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
March 22, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 37(1)(d)
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: copies of any diplomas, certificates or other evidence of the person’s training and skills
Corrective Actions Required: Ensure that a person employed in a community care facility has obtained a copy of evidence of diplomas and certificates as evidence of training and skills.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited 10 staff files and one staff file did not contain current copy of registration as Licensed Practical Nurse.
3010 - RCR 39(1)
Description: A licensee must not continue to employ a person in a community care facility who does not provide to the licensee evidence of continued compliance with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that a person who is employed in a community care facility provides evidence of compliance with the province's Tuberculosis and Immunization control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited ten staff files and two files did not contain TB test results, and one file did not contain immunization records.
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 that all staff files contain current performance reviews.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 22, 2023
Observations: Licensing audited ten staff files and eight were missing current performance reviews.
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 that all persons admitted to a community care facility provide a record of compliance with the province's tuberculosis and immunization control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited 11 files for persons in care and five files did not contain tuberculosis test results, and one file did not contain immunization records.
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required: Ensure that records are kept, for each person in care, be admitted and continue to be accommodated at a community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited 11 files for persons in care and one did not contain consent to care in a community care facility.
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: Ensure that each person in care's records contain consent to call an ambulance or medical practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited 11 files for persons in care and one did not contain consent to call an ambulance or medical practitioner.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure that care plans for persons in care contain a recreation and leisure plans.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2023
Observations: Licensing audited 11 files for persons in care and three did not contain recreation and leisure plans.