WorkSafeBC-2010-2012-Maples

7/29/2019 WorkSafeBC-2010-2012-Maples

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Obtained by Bob Mackin via Freedom of Information

[email protected]

twitter.com/bobmackin


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*The Time Recorded reflects only that time which has been charged to this inspection up until the document was printed for delivery.

Subsequent time may be added for additional activity related to this inspection.

11 - 50

Number ofWorkers

ProjectNumber

Lab SamplesTaken

DirectReadings

ResultsPresented

N N N2010/11/09

Head Office Job Site

PROVINCIAL GOVERNMENT

WORKERS' COMPENSATION PROGRAMS BC PUBLIC SERVICE A

PO BOX 9404 STN PROV GOVT

VICTORIA

BC V8W9V1

Maples Adolescent Centre

3405 Willingdon Ave

BC

Crossroads Program

PortionInspected

Violations

ETS exposure

REFER TO ORDERS ON FOLLOWING PAGE(S)

Employer Representative Name Accompanied by Employer Representative

Employer Representative Position Accompanied by Worker Representative

Phone Number Organization

Signature Officer of the Board / Signature

Roy Lucken

Shift Supervisor

Ray Lucken

BCGEU(604) 660-5864

STEVENSON, JOHN

Site Visit Date Sampling Inspection(s)

Burnaby

For Internal Use Only

Delivery Method: EmailDiscussed at site with workers and delivered via e-mail to program

coordinator------------------------------------------------------------

WORKERS' COMPENSATION BOARD6951 Westminster Highway, Richmond, BC

Mailing Address: PO Box 5350, Vancouver BC, V6B 5L5

Telephone 604 276-3100 Toll Free 1-888-621-7233 Fax 604 276-3247

OF BRITISHCOLUMBIA

An employer who fails to comply with the Occupational Health & Safety Regulation or Board orders or directions is subject to sanctionsas prescribed in the Workers Compensation Act.

The Occupational Health & Safety Regulation requires that one copy of this report remain posted in a conspicuous place at or near theoperation inspected for at least seven days, or until compliance has been achieved, whichever is the longer period.

in writing, request the Review Division of the WCB to conduct a review of an order, or the non-issuance of an order, in this report bycontacting the Review Division at the Board's Richmond Office. The time limit may be extended in certain circumstances. Employers

requiring assistance can contact the Employers' Advisers at 1-800-925-2233--workers can contact the Workers' Advisers at 1-800-663-4261.

INSPECTION REPORTWORKER AND EMPLOYER

SERVICES DIVISION

220100708900822010/11/16 4000 294 841102 1.506.25

Date of Issue Number Number of Orders

Employer Location ClassificationUnit Number

Activity TimeRecorded*

Travel TimeRecorded*

An affected employer, worker, owner, supplier, union or member of a deceased worker's family may, within 90 calendar days of this report,

52B17 (R05/2007) 2012/11/08 08:18Printed: Page 1 of 4

section 22

section 22


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OF BRITISHCOLUMBIA






SERVICES DIVISION

220100708900822010/11/16 4000 294 841102 1.506.25






Inspection Text

Comments issued on: Dec 06, 2010Conversations with the program coordinator suggest that compliance will be

achieved, since the outdoor (but enclosed) court has been closed totobacco

consumption, and the employer stated that control measures will be

instituted in other areas on site where ETS exposure remains, includingfinalizing a NoC.

A review of the order cited in this inspection report has determined thatfurther enforcement action is not necessary at this time. This decisionrelates only to this inspection date, location and order(s) noted on this

inspection report. A follow-up inspection will occur and a Notice ofCompliance document is required to authenticate compliance with the

order(s) noted.Issued on: 2010/11/16

To site per action request AR 2010-017487. Caller concerned about

unresolved issue of routine exposure of workers to environmental tobacco

smoke (ETS) from resident adolescents. Issue has been discussed with BCGEUand is estimated to be outstanding for 5+ years. Exposures occur underseveral circumstances:

- residents using a secured outdoor courtyard (covered on three sides and

overhead by building structure and chain-link fenced on the open face).The access door is occasionally left open permitting easy infiltration of

the ETS to the building interior and prevailing wind direction mayexacerbate this. In addition, direct supervision of the adolescents may

also occur- entering a resident room during and/or soon after smoking (prohibited)

has occurred- re-entrainment of ETS due to smoking near cottage door with nearby air

intakes

The ETS exposure history and profile was discussed with several workers atthe site and confirmed. All workers expressed an interest in an effectiveprohibition or appropriate safe outdoor location that would permit

management of resident flight risk. The OHSR guideline G4.81 and 4.82details compliance considerations and scenarios to facilitate

interpretation of the OHSR. Applicable sections include:

Employer Representative Officer of the Board

Roy Lucken STEVENSON, JOHN



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OF BRITISHCOLUMBIA






SERVICES DIVISION

220100708900822010/11/16 4000 294 841102 1.506.25






- restricted smoking within 3 meters from a doorway, window or air intake- the existing courtyard is 'substantially enclosed' (see definition) and

therefore unsuitable as an outdoor smoking area

Orders

Decision OHS4.81WCB ReferenceOrder No. A1

Workers are exposed to environmental tobacco smoke from resident youth at

this facility on a routine basis and this is acknowledged to have been anunresolved issue at this site for at least several years. See 'inspection

text' notes. The employer has not controlled the exposure of workers toenvironmental tobacco smoke by

(a) prohibiting smoking in the workplace, or(b) restricting smoking to a safe outdoor location that is a minimum of 3

metres from a doorway, window or air intake of an indoor workplace

This is in contravention of the Occupational Health and Safety RegulationSection 4.81.

The employer must control the exposure of workers at any workplace toenvironmental tobacco smoke by(a) prohibiting smoking in the workplace,

(b) restricting smoking to a safe outdoor location that is a minimum of 3metres from a doorway, window or air intake of an indoor workplace,

subject to section 4.22 (3) of the Tobacco Control Regulation, B.C. Reg.232/2007, and

(c) prohibiting working in an indoor area where smoking is allowed undersection 4.23 (2) (a) or (b) of the Tobacco Control Regulation, except aspermitted in section 4.82 of this regulation.

Decision WCA194.(1)WCB ReferenceOrder No. A2

You are required to notify the board in writing by 'Notice of Compliance'

(NoC) stating the steps to be taken to correct the deficiencies cited inorder no.1.

Per Workers' Compensation Act (WCA) s. 194(1), 194(2)(a) and 194(4)(d),





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OF BRITISHCOLUMBIA






SERVICES DIVISION

220100708900822010/11/16 4000 294 841102 1.506.25






e NoC mus nc u e an ac on p an w mp emen a on sc e u e an esent to J. Stevenson by December 10, 2010, using either e-mail at

[email protected], fax at 604.232.5950 or mail:

Workers' Compensation Board of BCWorker and Employer Services Division

Burnaby Work Center450 - 6450 Roberts Street

Burnaby BC, V5G 4E1





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11 - 50

Number ofWorkers

ProjectNumber

Lab SamplesTaken

DirectReadings

ResultsPresented

N N N2011/02/25





VICTORIA

BC V8W9V1


3405 Willingdon A ve

BC

Crossroads Program

PortionInspected

Violations

Follow-up to NoC re: ETS






Roy Lucken

Shift Supervisor

Roy Lucken

BCGEU(604) 660-5864

STEVENSON, JOHN


Burnaby


Delivery Method: EmailDiscussed at site with all parties

------------------------------------------------------------

WORKERS' COMPENSATION BOARD6951 Westminster Highway, Richmond , BC



OF BRITISHCOLUMBIA

An employer who fails to comply with the Occ upational Healt h & Safety Regu lat ion or Board orders or di rections is subject to sanctionsas prescribed in the Workers Compensation Act.



requiring assistance can c ontact t he Employers' Advis ers at 1-800-925-2233--workers can co ntact t he Workers' A dvisers at 1-800-663-4261.


SERVICES DIVISION

220110708900062011/02/28 4000 294 841102 0.751.25





An affected employer, worker, own er, suppl ier , union or member of a deceased wo rker's fami ly m ay, within 90 calendar days of this report ,


section 22


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OF BRITISHCOLUMBIA






SERVICES DIVISION

220110708900062011/02/28 4000 294 841102 0.751.25






Inspection Text

Issued on: 2011/02/28

This was a follow-up inspection to authenticate appropriate compliance

with the order(s) noted.

Orders

Decision OHS4.81WCB ReferenceOrder No. C1

THIS IS A FOLLOW UP TO INSPECTION 2010070890082 ORDER 1.

Order no. 1 of IR 2010070890082 has been complied with.

Continue to ensure per OHSR s. 4.81 that the employer controls the

exposure of workers to environmental tobacco smoke by

(a) prohibiting smoking in the workplace, or

(b) restricting smoking to a safe outdoor location that is a minimum of 3

metres from a doorway, window or air intake of an indoor workplace

Decision WCA194.(1)WCB ReferenceOrder No. C2



The notice-of-compliance (NoC) was received by e-mail on 2010-12-15 and

stated that the smoking prohibition zone was to include at least 3 meters

distance from:

- all enclosed or substantialy enclosed areas such as porches and alcoves

of any of the buildings on site as well as the 'cage'

- the entire perimeter of the individual building envelopes to ensure that

re-entrainment of ETS into any roof-mounted air intakes near the building

perimeter walls does not occur





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11 - 50

Number ofWorkers

ProjectNumber

Lab SamplesTaken

DirectReadings

ResultsPresented

N N N2011/02/25





VICTORIA

BC V8W9V1



BC

Crossroads Program

PortionInspected

Violations

Violence in the Work place (VitW)






Tom Jensen

Manager of Treatment Services

Tom Jensen

BCNU(604) 660-5810

STEVENSON, JOHN


Burnaby


Delivery Method: In Personand Ken Moore also present

------------------------------------------------------------




OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900052011/03/21 4000 294 841102 6.5042.50







section 22

section 22


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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900052011/03/21 4000 294 841102 6.5042.50






Inspection Text

Comments issued on: May 13, 2011

A review of the order(s) cited in this inspection report has determined

that further enforcement action is not necessary at this time. This

decision relates only to this inspection date, location and order(s) noted

on this inspection report. A follow-up inspection will occur and a Notice

of Compliance document was required to authenticate compliance with the

order(s) noted.

The NoC was received on 2011-04-14, reviewed and noted as acceptable on

2011-04-26.

Issued on: 2011/03/21

Reviewed FirmFile history on 2011-02-24. To site on 2011-02-25 re: action

request AR 2011-002161 generated by a BCNU regional safety advocate, that

violence related incidents are not sufficiently explored, documented or

communicated and that actions arising from them are inadequate. It was

stated that there are unresolved issues re: insufficient risk reduction to

minimize violence in the workplace, particularly with staff in the

Crossroads program, but also Response.

The WSBC inspection process was discussed with several line staff from

BCGEU and UPN as well as the management team and a request for documents;

i.e., incident investigations, joint safety committee minutes and access

to policy and procedures was initiated on 2011-03-01 to clarify the issues

and establish the extent of any deficiencies. On 2011-03-04, a meeting

with the nursing supervisor to discuss the care model and to review

documentation occurred. Subsequent meetings on 2011-03-07 with the manager

of response services and on 03-08 with the BCNU site representative were

convened to review findings.

History of violence and context

The action request highlighted several violent incidents last year between

residents and/or resident to staff, as well as ongoing risk associatedwith conveying youth to events in vehicles.

The nursing supervisor provided a data dump from the CARIS system of the

2010 incident reports. An overview report analyzes the data by type; e.g.,

danger to self and/or other (72), medical (51), property (31), restraint

(31), other (31), illegal substance (25), injury (25) etc. There is

overlap of these categories. Injuries to staff and residents are further


Tom Jensen STEVENSON, JOHN



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OF BRITISHCOLUMBIA






SERVICES DIVISION

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analyzed as to cause and it is stated that 22 incidents resulted in 26

staff injuries. Of the 26 worker injuries, 8 required time off for 1+

days. In the past 10+ years, staff injuries have declined but the data has

not been rate adjusted nor analyzed by gender. The decline has been

attributed in part to the introduction of the attachment care model

philosophy. This data was further summarized by the manager of treatment

services into an annual behaviour management report that featured an

overview analysis of physical intervention, restraints and/or seclusion of

clients by program type. These interactions have a higher likelihood ofresulting in injury to staff.

It was stated by management and confirmed by line workers that all current

staff have NVCI training. Training inadequacies may occur in the summer

months when casuals make up a higher percentage of the workforce.

The incident investigation process was described by the nursing supervisor

and confirmed by the manager of response services. A form package example

was reviewed. The incident investigation packages (about 30) for all

reported injuries last year were provided and a sample of incidents

affecting members from each of the three major unions were reviewed. Of 12

incidents reviewed, half involved violence and of those, none had the

PSC38 form completed, which is MCFD's root cause analysis form designed toexplore contributory factors and report recommendations to reduce

likelihood of recurrence. It was stated by the manager charged with

oversight for this process that at best, only 10-15 percent of all of the

packages had a completed PSC38.

The nursing supervisor, a member of the progressive quality improvement

team, provided resident behaviour log case notes for the violence related

packages. Although not identified as a part of the current investigation

review process documents, the case notes are integral to an understanding

of antecedent events and must be a routine part of the investigation

process for violence-related incidents.

The joint safety committee met eight (8) times last year and minutes for

the following months were unavailable; 2010-03, 04, 06, 08. The followingpoints are noted:

- the format does not differentiate old from new business, nor provide

effective tracking of outstanding items with a date identifiable tracking

number

- no date for actionable items

- no times noted re: meeting start/finish





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OF BRITISHCOLUMBIA






SERVICES DIVISION

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- no significant participation from either BCNU or UPN (UPN attended one

meeting in 2010-07)

- no detail re: incident investigation findings so of limited or no value

to readers outside of meeting participants.

Considerations and outstanding issues

- essential to provide adequate information re: triggers to violent

behaviour and the approaches to avoid triggering the behaviour- behaviour trend tracking of high risk youth

- consideration for FIPPA confidentiality requirements

- some incidents investigated on an informal basis

- effective documented behaviour logging can be challenging because of

computer access availability while undertaking routine youth care

responsibilities particularly at shift change

- instances where youth have distracted and/or injured the driver when

being transported in a vehicle

- policy and procedures must be reviewed to ensure they provide adequate

direction re: actionable outcomes designed to minimize risk

- consideration of pre-cursor events prior to the administration of

medication to facilitate regaining control

- recognition that individual line workers with different risk tolerancefor violence or abusive behaviour (intentional or otherwise), will not

self-report the same way unless the process and reporting criteria is

clear and is supported by effective supervision

Incident investigations and violence prevention program review

WSBC's OHSR s. 4.27 - 4.31 and the associated policy items R4.28-1 - R4.

31-

1 link the violence incident investigation process to the general accident

investigation process. Completion of the investigation report must include

an exploration of contributing factors, recommendations to prevent

recurrence, an action plan and communication. See WCA s. 173(1)(b-d),

174(2)(a-c), 175(2)(a-b), and 176(1)(2)(a-b). As this is a joint

management/worker investigation, every effort must be made to ensure thatthe affected worker(s) is/are the first choice as the worker

representative(s), and that the process be initiated promptly to ensure

effective recollection. The investigation of violence-related incidents

must also include those incidents with the potential for serious injury

and not just time-loss incidents.

Per OHSR policy R4.29-2, the program must be reviewed annually. WCA s.





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SERVICES DIVISION

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115(1-2), OHSR s. 3.10 and 4.28(2)(a) collectively require the employer to

reduce risk and once a hazard is identified to take corrective actions

without delay, including necessarily, the updating of behaviour and safety

plans to mitigate risk.

Copies of OHSR policy R4.28-1 - R4.31-1 provided.

Orders

Decision OHS4.28.(1)WCB ReferenceOrder No. A1

It was acknowledged that a site-wide formalized and documented violence in

the workplace risk assessment has not been undertaken for some time. A

large number of violence-related incidents have not been adequately

investigated to MCFD standards and are contrary to WSBC requirements. Line

staff in this youth forensic facility report varying degrees of risk

perception, due in part to factors of physical size and gender, but also

to prior workplace experiences and the associated tolerance for violence

risk in those environments. Several line staff expressed frustration with

delays in the implementation of a revised call alert system for backup

assistance and could not readily locate emergency call numbers. See'inspection text' notes.

A risk assessment has not been performed in a workplace in which a risk of

injury to workers from violence arising out of their employment may be

present.

This is in contravention of the Occupational Health and Safety Regulation

Section 4.28(1).

A risk assessment must be performed in any workplace in which a risk of

injury to workers from violence arising out of their employment may be

present.

The employer is directed to review:

- existing policy and procedures re: measures to eliminate or reduce staff

exposure to violence risk

- delays in the implementation of a revised emergency backup call system

- objective comparison of the existing backup system vs alternatives with

evidence of reviews of systems in similar risk environments

- the contribution of experience, education, training and supervision to





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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900052011/03/21 4000 294 841102 6.5042.50






incident response outcomes

- the incident report form package instructions for continuity with MCFD

policy and WSBC mandated investigation actions

- supplementary instruction to update documents that may require amendment

after analysis of an incident reports; e.g., behaviour logs, safety plans,

communication logs to ensure timely and effective risk control

communication

- the incident report follow-up actions section to determine if corrective

actions were taken and by whom- consider amendments and/or add-on fields to the CARIS system to better

capture root cause analysis and the tracking of recommendations arising

and to communicate same to the safety committee

- worker survey re: program implementation and violence risk perception

- any other relevant documents, procedures, practice methods, service

delivery care models, etc. that might inform the risk assessment process

and to develop an action plan from the risk assessment which will address

per OHSR s. 4.29(a)(b), procedures, policies and work environment

arrangements to eliminate the risk to workers from violence or if that is

not possible, minimize the risk.


A sample (12) of incident investigation reports involving workers from

each of the three major unions were reviewed. Half of those involved

violence and none had the ministry-wide investigation form (PSC38)

completed. It was acknowledged that only 10-15 percent of the incidents

resulting in injury last year (22+) had a completed form. See 'inspection

text' notes.

For those violence-related incidents reviewed, cause is frequently

ascribed to assault, but the investigations do not thoroughly identify

unsafe conditions, acts or procedures that may have contributed to the

incident, nor recommend corrective action to prevent similar incidents.

This is in contravention of the Workers Compensation Act Section 174 (2).

As far as possible, the investigation must:

(a) determine the cause or causes of the incident,

(b) identify any unsafe conditions, acts or procedures that contributed in





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SERVICES DIVISION

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any manner to the incident, and

(c) if unsafe conditions, acts or procedures are identified, recommend

corrective action to prevent similar incidents.

In addition, ensure that all workplace related incidents with the

potential for causing serious injury are investigated per requirements of

WCA s. 173(1)(c).

Decision WCA125WCB ReferenceOrder No. A3

The joint safety committee met eight (8) times last year, minutes for the

following months were unavailable; 2010-03, 04, 06, 08 and it was

acknowledged that meetings had not occurred in those months. Workers from

two unions (BCNU and UPN) providing direct care to youth (and subject to

significant violence risk) were not effectively represented on the

committee. See 'inspection text' notes.

The employer has not maintained a joint health and safety committee in

each workplace where 20 or more workers of the employer are regularlyemployed, and in any other workplace for which a joint committee is

required by order.

This is in contravention of the Workers Compensation Act Section 125.

An employer must establish and maintain a joint health and safety

committee:

(a) in each workplace where 20 or more workers of the employer are

regularly employed, and

(b) in any other workplace for which a joint committee is required by

order.


You are required to notify the board in writing by 'Notice of Compliance'

(NoC) stating the steps to be taken to correct the deficiencies cited in

order no.s 1-3 inclusive.





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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900052011/03/21 4000 294 841102 6.5042.50






Per Workers' Compensation Act (WCA) s. 194(1), 194(2)(a) and 194(4)(d),

the NoC must include an action plan with an implementation schedule and be

sent to J. Stevenson by April 15, 2011, using either e-mail at

[email protected], fax at 604.232.5950 or mail:

Workers' Compensation Board of BC

Worker and Employer Services Division

Burnaby Work Center450 - 6450 Roberts Street

Burnaby BC, V5G 4E1





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Employer Jobsite

ID: 4000

Name:

Address:

City:

Province:

Postal Code:

Location:

CU: 841102

294

V8W9V1

BCVICTORIA


WORKERS' COMPENSATIONPROGRAMS BC PUBLIC SERVICE A

PROVINCIAL GOVERNMENT Name:

Address:

City:

Province:

Project:

BC

Burnaby

3405 Willingdon Ave

Crossroads Program


Latitude:

Longitude:

Details

Employer Representative Consulted:Ken Moore

Phone Number: (604) 660-5811

Consultation Date: 2011/04/26

Response

Site Visit:

Addi tional Employers :

Regulations

Regulat ion Regulat ion Tex tWCA 194.(1) You are required to notify the Board, in writing, of the

steps to be taken to correct the contraventions cited that

require a 'Notice of Compliance' [Decision Code will contain

the letter N].

The Notice of Compliance shall be delivered to the nearest

Board office by month, day, year.

This order includes a requirement for a compliance report in

accordance with WCA section 194(1).

Text


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Admin Details

Activity: 1.25 Travel: Activity Type: Contact

Hours

WCB Project:

Officer Details

Name: STEVENSON, JOHN Role: PRIMARY ROLE

Related Documents:

Type: IR Number2011070890005 Issue Date: 2011/03/21

Triggered By:

Internal

Referrals:

For Internal Use Only:

Issued on: 2011/04/26

Memo to capture the employer NoC dated 2011-04-14. See attachments and

comments below provided to firm via e-mail on 2011-04-26:

I have reviewed the NoC and you and the team have prepared an excellent

response that will guide the process ahead. I'll be frank. This level of

detail is most unusual (and refreshing) compared with the majority of

responses that we see,

.

I think some challenge may lie with the analysis of near-misses and the

process that you establish, but you have a team consensus on this so lets

see how it plays out. I'll be interested in the final risk assessment toolthat you choose and whether you modify any of the survey questions as

noted in the initial e-mail of 2011-03-31 accompanying the inspection

report. WCA s. 194.(1) refers.

The following cover e-mail is associated with the NoC.

Pursuant to your Inspection Report 2011070890005, please find attached a

Notice of Compliance letter and an action plan with an implementation

schedule. I hope these are acceptable as they stand but, of course, we

stand ready for any queries or direction.

Once we receive notice that the plan is acceptable we will post it at the

workplace.

Ken Moore

Director, The Maples Adolescent Treatment Centre

Office 604.660.5811

Mobile section 22

section 22

section 22


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Employer Jobsite

ID: 4000

Name:

Address:

City:

Province:

Postal Code:

Location:

CU: 841102

294

V8W9V1

BCVICTORIA




Address:

City:

Province:

Project:

BC

Residence

Latitude:

Longitude:

Details

Employer Representative Consulted:

Phone Number:


Response

Site Visit: Activity occurred during core hours.


Text

Admin Details

Activity: 11.75 Travel: 3.50 Activity Type: Contact

Hours

WCB Project:

Officer Details


Related Documents:

Type: IR Number2011070890005 Issue Date: 2011/03/21

Triggered By:

section 22

section 22

section 22

section 22

section 22


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Internal

Referrals:


20/38


Issued on: 2011/09/20

Met with claimant to discuss recent assault involving three workers that

occurred on 2011-09-13 at 1420h. The PSC38 and a memo authored on 2011-09-

15 by the coordinator of response services to at BCNU providing

context and additional detail re: the incident precursors and the planned

follow-up actions and these documents were reviewed with the claimant.

We discussed the additional content in the memo vs the PSC38 and it wasstated that the PSC38 did capture the essential content and would be

intelligible to a JOHSCtte member charged with reviewing an AI related to

a VitW incident.

In the approximately years that the resident has been associated with

the Crossroads program at Maples, the resident has been involved in

significant assaultive behaviour, the most recent previous assault

occurring on 2011-05-16 which resulted in three injured female workers.

Subsequent to the event and arising out of discussion in the JOHSCtte, the

firm agreed to a trial of an additional communication tool; i.e., a 2-way

radio. It was stated that on the day of the most recent incident the 2-way

radio was inoperative, though it is doubtful that it's presence would have

altered outcomes.

the attachment model used to manage this resident

has placed HCWs at excessive risk because it doesn't provide effective

controls. it permits too wide a range of resident

privileges that are subject to individual risk tolerance

. Further, it sets up

expectations with the resident that may not be deliverable on a given

shift because of the shift staff profile, and this in turn raises

frustration, volatility, unpredicability and VitW risk.

The claimant notes the following additional recommendations or comments:

-

During the course of the interview, we also discussed the status of the

VitW risk assessment process as ordered in IR 2011070890005. We reviewed

the employer's NoC submitted on 2011-04-26 for status of the projectedwork tasks and the anticipated completion dates.

The CCC is conducting a monthly review of SSs weekly report summaries and

this data is reviewed by the JOHSCtte and it was stated that this has

resulted in changes to the youth management plans.

