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
October 12, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 30, 2023
Observations: Licensing audited two staff files. One staff file did not have a record of character refences 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: 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 30, 2023
Observations: Licensing audited two staff files; one did not contain evidence of immunization records.
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: November 30, 2023
Observations: Licensing audited two staff files. One staff file did not contain an annual performance review. Last date of review was April 15, 2021. The Licensee contact stated it was company policy that performance reviews be completed at least annually.
3020 - RCR 74(1)(b)(i)
Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care,
Corrective Actions Required: Ensure there is an agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 25, 2023
Observations: Licensing audited two care files for persons in care. One care file included an order from an Occupational Therapist for a wheelchair lap belt restraint for the person in cares' safety. Licensing was unable to locate a written agreement from the person in cares' representatives for the use of the restraint.
3020 - RCR 74(1)(b)(ii)
Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.
Corrective Actions Required: Ensure that there is agreement to use a restraint given in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 25, 2023
Observations: Licensing audited two care files for persons in care. One care file included an order from an Occupational Therapist for a wheelchair lap belt restraint for the person in cares' safety. Licensing was unable to locate a written agreement from medical or nurse practitioner for the restraint.
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 all policies are and procedures are reviewed and, if necessary revised at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2023
Observations: Licensing audited the facility policies. All policies had not been reviewed or revised annually, some policies had a review date of 2016. Majority of policies had not been revised to reflect the facilities company name change.
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: October 15, 2023
Observations: Licensing audited two person in care's weight records. Both persons in care were missing weights for multiple months.
3080 - RCR 8(3)(a)
Description: If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must notify a medical health officer
Corrective Actions Required: Ensure if the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must notify a medical health officer.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 13, 2023
Observations: Licensing was made aware upon entry that the Manager had been away on a leave since June 2023 and the interim supervisor was off on a short term leave.