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

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CRAU-BLXRCE
FACILITY NAME
Peace Arch Hospital ECU		SERVICE TYPES
401 Long Term Care (Hospital Act)
FACILITY LICENSE #
LBAA-962LQ8
FACILITY ADDRESS
15521 Russell Ave		FACILITY PHONE
(604) 541-5841
CITY
White Rock		POSTAL CODE
V4B 2R4		MANAGER
Karen Donaldson / Kashmiro Kainth
INSPECTION DATE
February 11, 2020		ADDITIONAL INSP. DATE (multi-day)
February 20, 2020		ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4.5
ARRIVAL
01:15 PM		DEPARTURE
05:00 PM		ARRIVAL
08:45 AM		DEPARTURE
09:30 AM		ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine		# OBSERVED IN CARE
229
Introduction

This is a unscheduled routine inspection conducted with the Managers of both buildings (Weatherby and Dr. Al Hogg Pavilions) to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.) and the relevant Director of Licensing Standards of Practice (D.L.S.P.). 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 the inspection.

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 operation.

Visit the Community Care Facilities Licensing website at https://www.fraserhealth.ca/health-topics-a-to-z/long-term-care-licensing#.XUHwhWyos2z for:

- Additional resources, and
- Links to the legislation (C.C.A.L.A. and R.C.R.).
Contraventions
Previous Inspection - Not Applicable
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: A random review of the hot water temperatures at the ensuite washroom sinks were as follows:

-> 49.2 degrees Celsius,
-> 50.9 degrees Celsius, and
-> 52.5 degrees Celsius

On February 12, 2020 the Manager touched base with the Chief Engineer to turn down the hot water temperature and the hot water temperature will be rechecked by the Manager with the Chief Engineer.
Corrective Action(s): Please ensure water accessible to a person in care from any source is not heated to more than 49 degrees Celsius.
Date to be Corrected: Please correct immediately and Manager addressed this on February 12, 2020.

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: In review of the care planning system, the oral/dental care plan for a person in care was not in-place and the Residential Care Coordinator stated this would be looked into.
Corrective Action(s): Please ensure all persons in care have a oral care plan in-place.
Date to be Corrected: Please provide a written response to this item by the timeline noted in this report.
Comments

Care and Supervision:
- A review of the care planning system indicated for a person in care their height on admission was not noted on the monthly weight, blood pressure and pulse sheet. In discussion with the Residential Care Coordinator the height on admission was noted on the MDS document. The Residential Care Coordinator will reinforce documenting the height on admission on the move in interview.
- In review of the care planning system indicated care planning is done differently floor to floor (e.g., one floor has printed care plans with all the relevant required items such as oral/dental, health, recreational and nutritional care plans), however on a different floor the different components are present, but not on a printed care plan. Recommendation to please ensure care planning is done consistently and the systems are similar to ensure consistency in care.
- In review of the care planning system, for a person in care the Residential Care Coordinator will look into how the short term care plan carries over to the ongoing care plan. Please let the writer know the outcome of this once looked into.
Medications:
- A random review of the medication systems indicated overall charting was thoroughly completed however there was one entry for a PRN (as needed) that had no result noted. Given overall the system appeared to be thorough, this was not made a contravention and that this would be reinforced with the care staff by the Residential Care Coordinator.
Physical Plant:
- A random review of the physical plant indicated there is a wooden pole placed in the front of the Dr. Al Hogg Pavilion building before entering the building. The Manager followed-up on this on February 12, 2020 and the wooden pole was put up on err on the side of caution due to the recent snowfall. The Manager stated further on February 12, 2020 that an outside contractor will be coming on-site shortly to address this and repair any cracks that may have been caused.
Thank you for your time to complete this routine inspection report. If there are any questions, please contact your assigned Licensing Officer.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingFollow-up Inspection Required
Due Date
Feb 27, 2020		Approximate Follow Up Date
31 Mar, 2020
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.