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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
KBEL-CPQQXC

FACILITY NAME
Fraser Hope Lodge
SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962MY9
FACILITY ADDRESS
1275 7 Ave RR2
FACILITY PHONE
(604) 860-7706
CITY
Hope
POSTAL CODE
V0X 1L0
MANAGER
Sylta Hellner

INSPECTION DATE
March 07, 2023
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
7.25
ARRIVAL
09:30 AM
DEPARTURE
04:15 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

Community Care Facility Licensing (CCFL) monitors Hospital Act Facility (HAF) sites for compliance with the Community Care and Assisted Living Act (CCALA), Residential Care Regulation (RCR), and the
Director of Licensing Standards of Practice (DOLSOP). The CCALA and RCR serve as the minimum standards to which the HAF sites are measured against.

This routine inspection was conducted to assess compliance with the CCALA, RCR and the DOLSOP. Evidence for this report was based on the Licensing Officer's observations, review of records, and information provided by staff at the time of the inspection.

The following areas were reviewed:

- 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 operation.

For additional resources and links to legislation, please visit the Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XUHwhWyos2z

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

Observed Violations
STAFFING: 32100 - RCR s.40(1)(a) - A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection 40(2) to ensure that the employee (a) continues to meet the requirements of this regulation.
Observation: It was confirmed through discussion with staff that the performance of each employee had not been regularly reviewed. A plan to complete the outstanding reviews had been developed in response to Routine Inspection MMON-CC6QZR (March 2022) and has not yet been implemented in full.
Corrective Action(s): Please ensure that the performance of each employee is reviewed as planned.
Date to be Corrected: March 24, 2023

CARE AND/OR SUPERVISION: 34690 - RCR s.81(3)(e)(iii) - A care plan must include all of the following: (e) in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address (iii) a plan for following up on any falls suffered by a person in care.
Observation: The care plan for a person in care with a history of falls did not include a plan for following up on any falls they experienced.
Corrective Action(s): Please ensure that all fall prevention care plans include a plan for following up on any falls suffered by a person in care.
Date to be Corrected: March 23, 2023

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: The Immunization and Tuberculosis Screening forms for one person in care (PIC) had not been completed by staff, therefore it could not be confirmed the PIC complied with the Province's immunization and tuberculosis control program when they were admitted more than 12 months ago.
Corrective Action(s): Please ensure all PICs comply with the Province's immunization and tuberculosis control program.
Date to be Corrected: March 24, 2023


Comments

This report and risk assessment was written off-site as additional information was required after the inspection. The observations made were reviewed with the facility manager and staff prior to being provided the report and no signature was collected.

Action Required by Licensee/ManagerAction Required by Licensing Staff
No action requiredNo action required

Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.