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
May 30, 2024
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 the community care facility is operated in a manner that will ensure the health, safety, and dignity of persons in care; specifically related to the storage of chemicals and cleaning agents.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 30, 2024
Observations: Licensing toured the facility and observed nail polish remover in the bathroom of a person in care, as well as chemicals and cleaning agents that were accessible to persons in care.
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: Ensure that all rooms and common areas are maintained in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: This contravention was carried over from Routine Inspection dated August 30, 2023. On this date, Licensing toured the facility and observed floor damage throughout the facility, a clogged sink in the bedroom of a person in care, and a rusty shower curtain rod in a bathroom.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: Licensing audited three staff files and observed that two staff had their performance last reviewed in 2019, and one staff did not have a record of any performance reviews.
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure that each employee has a criminal record check.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: This contravention was carried over from Routine Inspection dated December 9, 2022. On this date, Licensing audited three staff files and observed that all of the staff did not have up-to-date Criminal Record Check results kept on-file.
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required: Ensure that a record of character references are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: This contravention was carried over from Routine Inspection dated August 30, 2023. On this date, Licensing audited three staff files, and observed that one staff did not have any character references kept on file, and one staff was missing one character reference.
3020 - RCR 23(3)(a)
Description: A licensee must make a policy respecting all of the following the engagement by persons in care in restricted activities, other than the consumption of medical cannabis, on the premises
Corrective Actions Required: Ensure that a policy is made respecting the engagement by persons in care in restricted activities, other than the consumption of medical cannabis on the premise.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: This contravention was carried over from Routine Inspection dated August 30, 2023. On this date, Licensing was informed that the policy was still in process of being created.
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: Ensure that policies and procedures are reviewed and if necessary, revised at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: This contravention was carried over from Routine Inspection dated August 30, 2023. On this date, Licensing was informed that the policies were still in process of being reviewed.
3020 - RCR 85(2)(m)
Description: Without limiting subsection (1) (a), a licensee must have written policies and procedures in respect of all of the following: obtaining consent, in accordance with Part 3 of the Health Care (Consent) and Care Facility (Admission) Act, before admitting an adult to the community care facility.
Corrective Actions Required: Ensure that there is a written policy and procedure related to obtaining consent before admitting a person in care to the facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: This contravention was carried over from Routine Inspection dated August 30, 2023. On this date, Licensing was informed that the creation of this policy was still in process.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure that a care plan includes an oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: Licensing audited the care plans for three persons in care and observed that one person in care did not have an oral health care plan.
3070 - RCR 81(3)(e)(ii)
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 preventing the person in care from falling
Corrective Actions Required: Ensure that if a person in care is deemed at risk for falling, that there is a fall prevention plan included in their care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: Licensing audited the care plans of three persons in care and observed that one person in care, who was deemed at risk for falling, did not have a fall prevention plan included in their care plan.
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: Ensure that if a person in care is deemed at risk for falling, that there is a plan addressing follow-up to falls suffered included in the care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: Licensing audited the care plans of three persons in care and observed that one person in care, who was deemed at risk for falling, did not have a plan addressing follow-up to any falls suffered included in their care plan.
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required: Ensure that each care plan is reviewed and, if necessary, modified each year to ensure it still meets the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: Licensing audited three care plans for persons in care, and observed that two care plans were last reviewed in January 2023, and one care plan was last reviewed in December 2022.
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 of the medication has passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 30, 2024
Observations: This contravention was carried over from Routine Inspection dated August 30, 2023. On this date, Licensing audited the medications for persons in care, and observed a roll of PRN (as needed) medications that had expired in September 2023.