Ministry of Health and Long Term Care Performance Improvement and Compliance Branch Compliance Management Program

1
Ministry of Health and Long Term Care Performance
Improvement and Compliance BranchCompliance
Management Program

• Presentation to the North East Family Councils
  Network
• May 1, 2009
• Presentation by Monique Berger

2
Compliance Inspection and Enforcement Overview

• It is designed to safeguard residents rights,
  safety, security, quality of care and quality of
  life.
• It provides a framework for evaluating LTC homes
  compliance with Ministrys requirements as
  defined through applicable legislation, service
  agreements, and LTC Homes Program Manual, which
  sets out standards for care, services and
  operations.
• It is the monitoring arm of Ministrys
  accountability framework in administering the
  Service Agreements entered into with LTC homes.

3
Compliance Inspection and Enforcement Framework

• Legislation
• Nursing Homes Act
• Charitable Institutions Act
• Homes for the Aged and Rest Homes Act
• Regulations under these Acts
• LTC Home Program Manual
• Sets out requirements for care, services and
  operations

4
LTC Home Program Manual - Standards Criteria

• The LTC Home Program Manual is the source of
  operational policies and standards and criteria
  for resident care and services.
• MOHLTC retains responsibility for the LTC Home
  Program Manual.
• LTC Home Program Manual may change in purpose
  when new legislation is proclaimed. The focus of
  the LTCH Program Manual may change to incorporate
  interpretive guidelines as the homes will be
  inspected based on a consistent piece of
  legislation and accompanying regulations.

5
LTC Home Program Manual - Standards Criteria

• Resident safeguards Resident Rights, Restraints,
  Advocacy and Residents Council
• Resident Care and Services Assessment, Care
  Planning, Care according to assessed needs,
  evaluation of care and services.
• Nursing Services Nursing Care, Medication
  Administration, Role and Responsibility of
  Director of Care
• Volunteer Services Orientation Training
• Staff Education Orientation and ongoing Training
  for all Staff

6
LTC Home Program Manual - Standards Criteria

• Recreation and Leisure Services Resident needs
  and Programs
• Facility Organization Administration CQI, Risk
  Management, Infection Control, Health and Safety,
  Disaster Planning and Record Management
• Medical Services Medical Director and Attending
  Physician Services
• Environmental Services Housekeeping, Laundry,
  Maintenance, Safety and Building Services
• Nutritional and Dietary Services Meal
  Production, Meal service and Nutritional care
• Pharmacy Services Responsibilities of
  Pharmacist, Quality Management

7
Inspectors

• Inspectors
• Compliance Advisors (Registered nurses)
• Dietary Advisors (Registered dietitians)
• Environmental Health Advisors (Certified public
  health inspectors)

8
Authority of Inspectors

• For the purposes of the Acts and the Regulations,
  the Minister appoints inspectors.
• To determine compliance with the Acts,
  Regulations, license and service agreements.
• The Acts, Regulations, LTC Home Program Manual
  and other Ministry policies provide the basis for
  all inspections conducted by inspectors.
• LTC Home Program Manual has been the basis for
  the standard inspection tools used by inspectors.

9
Compliance Staff Role ? LAPADD

• Look observe, listen to what is happening in a
  home, review charts, talk to operators,
  management, staff, families, tour, record
  relevant information
• Assess compare observations in relation to
  Ministry expectations
• Point to gaps with respect to Ministry
  expectations, notify of instances were
  requirements are not being met, bring forward
  best practices and ideas to consider to support
  meeting of compliance, point to to other
  initiatives within broader LTC home sector
• Apply decision-making framework
• Decide on appropriate course of action/sanction
  as necessary
• Direct homes to develop and implement a plan of
  corrective actions as necessary to rectify all
  instances of non-compliance

10
Decision-Making Framework for Non-Compliance

• Severity degree of harm (conditions have been
  observed that pose actual or potential risks to a
  residents health, safety, welfare or rights)
• Prevalence frequency of risk or harm
  (conditions that have been observed that are
  prevalent or recurring conditions may or may
  not be serious)
• Recurrence pattern of non-compliance
  (conditions have been identified during previous
  reviews, but have not been corrected within the
  negotiated time frame for corrective action)
• Negligence or Lack of due diligence appropriate
  actions not taken to prevent or mitigate risk/
  harm or the home has not taken prompt measures
  to initiate corrective action.

11
Compliance Inspection Activities

• Annual Reviews
• Investigations of complaints submitted by
  residents/families and the general public by
  compliance staff
• Inspections on reports of Critical Incidents
  where required
• Follow-up inspections on compliance plan
  submissions by LTC homes and follow-up visits by
  compliance staff to ensure compliance
• Referral visits by Dietary and Environmental
  Health Advisors

12
Compliance Inspection Activities

• Special inspection visits by any compliance staff
• Pre-occupancy visits for new homes
• Pre-occupancy, pre-sale and post-sale
  comprehensive reviews by compliance, dietary and
  environmental health advisors
• Utilize standardized audit tools to conduct
  reviews

13
Recent and Upcoming Changes

• 3 Acts/regulations LTC Facility manual
  One act regulations (Bill 140)
• Moving to a risk management framework which will
  trigger inspections
• Appeal process to be implemented (Bill 140)
• Regional Office reporting to manager/regional
  director Service Area office
  with local manager, reporting to corporate
  manager/director
• 7 Regional offices 5 Service
  Area Offices
• Regions LHIN Areas

14
Other

• Info Line 1-866-434-0144 public complaint
  reporting
• Public Website http//publicreporting.ltchomes.ne
  t provides information
• On individual homes and their record of care.
• Home profiles, outcome of selected compliance
  inspections and verified concerns of compliant
  investigations for a 12-month period.
• Updated approximately every three months.

15
Questions?