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)
Follow-Up
October 26, 2021
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - 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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3010 - 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:
Corrective Actions Taken By Licensee: Licensing audited ten employee files and all files had a record of a tuberculosis test.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3020 - RCR 51(1)(b)
Description: A licensee must have a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3020 - RCR 51(1)(b)
Description: A licensee must have a plan that sets out how persons in care will continue to be cared for in the event of an emergency.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing reviewed one person in care's care plan which had been updated to include the level of elopement risk for the person in care. Manager indicated elopement checks were documented every shift as indicated in the care plan. Licensing audited the documented checks and observed all staff initials completed for October 2021.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 82
Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 82
Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing to audited eight person in care's weights from July to October 2021. All weights had been documented for persons in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3080 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations: