Ontario Health Coalition

 LONG-TERM CARE

The following is the OHC response to the Ministry of Health and Long Term Care's discussion document. It is pasted below and attached in pdf format. The Ministry is writing new legislation to roll the three acts governing long term care homes into one. The legislation will be introduced next year. We are encouraging concerned parties to please write, fax or email the Ministry http://www.health.gov.on.ca and let them know what you need to improve conditions for residents and staff in long term care homes. Please feel free to distribute, copy or clip from our submission below.

Ontario Health Coalition
Future Directions for Legislation Governing Long-Term Care Homes
Responses to Discussion Document

December 13, 2004

1. Residents‚ Quality of Life and Standards of Care

1. What do you think should be the top priorities in the proposed legislation to address care and safety standards as well as residents‚ quality of life?

There is complete consensus among all the individuals, community groups, unions and health professionals‚ organizations with whom we work that the chief priority should be the provision of enough staff and care hours to provide the improvements that the ministry, residents and staff are seeking in LTC homes. There should be a clear, understandable, enforceable standard of care guaranteeing residents a minimum amount of care per day, and the staff to provide that care for them.

  • A required staffing ratio of enough front-line staff to provide a minimum standard of 3.5 hours per day of nursing and personal care for residents. This is to reach the goal of prevention of risk, it is not the optimum;

  • Presence of an RN 24/7, with a requirement that each resident must be assessed each shift, by a RN, without a net reduction in registered nursing hours;

  • A completely random surprise inspection regime with an adequate number of inspectors to respond to complaints within a reasonable amount of time. Any assessment process must include talking with and examining residents, speaking with representatives from residents‚ and family councils where they exist and speaking to nursing and personal care staff;

  • A provincial elder care ombudsperson‚s office where residents, families and staff are (and are seen to be) safe when they blow the whistle. This office should be mandated to process complaints in facility and home care.

    • 2. Do you have any suggestions for changing the existing process for admission to LTC homes? If so, what are they and how would these changes improve the existing system?

    Greater dignity and discretion is required for people seeking placement in long term care facilities. Freedom of choice is an essential principle in all settings. Homecare should be an accessible choice.

  • A ratio of 60% of facility beds for non-preferred accommodation and 40% for preferred accommodation should be reinstated.

  • At present there seems to be no process for arranging emergency admissions if an emergency occurs on a weekend or at any time outside CCAC office hours. (Such emergencies are usually the result of an unforeseen breakdown in the family caregiver‚s health.) This situation should be remedied.

  • In addition to priorities currently in effect (our understanding is that, in addition to re-uniting eligible spouses, priority is also given to those who have temporarily accepted beds inappropriate to their ethnic and linguistic preferences) priority status for admission to a home among the three that a prospective resident has chosen should be extended to:

    • o Those who have been heavily pressured by an acute-care hospital to accept an empty bed in a home they have not chosen, and

    o Those who are living on Guaranteed Income Supplement, who cannot afford to pay privately to supplement inadequate public homecare or to pay for an accredited retirement home

  • The Ministry should consult on a clear standard to protect against offloading of patients from acute-care facilities to long term care homes that are inadequately staffed to provide appropriate care.

    • 3. Do you think that the existing requirements effectively promote the establishment of Residents‚ Councils?

    If residents are interested in forming a council, sufficient support and resources should be provided by the elder care ombudsperson‚s office.

    4. How could Residents‚ Councils become a more effective voice for residents?

  • A strenuous education/re-education of managerial personnel should be undertaken to change the culture of fear that now prevails among residents, staff and sometimes even family members. Attendance at workshops for such purposes should be mandatory.

  • A social worker (OHIP-paid), who is not associated with a given long term care home, could be sent in to meet privately with residents interested in forming a council and should return at least once to monitor their progress;

  • Residents‚ Councils should be mandated to meet annually (and more often if the Council so requests) with representatives of front-line staff;

  • Residents‚ Councils should be enabled to conduct resident-satisfaction surveys (a number of samples are available from U.S. studies) and to assure anonymity for all who complete surveys;

  • Councils should be free to submit the results of their survey, not only to the managerial staff but also to the Elder Care Ombudsperson‚s office;

  • Councils should be officially be recognized in legislation;

  • Inspectors should be mandated to speak to representatives from the Residents‚ Councils where they exist.

    • 5. What do you think the critical functions of Family Councils could be?

