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
October 10, 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 that the facility is operated in a manner that will promote the health, safety and dignity of persons in care. Specifically, that all cleaning agents and chemicals are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 25, 2023
Observations: Licensing toured the facility and observed a chemical disinfectant not safely or securely stored in the tub room on the second floor.
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:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed that the rooms and common areas were maintained in a good state of repair.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3000 - RCR 62(4)
Description: A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Corrective Actions Required: Ensure that the menu is displayed in a prominent place in the dining room area for each weekly period.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 9, 2023
Observations: Licensing toured the facility and did not observe a menu displayed in a prominent place in the dining room area.
3000 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored,
Corrective Actions Required: Ensure that all medication in the facility are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 25, 2023
Observations: Licensing toured the facility and observed multiple medications not safely and securely stored in the bedrooms of persons in care.
3010 - RCR 40(1)(a)
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 continues to meet the requirements of this regulation,
Corrective Actions Required: Ensure that the performance of each employee is reviewed regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 25, 2023
Observations: Licensing audited six staff files and observed four staff did not have up to date performance reviews.
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 that 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: September 25, 2023
Observations: Licensing audited the medication administration record and observed one medication was not signed or coded for by staff on September 20, 22, and 24, 2023, and two medications were not signed or coded for by staff on September 23, 2023.
3070 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited six staff files and observed that all staff had up-to-date criminal record check results kept in their employee files.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure that records are kept in respect to compliance with the Province's tuberculosis control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 25, 2023
Observations: Licensing audited six staff files and observed that two staff files did not contain records of tuberculosis test results.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure that a pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 25, 2023
Observations: Licensing toured the facility and observed a medication in the bedroom of a person in care that did not have a prescription.
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 dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 25, 2023
Observations: Licensing audited the medication cart and observed one medication that expired in July 2023. Licensing toured the facility and observed one medication that expired in April 2022 in the bedroom of a person in care.