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
April 21, 2022
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:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2022
Observations: Licensing audited seven staff files. One staff files did not have a record of character references kept in respect of the employee.
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2022
Observations: Licensing audited seven staff files. Two staff files did not have a probationary performance reviews, as required by the policy.
3030 - RCR 83(5)(a)
Description: If a person in care refuses or is unable to be weighed, the licensee must record in the nutrition plan of the person in care the reason why the person in care was not weighed
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 5, 2022
Observations: Licensing reviewed four person in care's charts. It was indicated in one person in care's care plan to document the reason why the person in care was not weighed monthly. The reason why the person in care was not weighted, was not documented monthly in the weight record.
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: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2022
Observations: Licensing audited four persons in care's charts. Two charts did not have a record of immunization history.
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 5, 2022
Observations: Licensing reviewed four person in care's care plans. One person in care's care plan included the use of a restraint. The Director of Care stated the person in care no longer required the use of the restraint.