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
February 29, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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:
Corrective Actions Taken By Licensee: Licensing reviewed facilities policy and procedure manual, which was last reviewed in 2023.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3030 - RCR 83(4)(b)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing reviewed the referral process for the Dietician who will be on site to complete an assessment of a person in care on March 7, 2024.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(3)(c)(i)
Description: A care plan must include all of the following: a nutrition plan that assesses a person in care’s nutrition status,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing reviewed two person in care's care plans. Both care plans contained nutrition care plans.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing reviewed two care plans and both plans have been updated with modified changes.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing reviewed care plans for two persons in care and both care plans were reviewed in February 2024.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 per month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 26, 2024
Observations: Licensing reviewed the weights of five persons in care. Weights had not been recorded monthly.