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
September 14, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 37(1)(c)
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:
a record of the person’s work history
Corrective Actions Required: Ensure to keep a record of work history for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2023
Observations: Licensing audited three staff files. One staff file did not contain a record of work history.
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 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: October 14, 2023
Observations: Licensing audited the Medication Administration Records for three persons in care. The Licensee confirmed that all three persons in care had medication administered on September 13, 2023 and there were no signatures on the Medication Administration Records.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure a care plan includes oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2023
Observations: Licensing audited three person in care's care plans. One person in care's care plan did not include an oral health care plan.
3070 - RCR 81(3)(c)(i)
Description: A care plan must include all of the following: a nutrition plan that assesses a person in care’s nutrition status,
Corrective Actions Required: Ensure a care plan includes a nutrition care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2023
Observations: Licensing audited three person in care's care plans. One person in care's care plan did not include a nutrition care plan.
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 to keep criminal record checks for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2023
Observations: Licensing audited employee files. Two employee files did not contain up to date criminal record checks.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure to keep character references for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 14, 2023
Observations: Licensing audited three staff files. One staff file did not contain references for the employee.