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
April 26, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2024
Observations: Licensing tested two sinks water temperature. The two sinks had water temperature readings of 56.0 degrees Celcius and 50.0 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. The Manager stated that they would contact maintenance on this date to correct the temperature on the hot water tank immediately. Full compliance will not be achieved until the plan has been implemented and completed.
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 and, if necessary, at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2024
Observations: Licensing audited the policies and procedures. The Manager stated some policies and procedures had not been reviewed within the last year.
3020 - RCR 85(2)(a.1)(i)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: if the licensee provides a type of care described as Substance Use, the monitoring of persons in care, including the use of electronic surveillance
Corrective Actions Required: Ensure that there are written policies and procedures in respect of the monitoring of persons in care, including the use of electronic surveillance.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2024
Observations: Licensing audited the policies and procedures. There was no policy regarding the monitoring of persons in care, including the use of electronic surveillance.
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 are written policies and procedures 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: May 15, 2024
Observations: Licensing audited the policies and procedures. There was no policy and procedure related to obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act.
3060 - DOLSOP (Outbreak Policies)
Description: Written policies and procedures for facility outbreak prevention and control
Corrective Actions Required: Ensure there are written policies and procedures for facility outbreak prevention and control.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2024
Observations: Licensing audited the policies and procedures. There was no policy related to facility outbreak prevention and control.
3070 - RCR 87(b)
Description: A licensee must keep a record of the following matters respecting food services menus and menu substitutions
Corrective Actions Required: Ensure that a record of menu substitutions is kept for the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2024
Observations: Licensing reviewed the menu and menu substitution record. The Manager stated there was no menu substitution record.