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
February 28, 2024
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 character references are obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2024
Observations: Licensing audited three employee files. Two employee files did not contain record of character references.
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: Ensure a record of compliance with the Province's immunization and TB control programs is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2024
Observations: Licensing audited three employee files. Two employee files did not contain a record of immunization. One employee file did not contain a record of TB results.
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:
Corrective Actions Taken By Licensee: On February 27, 2024, Licensing received two recent employee performance evaluations and the Manager confirmed that one employee had been employed for under a year and had not yet received an evaluation.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required: Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2024
Observations: Licensing audited the medication administration record of three persons in care. On multiple dates in February 2024, medications were not signed for or coded by staff for two persons in care.
3020 - RCR 85(2)(m)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility.
Corrective Actions Required: Ensure there is a written policy regarding obtaining consent in accordance with the Health Care Consent and Care Facility Admission Act.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 24, 2024
Observations: Licensing audited the policies and procedures and there was no written policy regarding obtaining consent in accordance with the Health Care Consent and Care Facility Admission Act.
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: Ensure that for each person in care, a record is kept showing 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2024
Observations: Licensing audited the charts of three persons in care. Two persons in care did not have a record of consent to be admitted or to continue to be accommodated in the community care facility.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure the care plan for each person in care includes a plan for recreation and leisure.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2024
Observations: Licensing audited the care plan of three persons in care. Two persons in care did not have a plan for recreation and leisure.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure the pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2024
Observations: Licensing audited the medication room and observed four contingency medications that were not labelled by the pharmacy.