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)
Non-Visit Follow-up
July 12, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required: Ensure a licensee must keep the following records in respect of each employee: character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 7, 2022
Observations: Licensing audited three staff files. Two staff files did not contain two character references.
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received a copy of employee character references.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 licensee must keep the following records in respect to each employee a record of any performance reviews .
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 7, 2022
Observations: Licensing audited three staff files. All three files were missing performance evaluations.
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:
Corrective Actions Taken By Licensee: Licensing received copies of employee performance reviews.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing received a copy of an email from the representative giving permission for restraints to be used on person in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 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: July 20, 2022
Observations: Licensing audited two persons in care's, care binders and observed one missing a consent form from parent or representative for use of restraints.
3020 - RCR 85(2)(b)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received a copy of the policy for Orientation of New Manager/ Employees.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3020 - RCR 85(2)(b)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act
Corrective Actions Required: Ensure a licensee must have written policies and procedures in respect of all of the following: the orientation of new managers and employees, including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 7, 2022
Observations: Licensing audited the policies and procedures manual. There was no written policy for the orientation of new managers and employees including orientation respecting the policies and procedures of the community care facility, the regulations and the Act.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure a licensee must require all persons admitted to a community care facility to comply 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 20, 2022
Observations: Licensing audited two persons in care's binders. One person in care's binder did not have immunization records.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received a copy of the immunization information for person in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 87(b)
Description: A licensee must keep a record of the following matters respecting food services menus and menu substitutions
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing received a copy of an Alternate Food Substitution Form.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 87(b)
Description: A licensee must keep a record of the following matters respecting food services menus and menu substitutions
Corrective Actions Required: Ensure a record of the following matters respecting food services menus and menu substitutions.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 20, 2022
Observations: Manager stated that there was no records for menu substitutions.