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
March 23, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: Ensure all rooms and commons areas are maintained and in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing toured the facility and observed the railings going upstairs to be significantly scuffed up with paint chipping.
3010 - CCALA 7(1)(d)
Description: A licensee must appoint a manager for the community care facility
Corrective Actions Required: Ensure that a manager is appointed to the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 13, 2023
Observations: On January 12, 2023 Licensing was made aware that the manager of the facility was on an leave of absence with no expected return date. Licensing exchanged communication with the Coordinator of the facility and the Licensee contact on January 12, 20, and 23, 2023 and February 6, 10, 17, and 22, 2023 regarding the manager being absent from the facility for more than 30 days and on February 22, 2023 requested confirmation to place the Licence under review with no confirmation having been received at time of inspection.
3020 - RCR 85(1)(c)(ii)
Description: A licensee must do all of the following: make all policies and procedures available to a medical health officer on request
Corrective Actions Required: Ensure all policies and procedures are available to a medical health officer on request.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 24, 2023
Observations: Licensing was not provided access to policies as there was no management present at the time of the inspection
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: Ensure that all person in care admitted to the community care facility comply with the Province's immunization and tuberculosis control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited the charts of two person in care. One person in care did not have a record of TB.
3070 - RCR 81(3)(a)(ii)
Description: A care plan must include all of the following: a plan to address behavioural intervention, if applicable
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the care plan's of two person in care and both care plans had a plan for behaviour intervention when applicable.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure all persons in care have a care plan that includes an oral care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited the care plan's of two person in care. One person in care did not include an oral health plan.
3070 - RCR 81(3)(c)(i)
Description: A care plan must include all of the following: a nutrition plan that assesses a person in care’s nutrition status,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the care plan's of two person in care and both care plans had a plan for nutrition.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the care plan's of two person in care and both care plans had a plan for recreation and leisure.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure that each person in care is weighed at least once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited the charts of two person in care and there was no record of weights in the person in care charts.
3080 - RCR 11(1)(b)
Description: A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility the most recent routine inspection record made under section 9 (1) (d) of the Act.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed the last routine inspection displayed.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3080 - RCR 68(2)(b)
Description: A licensee must appoint a supervising pharmacist to inspect the areas of the facility where medications will be stored
Corrective Actions Required: Ensure that the supervising pharmacist inspects medication storage area.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2023
Observations: Licensing audited the medication room and requested to see the last pharmacy inspection. There was no record available of the last pharmacy inspection.
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: Ensure that person in care's medication is returned to the dispensing pharmacy if the expiry date of the medication had passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 24, 2023
Observations: Licensing audited the medication cart and observed a medication card in the narcotics lox box that was expired January 2023.