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
January 17, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(c)
Description: A licensee must ensure that all rooms and common areas are maintained in a safe and clean condition.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed the person in care's bathroom floor on the lower floor was clean and dry.
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:
Corrective Actions Taken By Licensee: Licensing audited three staff files all of who had a performance review conducted in 2021/2022.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the Medication Safety and Advisory Committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 9, 2022
Observations: Licensing audited the Medication Administration Record. Two persons in care did not have medications signed for or coded by staff on December 6, 2022.
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure that all staff have a current criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 23, 2022
Observations: Licensing audited four staff files. One staff's criminal record check expired in July 2022.
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 three staff files. All staff had a record of immunization.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3030 - RCR 81(1)
Description: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited one person in care's care plan, who was admitted to the facility in October 2022, who had a comprehensive care plan.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure that there are clear and up to date records of immunization 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 9, 2023
Observations: Licensing audited four person in care's charts. One person in care did not have a record of immunization status.
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:
Corrective Actions Taken By Licensee: Licensing audited three person in care's charts. All persons in care had consent in writing to call medical/nurse practitioner or ambulance in case of accident or illness.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 each year to ensure it still meets the need 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 16, 2022
Observations: Licensing audited four person in care's care plans which were last reviewed in 2019/2020.
3080 - RCR 72(b)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the medication cart and cupboard. All medication were within their expiry date.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3090 - RCR 55(1)(a)(i)
Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care
Corrective Actions Required: Ensure that there is an ongoing plan of physical, social and recreational activities suitable to the needs of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 23, 2022
Observations: Licensing audited the facility recreational calendar for December 2022. There was not a full calendar of ongoing planned activities.