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
May 1, 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 that 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 1, 2024
Observations: Licensing audited two staff files. One staff file did not have a record of character refences checked.
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: 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 1, 2024
Observations: Licensing audited two staff files; one did not contain evidence of immunization records.
3010 - RCR 40(1)(b)
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 demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed a performance evaluation, dated in February 2024, for the staff member who had been missing one.
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 an 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: June 1, 2024
Observations: Licensing audited two care files for persons in care. One care file included an order from an Occupational Therapist for a wheelchair lap belt restraint for the person in cares' safety. Licensing was unable to locate a written agreement from the person in cares' representatives for the use of the restraint.
3020 - RCR 74(1)(b)(ii)
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 medical practitioner or nurse practitioner responsible for the health of the person in care.
Corrective Actions Required: Ensure that there is agreement to use a restraint given in writing by the medical practitioner or nurse practitioner responsible for the health of the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 1, 2024
Observations: Licensing audited two care files for persons in care. One care file included an order from an Occupational Therapist for a wheelchair lap belt restraint for the person in cares' safety. Licensing was unable to locate a written agreement from medical or nurse practitioner for the restraint.
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: Licensing reviewed the policy manual. Policies were last reviewed in November and December of 2023.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited weight records of two persons in care. Both persons in care had monthly weights recorded.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3080 - RCR 8(3)(a)
Description: If the manager of a community care facility resigns, or is or expects to be absent for at least 30 consecutive days, the licensee must notify a medical health officer
Corrective Actions Required:
Corrective Actions Taken By Licensee: The manager, who has been in place since August 2023, was placed on the facility licence as the Manager in February 2024.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: