CRFCN comments on Part 2 of
The Proposed Initial Draft Regulation
Long-Term Care Homes Act, 2007
General
A review of Part 2 of the proposed Regulation cannot be made in isolation from the Part 1 draft. Since the Champlain Region Family Council Network (CRFCN) provided comments on Part 1, we are attaching those comments for consideration under the relevant sections of Part 2.
Family Councils
It is clear that the Long-Term Care Homes Act, 2007 gives a statutory base to the Family Councils. Recently issues have arisen in connection with Family Councils which we feel need to be addressed in the regulations. To begin with, we are aware that the independence of the Family Council from the Long-Term Care (LTC) facility and staff is not always being respected. We are aware that there are still LTC homes where the Administrator opposes establishment of a Family Council. While enforcement of the provisions of Bill C-140 is not within the control of the drafters of the regulations, we ask that every effort be made to maintain the strength of the Family Council program in the regulations. For example, where Residents’ Councils are consulted or given access to documents, the same rights should be accorded Family Councils as Family Councils represent the viewpoints and concerns of all residents including those who cannot speak for themselves.
We further recommend that the existence of a Family Council become one of the accreditation criteria for the Licensee of a Long-Term Care home.
If the mandate of the Family Councils as spelled out in the Long-Term Care Homes Act, 2007, is not rigorously enforced, then the councils will have no purpose and indeed will be at the mercy of the LTC home administrators. This will have the effect of taking away the independence and autonomy that is so vital in the operation of a Family Council.
An issue has recently arisen with respect to membership on Family Councils. Some LTC Homes have taken the position that a Family Council Member must resign from the FC upon the death of their family member who was resident in the home. This measure will weaken Family Councils since it is possible that several Family Council members can lose a loved one within a short period of time. High turnover on a Family Council can render it ineffective. It is recommended that a regulation be made under paragraph 60(1)10 of the Long-Term Care Homes Act, 2007, giving each Family Council the power to write by-laws governing its operation and the power to define in those by-laws, the meaning of the expression “a person of importance to a resident” for purposes of paragraph 59(5) of the LTC Homes Act. Another approach would be to include a definition of the expression “a person of importance to a resident” in the Definitions under the Part 2 Regulations which definition would include, for purposes of Family Council membership, a family member of a former resident of the Long-Term Care home. At the very least, a policy directive from the Director is needed.
Appeal Mechanism following Compliance Review
We have commented under Part IX of Draft 2 on the lack of an appeal mechanism following a Compliance Review. We feel this is essential to the openness and transparency requirements under the Long Term Care Homes Act. This is particularly needed when the responsibility for compliance inspections under the Act rests with the same ministry as does the responsibility for operations and licensing. There should be an arms length mechanism to resolve matters where a serious dispute over compliance arises between the complainant and the inspectors.
Definitions (Part I, Sections 1 – 3)
The definitions of staff in the Long-Term Care homes need to be examined to make them more consistent. Some definitions include the required professional affiliations and training of the staff but others do not.
Several sections of the draft regulations refer to a “designated lead”. It is not clear what this means and should be defined.
Residents Rights, Care and Services (Part II, Sections 4 – 90)
11. Communications and Response System
11(1)(a) This section should mandate the use of wireless electronic monitoring devices for safety reasons.
There should be a standard governing response time,
14. Cooling Requirements
The requirement that the Humidex Level be maintained below 35 degrees should apply to residents’ rooms.
15. Plumbing
Homes should be encouraged to replace old toilets with higher ones with stronger flushing mechanisms.
18. 3 (a) Nursing and Personal Support staffing. How can the appropriate staffing mix be determined when there is no standard specified? A minimum standard should be referenced or at least a directive developed that outlines appropriate staffing mix?
See also CRFCN earlier comments on Resident Care - pp 2-3 of Proposed Initial Draft Regulations attached to this document.
18.3(c) Continuity of Care. The word “promote” should be replaced with “ensure”
20. (1) Bathing: It is commendable that residents will be given a choice under this regulation.
22. Foot Care: We assume this regulation means that each home is responsible for providing this care regardless of the ability of the resident to pay for the service. If this is the intent, we commend the regulation.
26. Dress: As certain types of footwear could be a safety hazard, it is recommended that the words ”taking safety into consideration” be added to this regulation.
37. Therapy Services: Subsection (c) should read “massage therapy”.
Subsection (d) should include music and art therapy
40. Social Work and Social Services Work: The requirement should parallel that of the Dietician. In other words there should be a requirement for social work services to be available for a specified number of hours per week per resident.
41. Social Work Qualifications: This new section is highly commendable.
47. Weight Changes: The resident’s family member or substitute decision maker should be advised and consulted in these situations.
49. (1) (e). Menus and Food Choices: This section should be re-worded to require “consultation with” rather than final approval of the Residents’ Council and the Family Council.
49. (5). Menus and Food Choices: This subsection of the regulations should require consultation with the resident’s family member or substitute decision maker.
49 (7) Food Choices: The wording should be clarified as it appears to mean that staff has access to food for personal use.
51. (1). Dining Service: We commend the use of the word ”shall” in this regulation. Who will be responsible for monitoring that this regulation is enforced?
51. (2) (a) This regulation is commendable.
52 (2) Dietitian: This section is highly commendable.
64 (2) b& 67. Housekeeping: There is no clear or identifiable standard for the quality or frequency of housekeeping services. Could there be reference to a hospital standard here? These sections should cover cleaning of rooms vacated by a resident before a new person moves in. It should also require the rooms to be kept in good repair.
PASDs should be written in full.
66 (a) (iii) Laundry Service: Laundry should be returned in a secure container to avoid individuals “shopping”.
75 1. and 77.(1) and (4) Reporting Investigations: Should require date and time of incident
89. Final Statement: We commend this as a good management practice.
Admission of Residents (Part III, Sections 91 – 109)
91. Criteria: We fail to understand the difference between “interim bed short-stay program” and “short-stay program”
The term “interim bed” means a bed in a long-term care home under the interim bed short-stay program. It is not clear what an interim bed short-stay program is.
95. Ranking on waiting lists – interim beds
This section refers to the “first draft regulations”, Sections 44 – 56. Section 45 states “Sections 46 to 55 apply only to applicants who meet the requirements of section 41 and who apply for authorization of admission to a long-term care home as a long-stay resident.”
Since this section states it only applies to applicants for long-term care stay, why do we need to include it in the interim stay requirements?
99. Removal from every waiting list, interim bed resident
The status of the individual who refuses to consent to admission to a long-term care home as a long-term stay resident is not clear. Can they continue to occupy an interim bed?
Waiting Lists – There is a problem when short-term patients need to be admitted to a long-term care home immediately because a hospital cannot allow them to stay any longer. Also in cases where the retirement home can no longer accommodate a resident’s needs even though additional personal workers have been hired to care for the residents. Long-term home beds are always full. It is only when someone passes away that a bed becomes available and that is always an unknown. How can short-stay or interim patients be properly accommodated under these terms? It could be a month or more before a bed becomes available.
Conclusions for this section
We find this section confusing especially trying to figure out what interim short-stay program actually means. There are provisions that are repeated in this draft from the first draft, and the need to refer back to the first draft makes it very difficult to follow. Could not everything pertaining to one area of the draft be put together in one place rather than creating the arduous task of flipping back and forth?
Other Comments
There is reference in the draft regulations to the minimum number of hours of service to be provided by a dietician and a nutrition manager. There is a need to ensue that these hours are monitored when a home shares the specialists with another establishment such as a hospital which is attached to the same building and these individuals work for both establishments concurrently.
Councils (Part IV, Section 110)
Operation of Homes (Part V, Sections 111 – 165)
101(3) Specialized Units: The LHIN should also be required to take into account the effect of designation of a specialized unit on residents of the Long-Term Care Home e.g. the potential negative effects of dislocation of residents, and the effects of ensuing training and funding requirements for the LTC home.
118 (1) Additional training: It is recommended that this regulation be expanded to include the following: training in safe and appropriate transfer techniques; and, training in cognitive impairment and behavior disorders.
Additional training must be provided to ensure all new front line staff are aware of the needs of dementia patients.
Training should also be required in palliative care, sleep disorders (CPAP), speech therapy, recreation, arts and music.
118 (1) 7 (ii.) PASDs – write out in full.
119. Orientation for Volunteers: Recommend adding transfer training unless it is determined that volunteers should not be assisting residents with transfers.
119.(2) (5). All volunteers who have taken feeding training should be able to be identified by staff.
120. (4) Information for Residents: The word “charges” should read ‘services”.
123. 2 Continuous quality improvement: Outcomes should be communicated in writing.
124. (4)1. ix. Emergency Plans: Add “excessive heat in hot weather”.
126 (b) Bedroom Furnishings: Resident beds should be capable of being elevated at the foot as well.
129. Resident Records: Resident records should be accessible to family members and substitute decision makers.
159. Drug Record: Drug records should be kept for a minimum of 5 years to facilitate investigation.
159. 3. Drug Record: subsection should read “The name, strength, quantity and frequency of the drug.”
Funding (Part VI, Section 166)
Licensing (Part VII, Sections 191 – 206)
Municipal Homes and First Nations Homes (Part VIII, Sections 207 – 210)
Compliance and Enforcement (Part IX, Sections 211 – 215)
An appeal process is required: In the regulations dealing with Compliance and Enforcement, an appeal process is required for family members/residents/friends of residents who have complained and are not satisfied with an investigation and the resultant report. At present, there is no recourse for family members, once the complaint is investigated and the report submitted, regardless of whether there have been deficiencies in the investigation.
It appears that inspections and/or compliance reviews can depend upon the results of audits/reviews conducted by the licensee/LTC facility management themselves without the Inspector/Compliance Advisor directly interviewing anyone who had direct hands on care for resident(s).
It is important that an appropriate and transparent inspection system be in place. Investigations and/or compliance reviews which are conducted without due regard for objectivity in the review process are open to the possibility of error or cover-up.
Evidence of harm presented by family member/family council:
Evidence of harm done to a resident that is presented by a Family Council, family member, friend of a resident, residents themselves or other relevant person, must be taken as relevant evidence in any inspection or compliance review process. We have seen cases where evidence from a family member has not been considered as "evidence" by an inspector/compliance advisor unless they are able to corroborate the family member's evidence by a statement from the Licensee/LTC facility staff. The evidence presented by the family member should be given equal weight to the evidence found in a medical record or a statement by a staff member of the LTC.
211. Notice of Inspection: Inspections should be completely unannounced whereby neither the licensee nor any of the staff of the LTC should know when an inspection will take place.
Inspections should not be conducted with such regularity that the licensee can determine the month in which the inspection will take place.
Section 214 - Protection of Privacy in reports
214 (1) (c) include the obligation to give copies of all inspection reports to the Family Council and the Residents’ Council at the same date and time that the licensee receives the inspection report.
214 (2) 1 - even if there is a finding of non-compliance all of the findings and all of the evidence supporting the findings should be posted, given or published, not just a summary of the evidence. We suggest using the words” a version of the report that has excluded personal information or personal health information” rather than reference to a summary. If “summary” is to be used, it should clearly apply only to any personal or personal health information in the report.
214 (2) 2 - where there is no finding of non-compliance all of the finding and all of the evidence should be posted, given or published, not just a summary of the report.
Transparency is extremely important to residents, family members and friends of residents. For this reason a summary report is not sufficient.
See also CRFCN earlier comments on Transparency - pp 4-5 of Proposed Initial Draft Regulations attached to this document.
Other Comments: We commend Section 149 of the Act requiring the Inspection Report to be given to the Family Council.
There should be reasonable time frames identified for completion of the inspection and production of the report.
Administration, Miscellaneous and Transition (Part X, Sections 216 – 246)
Territorial District Homes (Part XI, Sections 247 – 259)
October 29, 2009