    Family Councils can speak with louder voices. With the increasingly heavy care needs of persons entering long term care homes (see Alice Shulman‚s „Long-term Care Resident Profile from 1992 to2002‰), the number of residents with the stamina required to stand up for residents‚ rights is necessarily limited. Moreover the fear factor among residents will remain high under the best of circumstances (which certainly do not yet exist). Our most vulnerable citizens will always have considerable hesitation about biting the hand that feeds them.

  • We commend your definition of those eligible to join Family Councils and your intention to include their establishment in the proposed new legislation. Councils as you have defined them could bring the eye of the community to bear on the quality of life enjoyed (or endured) by residents of long term care homes.

    • Family Councils should be recognized in legislation with official recognition of their right to advocate. Such recognition should include:

  • Complaints by family councils should trigger an automatic inspection within two weeks of receipt of the complaint by the Ministry

  • Inspectors should be mandated to meet with reps from Family Councils where they exist.

    • Legislation must provide for public access to information that would allow Family Councils and others to effectively hold operators accountable. Information that must be made available should include but not be limited to:

  • financial reports on income and expenditure from all funding envelopes

  • reports on complaints regarding standards

  • level of care needs

  • Ministry or LHIN directives

  • facility funding & licensing agreements

  • inspection and compliance reports.

    • Support and resources to assist Family Councils should flow from the office of the elder care ombudsperson.

    6. How could the proposed legislation support and encourage the establishment of Family Councils? (eg. Requiring the home to tell families about the Family Council Project)

  • Homes should not only be required to tell families, but should also be required to furnish every family member with a one or two-page explanation of this part of the legislation. This explanatory note should be produced by the Ministry and should contain a phone number in the Ministry to call with any questions.

  • As an immediate measure, before a Family Council has been established, each Home should be required to convene an annual meeting of family members and invite representatives of the front-line workers, as well as Concerned Friends and/or the Advocacy Centre for the Elderly to attend. For locations where neither of the latter organizations has an established office, the Ministry should cover the expenses for one of their members or staff to travel to such meetings.

  • Funding should be accessible to existing agencies such as Concerned Friends and the Advocacy Centre for the Elderly to support the establishment of Family Councils.

    • 7. What information should the operator post? (eg. The home‚s abuse prevention programs, the home‚s policy on the use of restraints)

  • In addition to present requirements and your suggested examples, information about residents‚ councils and family councils and the phone number of the Elder Care Ombudsperson‚s office should be included.

  • Also posted should be: standards (in brief), inspection reports, the Bill of Rights, the manager of each department with a contact phone number.

  • Everything posted should be in at least 16 pt. bold type, preferably sans serif. (Like this).

  • Everything posted should also be available in printed form for residents and family members to take away and read at their leisure.

    • 8. What methods should the operator use to make information available to residents, families and the community?

  • CCACs

  • Posted items

  • Website

  • Info line

  • Public libraries

  • Information should be multilingual as appropriate

    • 9. What information would you like to see the Ministry make available to the public regarding LTC homes?

    This determination should be made with the goal of maximum transparency.

    On the Web site:

  • Full name, address and phone number for each facility

  • Number of beds in each facility

  • Staffing complement and schedule (front-line)

  • Any specialty, such as availability of ethnic minority language and cuisine, ability to care for persons with Alzheimer‚s disease

  • Date of last inspection

  • Record of any non-compliance reports

  • Access information for the office of the provincial elder care ombudsperson

    • In printed form, available on request from Ministry:

  • Details of non-compliance and steps taken to come into compliance for any LTC home

  • Financial information on revenues and expenditures from each funding envelope

  • Any complaints received and their resolution at any LTC home

  • Copy of any LTC home‚s last and second last report to Ministry

  • Province-wide Ministry reports on long term care homes

  • Copy of Ontario Association of Social Workers‚ How to Choose the Right Place (up-dated version)

    • 10. What methods should the Ministry use to make the information available?

  • Existence of the web site needs to be heavily publicized by:

    • -household mailings

    -public interest announcements on radio and TV

    -newspaper ads, including community papers

  • Ministry phone numbers for information and for the Ombudsperson‚s office should be equally well publicized

    • 2. Residents‚ Rights and Safeguards

    11. What should the Ministry consider when developing legislation concerning the use of restraints?

    The purpose of the use of restraints should be clearly stated. Restraints should be used only for the purpose of preventing harm of residents or staff. All forms of restraint ˆ physical, chemical and environmental ˆ should be covered by the legislation.

  • There should be a clear decision-making process before any restraints are employed. In case of emergency, this procedure should be used to review and verify the decision to use restraints.

  • Families or substitute decision-makers should be notified whenever restraints are used.

  • Restraints must always be seen as a last resort and never as a convenience for staff or a way for a profit-seeking owner to lower staffing costs.

