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
June 15, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 that all rooms and common areas are maintained 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: July 7, 2023
Observations: Licensing audited seven bedrooms of person's in care. One bedroom had a screen removed from the window. One bedroom had significant damage to the baseboards from an electric wheelchair.
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 that 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: July 7, 2023
Observations: Licensing audited ten employee files. Two employee's did not have a record of any character references checked. Seven employee records only had one character reference checked.
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 that each employee has complied with the Province's immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 7, 2023
Observations: Licensing audited ten employee files. Four files were missing records of TB. Seven files were missing records of immunizations.
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required: Ensure that all employees comply with the policy and procedures of the medication safety and advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 14, 2023
Observations: Licensing audited the bedrooms of four person in care on the second floor and observed multiple medications in three bedrooms not labelled by the pharmacy. Licensing audited the Medication Administration Records and observed medications not signed or coded for on May 31 and June 2, 2023. Licensing audited the Narcotic Count Record and observed the second staff signature missing on May 25.
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure the criminal record check records are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 7, 2023
Observations: Licensing audited ten employee files. One employee did not have a criminal record check.
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 each person in care has a record of the following: (b) in the case of an adult, the consent for that person in care to be admitted or to continue to be accomodated 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.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 7, 2023
Observations: Licensing audited the records of seven person in care. One person in care had consent to admission signed by the person in care's daughter, when the person in care was deemed capable. One person in care did not have a record of consent to admission.
3070 - RCR 77.1(1)(c)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: each assessment report, if any, provided under section 22 (1) (c) of the Health Care Consent Regulation.
Corrective Actions Required: Ensure a record is kept for each person in care, of each assessment report, if any, provided under Section 22(1)(c) of the Health Care Consent Regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 7, 2023
Observations: Licensing audited the records of seven person in care. Three person in care who were deemed incapable, did not have a incapability assessment completed.
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 care plans include a fall prevention plan which must address a plan for following up to falls suffered.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 7, 2023
Observations: Licensing audited seven person's in care's care plan. Three person in care who were prone to falling did not have a plan to follow up to falls suffered.
3080 - 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:
Corrective Actions Taken By Licensee: Licensing audited five bedrooms of person in care and found no chemicals or cleaning agents.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3080 - 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: Licensing audited five bedrooms of person in care and found all medication 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:
Observations:
3080 - RCR 72(b)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited the medication room and observed medications that had expired were in a return to pharmacy bin. Licensing audited five bedrooms of person in care and observed no expired medication.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: