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
September 12, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure the facility is operated in a manner that will promote the heath, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 14, 2022
Observations: Licensing toured all areas of the facility and observed two clean linen rooms that had unsecured chemicals.
3010 - RCR 37(1)(e)
Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure all employees have evidence of compliance with the Province's Immunization and TB policy.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 19, 2022
Observations: Licensing reviewed 15 staff files. Three of the files had signed the immunization information sheet, but had not ticked off the box to say if they had been immunized or not.
3010 - RCR 40(1)(b)
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 demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required: Ensure the performance of each employee is reviewed regularly to ensure the employee demonstrates the competence required for the duties assigned.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2023
Observations: Licensing reviewed 14 staff files. None of the files had current performance reviews completed.
Facility policy stated Performance reviews are done annually.
3010 - RCR 44(2)(a)
Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,
Corrective Actions Required: Ensure food services manager has a membership in the Canadian Society of Nutrition Management.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 19, 2022
Observations: Licensee stated they did not have a food services manager with membership in the Canadian Society of Nutrition Management.
3020 - RCR 74(1)(b)(ii)
Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.
Corrective Actions Required: Ensure restraint agreements are signed by the person in care's medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 19, 2022
Observations: Licensing reviewed 10 care plans. Two care plans had restraint agreements that had been signed by the Licensed Practical Nurse, who does not meet the definition of the medical practitioner or nurse practitioner for the person in care.
3050 - RCR 62(2)(a)
Description: A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada’s Food Guide,
Corrective Actions Required: Ensure cycle menu posted provides for a nutritious morning, noon and evening meal.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 19, 2022
Observations: Licensing toured facility and observed the cycle menu posted in dining room. The menu did not include breakfast.
3050 - RCR 62(2)(b)
Description: A licensee must ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada’s Food Guide,
Corrective Actions Required: Ensure that each menu provides for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: October 19, 2022
Observations: Licensing officers reviewed cycle menu posted in dining room. Menu did not include snacks.
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 care plans are reviewed and if necessary modified annually.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 19, 2022
Observations: Licensing reviewed 10 care plans. Three plans had not been updated in the past year.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure all medications are packaged by the pharmacist.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 19, 2022
Observations: Licensing toured facility medication rooms, and observed unlabeled Marijuana in one medication room. RN stated the Marijuana had been prescribed to a person in care, but had not been packaged by the pharmacist.