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
June 9, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 37(1)(e)
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: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that each employee has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 10, 2022
Observations: Licensing audited 5 staff files 3 files did not contain evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
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 that each employee is reviewed regularly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 10, 2022
Observations: Licensing audited five staff files. All staff files did not contain a performance evaluation completed within the last year as per facility policy.
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 that policies and procedures are reviewed at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 10, 2022
Observations: Licensing reviewed policy and procedure binders and observed the last date of review/revision was 2020.
3020 - RCR 85(2)(e)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: access to persons in care by persons who are not employees of the community care facility
Corrective Actions Required: Ensure that there is a policy and procedure in respect of access to persons in care by persons who are not employees of the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 10, 2022
Observations: Licensing reviewed policies and leadership could not locate the policy related to access to persons in care by persons who are not employees of the community care facility.
3020 - RCR 85(2)(f)(i)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: release of children, youths and vulnerable adults from the community care facility, including if a person who is authorized to remove the person in care from the community care facility appears to be incapable of providing safe care to the person in care,
Corrective Actions Required: Ensure that there is a policy and procedure in respect of release of children, youths and vulnerable adults from the community care facility, including if a person who is authorized to remove the person in care from the community care facility appears to be incapable of providing safe care to the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 10, 2022
Observations: Licensing reviewed policies and leadership could not locate the policy related to Release of children, youths and vulnerable adults from the community care facility, including if a person who is not authorized to remove the person in care from the community care facility requests the release of the person in care.
3020 - RCR 85(2)(m)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility.
Corrective Actions Required: Ensure that there is a policy and procedure in respect of obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 10, 2022
Observations: Licensing reviewed policies and procedures and leadership on site could not locate the policy pertaining to consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility.
3030 - 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: A Licensee must operate the community care facility in a manner that will promote the health, safety & dignity of persons in care. Specifically, that all cleaning materials are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2022
Observations: A Licensee must operate the community care facility in a manner that will promote the health, safety & dignity of persons in care. Specifically, that all cleaning materials are safely and securely stored.