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
January 4, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
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:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3060 - CCALA 7 (1)(b)(i)
Description: A Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Required: Ensure Covid-19 Policies and Public Health Orders are followed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 14, 2022
Observations: Licensing observed the staff room.
- There were personal items left behind on one of the tables - large bag of potato chips, bottle of hot sauce, and single use water bottle, which are personal items and shared condiment.
- There was no sign listing occupancy for the staff room. Staff are aware that there are only enough chairs for the number of persons permitted.
- There is no documentation regarding the cleaning of clinical equipment before/after use. It was reported to be usual practice, however no flow sheet to confirm the practice.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 81(3)(e)(iii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations: