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
April 19, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 37(1)(a)
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 criminal record check for the person
Corrective Actions Required: Ensure that all staff have valid criminal record checks.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 24, 2024
Observations: Licensing reviewed five staff files and one staff file had an expired criminal record check.
3010 - RCR 40(1)(b)
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 demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required: 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 demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 19, 2024
Observations: Licensing reviewed five staff files. Two staff had no record of a performance review conducted.
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 all 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: May 19, 2024
Observations: Licensing reviewed policies and procedures. The last review for all policies and procedures was between 2019 and 2021.
3070 - RCR 78(1)(a)
Description: A licensee must keep, for each person in care, a record showing the following information: name, sex, date of birth, medical insurance plan number and immunization status
Corrective Actions Required: Ensure that for each person in care, there is a record showing the following information: name, sex, date of birth, medical insurance plan number and immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 19, 2024
Observations: Licensing reviewed eight person in cares files. Eight files were missing immunization records.
3070 - RCR 81(3)(a)(iii)
Description: A care plan must include all of the following: a plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment
Corrective Actions Required: Ensure that if a person in care has a restraint, that they have a care plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 19, 2024
Observations: Licensing reviewed eight person in care's care plans who had an environmental restraint. All eight care plans did not include the use of an environmental restraint.
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care
Corrective Actions Required: Ensure that in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, they have a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 19, 2024
Observations: Licensing reviewed eight person in care's care plans. Five person in care's care plans did not include a follow up on any falls suffered by persons in care.
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required: Ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 19, 2024
Observations: Licensing reviewed eight person in care's care plans. Four care plans had not been reviewed in the last year.