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
December 16, 2021
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: Ensure that all policies and procedures are reviewed or revised at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 16, 2022
Observations: Licensing audited the policy and procedures. Three policies were dated 2020 and one policy was dated 2019 for the review dates.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure that there are clear & up to date records of immunization status for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 16, 2022
Observations: Licensing audited eight person in care's files. One person in care's file did not have a record of immunization.
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 that all persons in care admitted to the facility 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: January 16, 2022
Observations: Licensing audited eight person in care's files. Three persons in care did not have a record of a Tuberculosis test or chest x-ray.
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required: Ensure that if a person in care is identified as a risk of leaving the facility without notifying an employee, a plan includes how to locate a person in care if they left the facility without notifying an employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 16, 2022
Observations: Licensing audited eight person in care's care plans on this date. One care plan did not have a plan on how to locate a person in care if they left the facility without notifying an employee.