  • Environmental restraints (e.g. locked Alzheimer‚s wards) should be agreed upon when a person becomes a resident, either by the resident or by his/her substitute decision-maker.

  • Physical restraints should be designed so that there is no potential for serious harm to the restrained person if he/she resists or grows impatient with the restraint.

  • Chemical restraints are the most worrying because they are invisible to visiting family members. The ICES report, on the outrageous number of LTC home residents being given anti-psychotic drugs, should be seen as an urgent alarm signal. The administration of such drugs without the informed consent of either the resident or the substitute decision-maker must be absolutely forbidden.

    • 12. What changes would you suggest to strengthen the existing Residents‚ Bill of Rights?

  • The right to the care each resident needs should be included in the Bill of Rights.

  • The significance of the Residents‚ Bill of Rights is determined, however, not so much by its provisions, as by the accessibility of advocates who can ensure its enforcement. Two community organizations ˆ Concerned Friends of Ontario Citizens in Care Facilities and the Advocacy Centre for the Elderly should be mandated and funded to undertake such advocacy.

  • The elder care Ombudsperson‚s office should be made responsible for ensuring that these advocacy organizations are enabled to carry out such responsibilities.

  • Phone numbers, including 1-800 numbers, for Concerned Friends and ACE should be posted prominently in every LTC home.

    • 13. Should all staff and the general public be required to report abuse and other unlawful activities in LTC homes?

    The legislation should recognize the primacy of prevention in abuse. This must include adequate staffing and a culture of respect.

  • Proactive mandatory education similar to models used to prevent harassment and family abuse should be instituted. Whistleblower protection must be implemented and proven effective as a pre-condition to any mandatory reporting regime. Penalties should be instituted only after these measures are taken.

  • It would be peculiar to impose mandatory reporting on staff and the public with no mandatory reporting for operators. There should be a pro-active duty of operators to provide a living and working environment that is respectful and free of fear. Gag orders and other such clauses in employment contracts must be unlawful, and this must be enforceable. Facility operators who hastily fix up facilities because they are tipped off about inspections prior to the inspectors‚ visit must face penalties. Families must have the right to access to their family members in facilities without being threatened with trespassing charges. Any requirement for reporting will only work if facilities operate as public services, with transparency, and without the culture of fear that currently exists in facilities.

    • 14. Should penalties be imposed on staff and the general public who fail in their duty to report abuse and other unlawful activities?

    See above.

    15. Should the reporting requirement be more strict for professionals and other members of the staff in an LTC home than for the general public?

    No comment.

    16. Would people be more likely to report their concerns about abuse if these approaches were used?

    Whistleblower protection must be implemented and people must know it is there.

  • The proposals to protect whistleblowers are commendable but their value will have to be judged in action.

  • Penalties for managerial staff who retaliate against a whistle-blower must be credible. Fines should be levied not only on the license-holder but also directly on the managers involved. The amount of the fine should be deducted from the pay of the manager, with dismissal mandated for a second similar offence.

  • Fines must be substantial so that corporate owners cannot simply write off the sanctions as a cost of doing business. Owners must also be prohibited from reimbursing their managers‚ fines (a kind of backhanded commendation for getting rid of troublemakers).

  • The Ministry must be aware, however, that retaliation for reporting abuse is not necessarily visible to the naked eye. There are many subtle ways to make an employee‚s life miserable.

  • Family members who make a public statement about abuse or conditions they have observed must also be protected from retaliation. Only a few months ago two daughters, who were vocally dissatisfied with the care their mothers were receiving, were denied entry to an LTC home to visit them.

    • 17. What other methods could be used to encourage or enable people to report abuse, neglect or harm done to residents through unlawful actions or incompetent care?

  • An Elder Care Ombudsperson should be created to investigate and act upon complaints and non-compliance within the long term care facility sector and in homecare.

  • Whistleblower protection should be extended to residents, families, advocates and staff in long term care facilities.

  • Inspectors should be required to talk to residents, family and staff while conducting inspections of facilities.

  • This section should look at abuse, neglect & harm done to residents and also illness, accident, injury and unsafe workplaces for staff.

    • 3. Compliance, Inspection and Enforcement Programs

    18. What methods should the Ministry use to inform all affected parties about the outcome of a complaint investigation conducted by the Ministry?

  • First of all, any complaint about standards should trigger an immediate inspection.

  • Interested parties should include all residents in the LTC Home where the complaint was registered. The complaint and its resolution should be posted without identifying information included.

  • All operators of LTC Homes should know about the resolution of a complaint, for their guidance in situations like or analogous to the situation complained about. (Perhaps the name of the Home need not be included in advising other operators.)

  • The Ombudsperson‚s files on complaints received should be an active file, to be referred to when evaluating new complaints.

  • There should be an annual ombudsperson‚s report outlining the trends in complaints and compliance.

    • 19. Should the Residents‚ and Family Councils be formally advised of the outcome of complaint investigations conducted by the Ministry? And if so, at what point in the investigation should they be advised?

    Yes, they should be advised, from the beginning of the process. In addition, representatives of staff and health professionals should be notified.

    20. What process should be put in place for operators who disagree with the results of an inspection or the imposition of a sanction by the Ministry?

    Operator should be required to comply first. Operators should not be able to defer their sanctions through endless appeal processes.

    21. How should these sanctions be changed or strengthened?

    Penalties must be enough that they are not considered simply a cost of doing business.

    22. How could these sanctions be used more effectively to make sure that operators correct problems that have been identified in their homes?

    Sanctions could be progressive, up to licenses pulled. In the case of loss of license, the facility should be operated by the public, non-profit sector.

    23. Do you think these proposed sanctions will be effective?

    No comment.

    24. When should these sanctions be used?

    No comment.

    25. Are there any other sanctions that the Ministry should consider?

    No comment.

    26. Do you think that it would be appropriate in some circumstances to permit the Ministry to impose sanctions on persons other than the operator? (eg. An operator‚s officers and directors)

    Yes, boards of directors, management personnel, management companies or other contracted third parties should be included.

    27. Do you think that it is appropriate to have a requirement on the directors and officers of organizations that operate homes to take reasonable care to ensure that the home operates in accordance with the law?

    See 26.

    4. Systems for Licensing Homes and Approving Beds

    28. Do you agree that there should continue to be a requirement for municipalities to operate a LTC home?

    Yes. Municipalities should also be prevented from reducing their current number of beds.

    29. If municipalities were no longer required to operate a home, how would the Ministry make sure that LTC home beds are available province-wide?

    Municipalities should be required to run a home.

    30. What factors should the Ministry consider when designing a new licensing and bed-approval system?

    Beds should be owned and operated on a public, non-profit basis.

  • Potential for integration should be investigated;

  • Such a system should be based on an assessment of population need;

  • Capital funding should be provided to build public and non-profit beds.

    • 31. What factors should the Ministry consider when setting terms (time limits) on the license approval of a particular home? (eg. the physical structure of the home)

    No comment.

    32. What criteria should the Ministry use when deciding whether to renew a license or approval?

    Beds should be public or non-profit.

    33. What criteria should the Ministry use when deciding whether to revoke a license or approval?

    No comment.

    34. Should the public have an opportunity to comment on the application for a license or approval? What methods should be used to allow the public to make such comments?

    Yes, by means similar to those used for new building permits.

    35. In the future, should an operator be permitted to transfer their license to another operator in another location? If so, what criteria should the Ministry use when deciding whether to approve the transfer?

    If beds have been constructed with public money, as all the new beds have been, then they should be returned to public or non-profit ownership. Transfers of license should be only to non-profit or public institutions.

    5. Planning and Renewal of LTC Homes

    36. How can Ontario ensure that operators undertake renovation, renewal and rebuilding of their homes?

  • The provincial government should set up a fund for public infrastructure renewal based on an assessment of population need.

  • Priority should be given to publicly-owned and operated homes.

  • The provincial government should pursue funding from the federal government for infrastructure renewal including hospitals and LTC homes, along the lines of the Canada Health Grants system that built much of our capital stock from 1948-1971.

    • 37. Should the Ministry require operators to reserve a specified amount of their government funding for ongoing maintenance and repair of the physical structure of their homes?

  • Such reserve funds should be allowed to be created only from the accommodation funding envelope so as not to diminish personal support and programs.

  • A public capital fund should be available to municipalities and non-profit homes only, with for-profit homes required to fund maintenance and repair from the accommodation envelope and the capital funding they already receive.

    • Additional Comments

    Access to LTC homes relies not only on a principled admissions process, but also on affordability. The structure of fees and living allowances for residents must be modernized and affordable as follows:

  • Resident Fee increases above the cost of living should be revoked and accommodation fee increases should be limited to the cost of living adjustment for senior income support programs.

  • The resident Comfort Allowance should be increased by at least 15%. In addition, a review should be undertaken to examine items that should be funded rather than paid out-of-pocket by resident (including $2 prescription fees, lab test fees, and provision of on-site visits for dental, hearing and glasses)

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