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
January 21, 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 hot water does not exceed 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 24, 2022
Observations: Licensing tested the hot water in two persons in care's room. One reading was 56 degrees Celsius, the other was 58 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A plan for corrective action was received while on site. The maintenance staff called the plumber to adjust the hot water tanks. Full compliance will not be achieved until the plan has been implemented and completed.
3010 - RCR 37(1)(a)
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: a criminal record check for the person
Corrective Actions Required: Ensure that all staff have a current criminal record check on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 15, 2022
Observations: Licensing reviewed 20 staff files. Two staff files did not contain current criminal record checks.
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 staff receive a performance review on a regular basis.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 15, 2022
Observations: Licensing reviewed 20 staff files. Six staff files did not contain a performance review within the past 2 years.
3070 - RCR 78(1)(a)
Description: A licensee must keep, for each person in care, a record showing the following information: name, sex, date of birth, medical insurance plan number and immunization status
Corrective Actions Required: Ensure that all care records contain the immunization status for persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 15, 2022
Observations: Licensing audited 13 care records. Six files did not contain the immunization status for persons in care.
3070 - RCR 82
Description: A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Corrective Actions Required: Ensure that the care provided is consistent with the terms and conditions in the person in care's care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 15, 2022
Observations: Licensing reviewed 13 care records. One person in care had monitoring of a restraint indicated in the care plan and staff had not documented the restraint checks.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure that a pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 15, 2022
Observations: Licensing audited two medication rooms. One over the counter medication was found for a person in care with no pharmacy label.