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
August 31, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that water accessible to persons in care in not heated to more than 49° Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 4, 2022
Observations: On March 4, 2022 Licensing tested three sources of water accessible to persons in care and two temperatures were 57° Celsius and 56.5° Celsius, respectively. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately The Director of Care stated that that Maintenance Person would immediately correct the water temperature. Full compliance will not be achieved until the plan has been implemented and completed.
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 current criminal record check for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 7, 2022
Observations: Licensing audited 20 staff files and four were missing current Criminal Record Checks.
3010 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure for each employee compliance 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: April 7, 2022
Observations: Licensing audited 20 staff files and two tuberculosis tests were missing and two immunization status files were missing.
3010 - RCR 86(d)
Description: A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Corrective Actions Required: Ensure for each employee performance reviews are completed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 7, 2022
Observations: Licensing audited 20 staff files and all were missing current performance evaluations. The policy stated that reviews occurred within the probationary period and then every two years.
3030 - 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 inspected the facility. All staff were observed wearing masks appropriately.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited 12 files for persons in care and all had required Consent to Care documentation.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3090 - 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 inspected the facility. All staff wore masks appropriately.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: