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
November 14, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed that the two chairs in the foyer of the second floor had been replaced.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed the drywall repaired in the person in care's bedroom on the first floor.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - 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: Licensing toured the facility and audited three person in care's bedroom and observed no prescribed medication left in any of the bedrooms.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 37(1)(b)
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: character references in respect of the person
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed character references had been obtained for the staff member missing character references.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 37(1)(c)
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:
a record of the person’s work history
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed a record of work history had been obtained for the staff file missing a record of work history.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited three staff files and observed all had record of immunization.
Actions Required By Licensing: No further action required; this contravention has been addressed.
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: Ensure regular employee performance reviews completed to ensure they continue to meet the requirements of the RCR.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing audited five staff files and observed five staff file's did not have a current performance evaluation.
3020 - RCR 85(2)(m)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed a policy and procedure for obtaining consent in accordance with the Health Care (consent) and Care Facility (Admission) Act.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited two person in care charts and observed all person in care had a record of tuberculosis.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: