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
January 28, 2025
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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: February 28, 2025
Observations: Licensing audited three person in care's Medication Administration Records (MARs). All three person in care's MARs had multiple dates and medications not signed and/or coded for by staff.
3010 - RCR 86(d)
Description: A licensee must keep the following records in respect of each employee: (d) a record of any performance reviews made under section 40 [continuing monitoring of employees] and any attendance at continuing education programs.
Corrective Actions Required: Ensure that a record of any performance reviews are kept in respect of each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2025
Observations: Licensing audited four employee files. Four employee files did not have a record of a performance review. The Manager stated they were working on obtaining and organizing staff files.
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: Ensure that each person in care is weighed at least once a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 28, 2025
Observations: Licensing audited three person in care's weight records. Three person in care's records did not include a weight record for June 2024, and one did not include a record for May 2024.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure that character references are kept in respect of each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 28, 2025
Observations: Licensing audited four employee files. Two employees did not have any character references in respect of the employee.