at inservices, one on one education or huddles. It appears that education is occurring, but documentation is not consistent.
ACTION: Please provide a plan that will allow attendance at internally provided education to be recorded for the staff who attend.

The dietitian stated that there is a system for monthly weights review for all PIC's and if the weight is missing, the dietitian follows up with staff.

The water temperature over 49.0 degrees celcius was investigated and the cause found and adjusted since the first inspection.

There were 7 firedrills conducted last year including one night drill. There was one earthquake drill conducted in October. There are written procedures for the less common drills. The Executive Director and the Manager of Support Services stated that discussions were taking place with relation to revising Policy and Procedure for Emergency drills to include the interval for emergency preparation training for staff.
ACTION: Please provide a plan that will indicate a policy that directs the emergency preparation for staff at this facility.

The Activity Coordinator was not available at this inspection. A discussion with the ED reviewed observations of the quantity and variety of activities available. This will be reviewed at the next Routine Inspection.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Feb 21, 2019
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.