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
August 30, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure the community care facility is operated in a manner that promotes the health, safety, and dignity of persons in care. Specifically, that cleaning agents are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 30, 2023
Observations: Licensing toured the facility and observed an unlocked cabinet, that had signage nearby stating the cabinet had to be locked, with cleaning agents accessible to persons in care.
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 30, 2023
Observations: Licensing toured the facility and observed floor damage near the kitchen.
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required: Ensure that a record of character references are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 30, 2023
Observations: Licensing audited three staff files and observed that one staff was missing one character reference, and another staff was missing both character references.
3020 - RCR 23(3)(a)
Description: A licensee must make a policy respecting all of the following the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises
Corrective Actions Required: Ensure that a policy is made respecting the engagement by persons in care in restricted activities, other than the consumption of medical cannabis on the premise.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 30, 2023
Observations: Licensing was informed that there was no current policy respecting persons in care engaging in non-medical use of cannabis on the premise.
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 policies and procedures are reviewed and if necessary, 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: October 30, 2023
Observations: Licensing observed that the policies were not revised in the past year.
3020 - RCR 85(2)(d)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following:how persons in care, their parents or representatives and contact persons may express concerns, make complaints and resolve disputes under section 60 [dispute resolution]
Corrective Actions Required: Ensure there is a written policy and procedure in place in respect of how persons in care, their parents or representatives, and contact persons may express concerns, make complaints and resolve disputes.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 30, 2023
Observations: Licensing audited the policies and procedures and did not observe a policy related to how persons in care, their parents or representatives, and contact persons may express concerns, make complaints and resolve disputes.
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 that that there is a written policy and procedure related to obtaining consent before admitting a person in care to the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 30, 2023
Observations: Licensing audited the policies and procedures and did not observe a written policy related to obtaining consent before admitting a person in care to the facility.
3050 - RCR 62(1)(b)
Description: A licensee must ensure that a menu, made in accordance with this section, is developed in any other case, for at least each 4 week period.
Corrective Actions Required: Ensure that a menu, made in accordance with this section, is developed for at least a four week period.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2023
Observations: Licensing was informed by the Manager that a menu had not been developed for at least each four week period.
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: 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 13, 2023
Observations: This contravention was carried over from the Routine Inspection dated December 9, 2022. On this date Licensing audited four care plans for persons in care and observed three care plans had not been reviewed in the last year.
3070 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure that criminal record check results are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 30, 2023
Observations: This contravention was carried over from the Routine Inspection dated December 9, 2022. On this date Licensing audited three staff files and observed that two staff had expired criminal record checks.
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 that records are kept respecting food service menus and menu substitutions.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 16, 2023
Observations: The Manager stated that there was not a current record kept of menu substitutions.
3080 - RCR 72(b)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Required: Ensure that a person in care's medication is returned to the pharmacy if the expiry date of the medication has passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 30, 2023
Observations: Licensing audited the medications of persons in care and observed a medication that had expired in February 2023.