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
April 23, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: Ensure employee files contain a record of the employees work history.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 23, 2024
Observations: Licensing audited four employee files and two employee files did not have a record of work history.
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required: Ensure all employee's have a record of character references kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 23, 2024
Observations: Licensing audited four employee files and two employee files did not contain a record of character references.
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: Ensure a record of compliance with the Province's immunization and tuberculosis control program is kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 23, 2024
Observations: Licensing audited the four employee files and three employee files were missing a record of immunization and one employee file was missing a record of TB.
3020 - RCR 85(1)(b)
Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year
Corrective Actions Required: Ensure all policies and procedures are reviewed at least each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 23, 2024
Observations: Licensing audited the policies and procedures manual and observed several policies had not been reviewed in the last year.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure a care plan includes a plan for recreation and leisure.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 23, 2024
Observations: Licensing audited the care plans of two persons in care and both care plan were missing a plan for recreation and leisure.
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 to circumstance of the persons 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 subject of the care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 23, 2024
Observations: Licensing audited the care plans of two person in care and the nutrition plan for both person in care had not been reviewed since 2022.