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
October 14, 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: Ensure 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 14, 2022
Observations: Licensing audited four staff files. All four staff files did not have a record of a recent performance evaluation.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure all person in care have a record of immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 28, 2022
Observations: Licensing audited charts of two persons in care. One person in care did not have a record of immunization status.
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 all person in care have a record of compliance with the Province's Tuberculosis control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 28, 2022
Observations: Licensing audited charts of two persons in care. One person in care did not have a record of compliance with the Province's Tuberculosis control program
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required: Ensure all person in care have a record of consent to admission.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 28, 2022
Observations: Licensing audited two person's in care charts. One person in care did not have a record of consent for the person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation.
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: Ensure all person in care have a record of consent to call a medical practitioner, nurse practitioner, or ambulance in the case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 28, 2022
Observations: Licensing audited charts for two persons in care. One person in care did not have a record of consent to call a medical practitioner, nurse practitioner, or ambulance in the case of accident or illness.
3080 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure the community care facility is operated in a manner that promotes the health, safety and dignity of person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 21, 2022
Observations: Licensing toured the facility and observed chemical cleaners out in the bathroom and accessible to person's in care.
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 a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2022
Observations: Licensing audited the medication room. One person in care's sterile water injection medication was expired in September 2022.