It was also stated that the airing court has again been used as a secure

location for resident smoking on at least one occasion and HCWs have

expressed concern to management re: ETS exposure and are seeking a

permanent resolution to this problem.

section 22

s. 22

section 22

section 22

section 22

section 22

section 22


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Employer Jobsite

ID: 4000

Name:

Address:

City:

Province:

Postal Code:

Location:

CU: 841102

294

V8W9V1

BCVICTORIA




Address:

City:

Province:

Project:

BC

Burnaby

3405 Willingdon Ave

Crossroads Program


Latitude:

Longitude:

Details

Employer Representative Consulted:Andy MacDonald

Phone Number: (604) 660-5813


Response

Site Visit: Activity occurred during core hours.


Regulations

Regulat ion Regulat ion Tex tOHS 4.28.(1) A risk assessment must be performed in any workplace in which

a risk of injury to workers from violence arising out of

their employment may be present.

Text

Admin Details

Activity: 6.50 Travel: 1.50 Activity Type: ContactHours

WCB Project:

Officer Details


Related Documents:

Triggered By:


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Internal

Referrals:


Issued on: 2011/10/06

Meeting with the response services manager on 2011-10-06 to discuss the

status of VitW risk assessment issues identified in the notice-of-

compliance (NoC) dated 2011-04-26 and to assess the extent ofimplementation of the outstanding tasks as well review the discussion

points of the meeting highlighted below.

We also reviewed the details of an injured worker interview conducted by

WSBC for a VitW incident occurring on 2011-05-16. See details in CR

2011070890050 dated 2011-09-20.

The details of that interview and some of the worker recommendations

arising were also raised at a meeting on 2011-09-22 at MATC with

representatives from management as well as BCGEU, UPN, BCNU, the assigned

safety specialist from BCPSA, and WSBC convened by BCNU re: the VitW

incident mentioned above.

Discussion points

The draft VitW staff perception survey completed and delivered to the MATC

staff on approximately 2011-07-31 was presented to the union

representatives either at or shortly before the meeting. The UPN

representative advised that some of his member's opinions were not

reflected in the survey. The BCNU VitW prevention advocate stated that the

survey contained no significant assessment of environmental risk factors,

and offered to provide templates of finalized risk assessment undertakings

at other worksites, particularly to demonstrate effective documentation

and remedial task planning arising out of the process.

The BCPSA safety specialist was not involved nor made aware of the

planning activities around the risk assessment process or staff perceptionsurvey. In the interim, the safety specialist has conducted several

training sessions re: incident investigation and employer responsibilities

re: safety management.

The UPN representative noted that an identified risk factor in the staff

perception survey, and also in the incident investigations arising out of

assaults with one repeat perpetrator (i.e. insufficient male presence in

the caregiver shift makeup on the incident dates) was being ineffectively

managed. The management team expressed concerns of a labour union

challenge re: gender discrimination if the hiring and/or staffing practice

specifically stipulated or increased the ratio of male caregivers. The UPN

representative countered with a defense based on the safety component and

cited examples of similar decisions.

Actions arising

The response services manager agreed to complete the environmental risk

assessment process and on 2011-10-07 e-mailed completed minutes of the

JOHSCtte, and on 2011-10-17 forwarded an updated NoC.

OHSR s. 4.28.(1) refers.


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Number ofWorkers

ProjectNumber

Lab SamplesTaken

DirectReadings

ResultsPresented

N N N2011/10/06





VICTORIA

BC V8W9V1



BC

Crossroads Program

PortionInspected

Violations







Andy MacDonald

Manager of Response Services

Andy MacDon ald

UPN(604) 660-5813

STEVENSON, JOHN


Burnaby


Delivery Method: In PersonMeetings at site to review draft report and e-mailed copies

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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900562011/11/24 4000 294 841102 1.5013.75







section 22


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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900562011/11/24 4000 294 841102 1.5013.75






Inspection Text

Issued on: 2011/11/24

This was a follow-up inspection to authenticate appropriate compliance

with the order(s) noted.

Violence risk assessment

A meeting was convened at MATC by BCNU on 2011-09-22 to explore issues re:

a significant VitW incident occurring on 2011-09-13. Representatives from

management as well as BCGEU, UPN, BCNU, the assigned safety specialist

from BCPSA, and WSBC were present.

The MATC VitW staff perception survey was tabled by the management team

but by itself does not meet WSBC requirements for a violence risk

assessment and this shortcoming was discussed. The BCNU VitW prevention

advocate stated that the survey contained no significant assessment of

environmental risk factors including but not limited to travel in

vehicles. The BCNU representative offered to provide templates of

finalized violence risk assessment undertakings at other worksites,

particularly to demonstrate effective documentation that includespriorizing of relative risks and the preparation of an action plan arising

out of the process.

Finalized violenec risk assessment reports have been obtained from VIHA

that will be used to guide the report format.

The BCPSA safety specialist stated that she was not involved in nor made

aware of the planning activities around the risk assessment process or

staff perception survey at the outset. In 2011-Q2, the safety specialist

conducted several training sessions re: incident investigation and

employer responsibilities re: safety management.

The draft MATC VitW staff perception survey was distributed to the

JOHSCtte in early September and the committee recommends requestingadditional analysis by the research assistant into:

- staff perceptions of causation such as working alone or enforcing policy

where a VitW incident had been experienced

- knowledge of and desire for revisons to P&Ps

The response services manager agreed to the inclusion of an environmental


Andy MacDon ald STEVENSON, JOHN



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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900562011/11/24 4000 294 841102 1.5013.75






risk assessment process to augment the staff perception survey and on

2011-

10-17 forwarded an updated NoC to WSBC. With respect to other outstanding

tasks arising from the risk assessment process, the NoC notes that the

contribution of experience, education, training and supervision to

incident response outcomes will be incorporated into the final VitW risk

assessment report.

The 2-way radio system continues to present some concerns to users, someof which may be attributable to user competency with the system and some

of which is radio system dependent; i.e., batteries without adequate

charge for second shift (insufficient charged batteries) and possible dead

zones on site. This interim communications system needs support and

resolution to any identified issues until alternatives are available.

Shared services is currently reviewing alternative systems.

The environmental risk assessment was scheduled for completion on 2011-10-

19 and on 2011-11-24 was reported as complete for the high risk cottages

and likely complete for the remainder of the site within approximately one

week. It was also stated that the manager of nursing quality control was

finalizing a review of the resident behaviour logs for near-misses related

to transporting youth in vehicles as a component of the environmental riskscan.

Incident investigations

The incident investigation order is noted as in partial compliance because

all timeloss incidents now have documented evidence of an investigation,

however investigation of VitW near-misses has not been adequately

integrated into the process. It was stated by the manager of response

services that the JOHSCtte would be involved in establishing the criteria

for inclusion of and definition of near-misses into a formal incident

investigation; i.e., one requiring the use of a PSC38 process. That

process has not been finalized but the task was tabled in the committee

minutes of 09-20. WCA s. 173(1)(c) refers. The current implementation plan

under item 2.0 states that near-misses will be tracked through a monthlyreview. That frequency is not consistent with regulatory expectation. It

is understood that there are degrees of near-misses and not all of them

can be evaluated due to time constraints, however the intent of the

regulation is to investigate any of these with the potential for serious

injury. Assaultive behaviour is to be included in this analysis and

investigative process. Alternative review processes are currently used to

manage this risk, but require integration with periodic PSC38 style





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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900562011/11/24 4000 294 841102 1.5013.75






investigations into near-misses meeting the criteria to be established by

the joint committee.

Assaults to staff occurring on 2011-05-16 and on 2011-09-13 by the same

perpetrator have been documented on PSC38 forms. The content of those

forms, particularly cause and contributing factors and corrective measures

taken and/or recommendations, was reviewed and has significantly improved

relative to completed forms from last year.

An e-mail communication between the manager of response services and the

BCNU violence prevention advocate re: the second assault noted above was

also reviewed. The e-mail contains more detailed analysis and corrective

measures that are insufficiently conveyed when brought forward to the

PSC38. There are common contributing factors in both incidents and

effective controls were not in place to prevent a recurrent event. The

analysis of the second incident does not include evidence of an effective

exploration of the repeating contributing factors common to the events,

nor of the possible role of supervisory decisions in the outcome.

The PSC38 must have sufficient detail to effectively communicate the

analysis of contributing factors and recommendations with actions arising.

All significant information must be available for review by both theJOSHCtte and other interested parties such as the year-end analysis as

part of the annual risk assessment process. Documentation of the follow-up

actions must also be available.

Joint safety and health committee

The minutes of the JOHSCtte from 2011-Q2 forward have been reviewed to

assess content and quality of the discussion summary notes. The most

current three months of minutes must be posted, in addition to WSBC

inspection reports (until compliance against any outstanding orders is

acknowledged to have occurred). You must also post any notice-of-

compliance responses and updates of same to the same location as the

inspection report.

In addition, please amend the e-mail distribution contact person at WSBC

to: [email protected].





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OF BRITISHCOLUMBIA






SERVICES DIVISION

420110708900562011/11/24 4000 294 841102 1.5013.75






Orders

Decision OHS4.28.(1)WCB ReferenceOrder No. D1


Order no. 1 of IR 2011070890005 has been partially complied with.

The violence-in-the-workplace (VitW) risk assessment process has beeninitiated and the status of some of the tasks identified in the

implementation plan are summarized below and noted as completed (C) or in

progress (IP):

1.0 - staff perception survey of VitW vetted and approved by JOHSCtte on

2011-09-20 (C)

1.1 - revise policies HS150 and HS160 with inclusion of key security (C)

1.2 - two-way radio pilot tested, issues identified and corrected, system

accepted with proviso to continue to monitor alternatives (C)

1.4 - investigation into the contribution of experience, education,

training and supervision to incident response outcomes (IP)

1.65 - incident investigation report quality control (C)

2.0 - investigation of near-misses consistent with the process used for

serious and/or timeloss incidents (IP)2.1 - establish a workplace violence prevention program (IP)

See inspection text notes for additional comment re: these tasks and

especially investigations.

The risk assessment process at the time of this inspection has not been

finalized in this workplace in which a risk of injury to workers from

violence arising out of their employment is present.

This is in contravention of the Occupational Health and Safety Regulation

Section 4.28(1).

A risk assessment must be performed in any workplace in which a risk ofinjury to workers from violence arising out of their employment may be

present. Continue to communicate with the joint safety committee re: the

actionable items arising from the risk assessment to address risk

controls; i.e., procedures, policies and work environment arrangements to

eliminate the risk to workers from violence or if that is not possible, to

minimize the risk per OHSR s. 4.29(a)(b).





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Order no. 2 of IR 2011070890005 has been partially complied with.

The approved incident investigation form is now completed for all timeloss

incidents. A review of PSC38 forms associated with violent incidents

occuring on 2011-05-16 and on 2011-09-13 was conducted. In addition, a

supporting memo providing additional detail and context re: the incident

precursors and the planned follow-up actions for the second event was

reviewed and discussed. See details in 'inspection text'.

At present, the PSC38 summarizes the unsafe conditions, acts or procedures

that may have contributed to the incident and the recommended corrective

actions to prevent similar incidents, but additional detail is required to

disclose all significant contributors and clarify the analysis and

actionables arising from the recommendations. WCA s. 174(2)(c) refers. In

addition, near-misses with a potential for serious injury must be explored

and documented using the investigation process. WCA s. 173(1)(c) refers.

Decision WCA125WCB ReferenceOrder No. C3



The joint safety committee has been reinforced and representatives from

all unions including BCNU and UPN are now in attendance. Minutes from

meetings scheduled in 2011 since revisions have taken place are dated: 05-

11, 06-07, 07-05, 08-02, 09-06, 09-20 and 10-04. The minutes are either

available or in draft as review status. The format has been enhanced

significantly with more content and more effective tracking of issues.

Continue to maintain an effective joint health and safety committee.







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420110708900562011/11/24 4000 294 841102 1.5013.75






Or er no. 4 o IR 2011070890005 as een comp e w .

The employer's notice-of-compliance was e-mailed on 2011-04-26.





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Employer Jobsite

ID: 4000

Name:

Address:

City:

Province:

Postal Code:

Location:

CU: 841102

294

V8W9V1

BCVICTORIA




Address:

City:

Province:

Project:

BC

Burnaby

3405 Willingdon Ave

Crossroads Program


Latitude:

Longitude:

Details

Employer Representative Consulted:Andy MacDonald

Phone Number: (604) 660-5813


Response

Site Visit:


Regulations

Regulat ion Regulat ion Tex tOHS 4.28.

(2)(c)

The risk assessment must include the consideration of the

location and circumstances in which work will take place.

OHS 4.28.(1) A risk assessment must be performed in any workplace in which

a risk of injury to workers from violence arising out of

their employment may be present.

Text

Admin Details

Activity: 1.25 Travel: Activity Type: Contact

Hours

WCB Project:

Officer Details


Related Documents:

Triggered By:


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Internal

Referrals:


Issued on: 2012/02/13

This CR is generated to update FirmFile for outstanding order no. 1 of IR

2011070890005 dated 2011-03-21 for a VitW risk assessment. The order was

issued subsequent to a complaint from BCNU re: insufficient incidentinvestigation particularly wrt contributory factors and follow-up actions

for circumstances around expressions of violence to custody workers in

this youth forensic facility.

Significant assistance was provided to the management team and JOHSCtte

members with document templates re: the risk assessment process. Despite

encouragement to utilize MoCF safety resources, the management team

elected unilaterally to proceed with a worker survey linked to a semi-

annual worker satisfaction process. The survey had intrinsic flaws that

delayed the risk assessment process. It did not have an environmental scan

integrated with the content evaluating worker risk arising out of

interactions with aggressive youth in the program. See details regarding

continued violence especially from one youth and the details of the

injuries arising in IR 2011070890056 dated 2011-11-24. This IR wasgenerated to update the file for all outstanding orders.

Subsequent e-mail correspondence from BCNU, UPN and the safety

representative from BCPSA was received by WSBC expressing some minor

concerns with perceptions of delays and failures to adequately communicate

with and involve the JOHSCtte in the outstanding issues re: the VitW risk

assessment process, particularly in the development of risk mitigation

strategies. BCNU and UPN elected to work cooperatively with the employer

if there was sustained evidence of progress. In e-mail communication dated

2011-12-05, BCNU representative acknowledged some environmental

risk reduction measures and the time required to budget for these measures

as well as noting a pending move of the physical premises of the most

violence risk-prone program to a another building on site.

It was acknowledged that WSBC would follow-up in 2012-Q1. Minutes of the

JOHSCtte meeting dated 2012-01-10 were received recently and there is a

very significant attempt to capture the nuance of discussion. BCNU

violence prevention advocate is attending most of the committee

meetings.

OHSR s. 4.28.(1) and 4.28.(2)(c) applies.

section 22

section 22


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11 - 50

Number ofWorkers

ProjectNumber

Lab SamplesTaken

DirectReadings

ResultsPresented

N N N2012/04/10





VICTORIA

BC V8W9V1



BC

Crossroads Program

PortionInspected

Violations







Andy MacDonald

Manager of Response Services

Andy MacDon ald

UPN(604) 660-5813

STEVENSON, JOHN


Burnaby


Delivery Method: EmailAlso discussed at site.

------------------------------------------------------------




OF BRITISHCOLUMBIA

An employer who fails to comply with the Occ upational Healt h & Safety Regu lat