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
August 5, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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: Ensure all chemicals are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: August 5, 2022
Observations: Licensing observed chemicals in a laundry area accessible to persons in care. Lock was added to the storage cupboard and laundry chemical stored securely at the time of visit.
3010 - DOLSOP (Prevent Overdose Deaths)
Description: Staff Trained Ensure that trained staff are available to administer Naloxone to persons in care when persons in care are on the premises of the licensed facility or away from the premises and remain under the care of facility staff.
Corrective Actions Required: Ensure that a supply of Naloxone is maintained and that trained staff are available to administer Naloxone to persons in care who are prescribed an opioid.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing noted one person in care is prescribed an opioid. No Naloxone kit on site and no staff trained to administer.
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 employees performance is reviewed regularly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing audited five out of ten staff files. One file did not contain a performance review in the past 1 year.
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: November 6, 2022
Observations: Licensing reviewed policy and procedure binders and with the exception of two policies - the majority had not been reviewed in the last year.
3030 - RCR 83(5)(a)
Description: If a person in care refuses or is unable to be weighed, the licensee must record in the nutrition plan of the person in care the reason why the person in care was not weighed
Corrective Actions Required: Ensure that each person in care is weighed at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing audited two care files. Two persons in care did not have monthly weights on file.
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure that each person in care is weighed at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 6, 2022
Observations: Licensing audited two care files. Two person in care did not have monthly weights on file.