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
December 5, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required: Ensure policies are implemented by employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 5, 2023
Observations: Licensing audited the narcotic counts and observed narcotics were not counted on November 13, 14 and Dec 4, 2022. The narcotic count policy stated it was required to be counted once per shift. The Manager stated they were in the process of discussing the counts with the pharmacy.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure clear and up to date records of immunization status is 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: January 5, 2023
Observations: Licensing audited three person in care's records and observed one person in care did not have records of immunization status kept.
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 comply with the Province's immunization and tuberculosis programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 5, 2023
Observations: Licensing audited three person in care's records. One person in care did not have documentation that they complied with the tuberculosis control program.
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 each person in care has consent in writing from the person in care or 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 5, 2023
Observations: Licensing audited three person in care's charts. One person in care did not have consent in writing from the person in care or parent or representative of the person in care, to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness.
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 health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 5, 2023
Observations: Licensing audited three person in care's care plans and observed one person in care did not have an oral health care plan.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure each care plan includes a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 5, 2023
Observations: Licensing audited three person in care's care plans and observed two care plans did not have a recreation and leisure plan.
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: 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 a plan for following up on any falls suffered by a person in care
Corrective Actions Required: Ensure that a care plan includes a fall prevention plan, that addresses a plan for following up on any falls suffered by a person in care, who is identified as prone to falling.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 5, 2023
Observations: Licensing audited three person in care's care plans. One care plan did not include a plan for following up on any falls suffered by a person in care, identified as prone to falling.
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required: Ensure that each care plan is reviewed, and if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 5, 2022
Observations: Licensing audited three person in care's care plans and observed one care plan was dated April 2022.