Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
Routine
March 29, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 40(1)(a)
Description: 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 continues to meet the requirements of this regulation,
Corrective Actions Required: Ensure that that the performance of each employee is reviewed regularly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited three staff files and one staff file had a performance review dated September 2020. The facility's policy was to conduct performance reviews annually.
3020 - RCR 85(3)
Description: A licensee must keep a copy of each policy and procedure of the medication safety and advisory committee.
Corrective Actions Required: Ensure a copy the policy and procedure established by the medication safety and advisory committee is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing reviewed the facility's policy and procedure manual which did not include a policy and procedure as established by the medication safety and advisory committee.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure there is clear up to date records of immunization status kept for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s records and one person in care did not have a record of immunization history.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s records and one person in care’s records did not include evidence of a tuberculosis screening.
3070 - RCR 78(3)(a)
Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,
Corrective Actions Required: Ensure there consent in writing from the person in care’s representative to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s records and two person in care’s records did not include consent in writing to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
3070 - RCR 81(3)(a)(ii)
Description: A care plan must include all of the following: a plan to address behavioural intervention, if applicable
Corrective Actions Required: Ensure a care plan includes a behavioural intervention plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s care plans and one person in care’s care plan did not include a behavioural intervention plan.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure a care plan includes an oral care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s care plans and two person in care’s care plan did not include an oral care plan.
3070 - RCR 81(3)(c)(i)
Description: A care plan must include all of the following: a nutrition plan that assesses a person in care’s nutrition status,
Corrective Actions Required: Ensure a care plan includes a nutritional care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s care plans and two person in care’s care plan did not include a nutritional care plan.
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure that persons in care are weighted monthly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s record and two persons in care had no weight records.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure that character references are kept in respect of each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited three staff files and one staff files did not have a record of references in respect of the employee.
3070 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure that records are kept in respect of each employee complying with the Province’s immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited three staff files and three staff files did not have a record of immunization history in respect of the employee.
3080 - CCALA 7(1)(c.1)(i)
Description: A licensee must display the rights of adult persons in care in a prominent place in the community care facility
Corrective Actions Required: Ensure the Rights of Adult Persons in Care is posted in a prominent location.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing toured the facility and did not observe the Rights of Adult Persons in Care posted.
3080 - RCR 69(2)
Description: A licensee must ensure that, except as authorized by the medication safety and advisory committee, a person in care’s medications remain in the original labelled container or package provided by the dispensing pharmacy until administered.
Corrective Actions Required: Ensure that a person in care's medications remain in the original labelled container or package provided by the dispensing pharmacy until administered.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 12, 2022
Observations: Licensing audited two person in care’s medications. One person in care’s medications had a pill fall out of the secure packaging.