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Community Care Facilities Licensing FACILITY INSPECTION REPORT HEALTH & SAFETY

KBOI-AFHRFT

FACILITY NAME Kiwanis Care Centre		SERVICE TYPES 130 Long Term Care	FACILITY LICENSE # 2501021
FACILITY ADDRESS 35 Clute St			FACILITY PHONE (604) 525-6471
CITY New Westminster	POSTAL CODE V3L 1Z5		MANAGER Lorrie Gerrard

INSPECTION DATE October 31, 2016	ADDITIONAL INSP. DATE (multi-day) November 08, 2016		ADDITIONAL INSP. DATE (multi-day)		TIME SPENT (HRS.) 5.25
ARRIVAL 09:30 AM	DEPARTURE 12:30 PM	ARRIVAL 10:15 AM	DEPARTURE 12:30 PM	ARRIVAL	DEPARTURE
INSPECTION TYPE Routine					# CHILDREN ENROLLED

Introduction

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (CCALA), the Residential Care Regulations (RCR) and the relevant Director of Licensing Standards of Practice (DLSP). 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 inspection was completed over two days for the availability of the DOC. The following areas were reviewed: · Licensing · Physical Facility · Staffing · Policies and Procedures · Care and Supervision · Hygiene and Communicable Disease Control · Medication · Nutrition and Food Services · Program · Records and Reporting As part of this 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 operations. Visit the CCFL website at www.fraserhealth.ca/your_environment/ccfl for: · Additional resources, and · Links to the Legislation (CCALA and RCR) If you have any questions or concerns regarding this report, please contact me at 604-949-7730, or email, kara.bonkowski@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

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: 1/5 care plans reviewed did not include an oral health care plan Corrective Action(s): Ensure all care plans include oral health care plans Date to be Corrected: December 15, 2016 HYGIENE AND COMMUNICABLE DISEASE: 35040 - RCR s.63(1) - A licensee must ensure that all food is safely prepared, stored, served and handled. Observation: Containers with pureed food for PIC's to take with medication is kept in two containers in the medication fridge but not labelled with contents and date Corrective Action(s): Ensure all food is safely stored Date to be Corrected: November 30, 2016

Comments

The tray service policy reviewed (RC:IV-40) mentions the requirement of a physician to review every 30 days. This can be updated to reflect the new Residential Care Regulations that states that a Nurse Practitioner or Dietician can also sign off on the 30 day tray service review. Thank you to the ED, DOC and staff at Kiwanis for their assistance during the two days of the inspection.

Action Required by Licensee/Manager	Action Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to Licensing	No action required
Due Date Nov 22, 2016

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