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)
Non-Visit Follow-up
October 31, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required: Ensure all furniture and equipment 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: November 3, 2022
Observations: Licensing toured the facility and observed two chairs in the foyer of the second floor with the material significantly peeling off.
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 common 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: November 3, 2022
Observations: Licensing toured the facility and observed drywall damaged in one person in care's room on the first floor.
3000 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored,
Corrective Actions Required: Ensure all medications are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing toured the facility and observed a prescribed medication left out in a person in care's bedroom on the first floor.
3010 - RCR 37(1)(b)
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: character references in respect of the person
Corrective Actions Required: Ensure all character references are obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing audited five staff files and observed one staff file did not have character references.
3010 - RCR 37(1)(c)
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:
a record of the person’s work history
Corrective Actions Required: Ensure record of work history obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing audited five staff files and observed one staff file did not have record of work history.
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 a record is kept of evidence of the employees compliance with the Provinces immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing audited five staff files and observed two staff file's did not have record of immunization.
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:
Corrective Actions Taken By Licensee: The Licensee of the facility emailed records of immunization for the two employee files that were missing.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 regular employee performance reviews completed to ensure they continue to meet the requirements of the RCR.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing audited five staff files and observed five staff file's did not have a current performance evaluation.
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 written policies and procedures in respect to obtaining consent in accordance with the Health Care (consent) and Care Facility (Admission) Act.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing audited the Policy and Procedures and observed a missing policy and procedure for obtaining consent in accordance with the Health Care (consent) and Care Facility (Admission) Act.
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 persons admitted comply with the Provinces immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 3, 2022
Observations: Licensing audited four person in care charts and observed one person in care did not have a record of tuberculosis.