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
October 27, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited all person in care's Medication Administration Records, dated October 7 to 27, 2025 and all medication had been signed and/or coded for by staff.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 that policies are implemented by employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 7, 2025
Observations: Licensing audited two staff performance reviews. One staff file did not have a performance review on file, and one staff file had a performance review last completed April 2023. The Licensee Contact stated the policy indicated performance reviews were conducted at minimum once every two years.
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:
Corrective Actions Taken By Licensee: Licensing audited one person in care's records which included consent in writing, from the person in care, to call a medical practitioner, nurse practitioner or ambulance in case of accident of illness.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited the medication cabinet and observed all medication had been returned to the dispensing pharmacy if the expiry date had passed.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: