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
November 17, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: Follow Up Inspection to be conducted.
To Be Corrected By: December 17, 2022
Observations: Licensing audited four staff files and observed four performance reviews were dated December 2021, January 2019 and two were dated February 2022. The Licensee Contact stated the performance reviews were to be conducted quarterly, as per the policy.
3020 - RCR 74(1)(b)(i)
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 person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care,
Corrective Actions Required: Ensure if a person in care requires the use of a restraint, there is an agreement in writing, by the person in care, the parent or representative of the person in care, for the use of the restraint.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 17, 2022
Observations: Licensing audited two person in care's records. One person in care required the use of bed rails as a restraint and did not have an agreement to the use of the restraint, in writing, by the person in care, the parent or representative of the person in care.
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 if a person in care requires the use of a restraint, there is a signed agreement in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care, for the use of the restraint.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 17, 2022
Observations: Licensing audited two person in care's records. One person in care required the use of bedrails as a restraint and did not have a signed agreement in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care.
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required: Ensure policies are implemented by employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 17, 2022
Observations: Licensing observed person in care's archived personal files located in a closet, in an administrative area. The Manager stated the administrative area did not include a lock to secure the files. The Confidentiality Policy stated records had to be securely and safety stored, not in view.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure immunization records are 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: December 17, 2022
Observations: Licensing audited two person in care's records and observed one person in care did not have up to date records of immunization status.
3070 - RCR 81(3)(a)(iii)
Description: A care plan must include all of the following: a plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment
Corrective Actions Required: Ensure a care plan includes a plan to address the use of restraints.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 17, 2022
Observations: Licensing audited two person in care's care plans. One person in care required the use of bed rails, which was not addressed in the care plan.