a g e n d a dearness home committee of management · a g e n d a . dearness home committee of...

A G E N D A DEARNESS HOME COMMITTEE OF MANAGEMENT Meeting to be held on Thursday, June 16, 2016, commencing at 12:00 PM, at Dearness Home, 710 Southdale Rd E, London ON N6E 1R8. Committee Members: Councillors J. Zaifman (Chair), A. Hopkins (Vice Chair), T. Park, V. Ridley, and H.L. Usher, and C. Saunders (Secretary). I. CALL TO ORDER

1. Disclosures of pecuniary interest(s), if applicable. II. CONSENT ITEMS

2. 2nd Report of the Dearness Home Committee of Management

3. Administrator’s Report to the Committee of Management for the Period March 1, 2016 to May 15, 2016

4. Accreditation

5. Ministry of Health and Long-Term Care Resident Quality Inspection Process of

Long-Term Care Homes

6. Dearness Home Level 4 Evacuation III. SCHEDULED ITEMS IV. ITEMS FOR DIRECTION V. DEFERRED MATTERS/ADDITIONAL BUSINESS VI. CONFIDENTIAL VII. NEXT MEETING DATES

October 19, 2016 – City Hall Committee Room #4. VIIl. ADJOURNMENT

MINUTES OF THE

2ND MEETING OF THE

DEARNESS HOME COMMITTEE OF MANAGEMENT Meeting held on March 23, 2016, commencing at 12:11 PM at the Dearness Home, 710 Southdale Road East, London Ontario. PRESENT: Councillor J. Zaifman (Chair), Councillors A. Hopkins, T. Park, V. Ridley and H.L. Usher, and C. Saunders (Secretary). ALSO PRESENT: S. Datars Bere, A. Hagan, B. Hall (Extendicare), A. Heinz (Extendicare), A. Hagan, and L. Marshall. 1. Disclosures of Pecuniary Interest

None were disclosed. 2. Minutes of the 1st Meeting of the Dearness Home Committee of Management

USHER AND PARK That the Minutes of the 1st Meeting of the Dearness Home Committee of Management,

from its meeting held on January 27, 2016, BE RECEIVED. CARRIED 3. Administrator’s Report to the Committee of Management for the Period January 1, 2016

to February 29, 2016

USHER AND RIDLEY

That, on the recommendation of the Administrator, Dearness Home, with the concurrence of the Managing Director, Housing, Social Services and Dearness Home, the Administrator’s Report dated March 23, 2016 for the period January 1, 2016 to February 29, 2016 BE RECEIVED for information. CARRIED

4. 2016 - 2019 Service Accountability Agreement Between The Corporation of the City of

London (Dearness Home) and the Southwest Local Health Integration Network (LHIN)

USHER AND PARK That, on the recommendation of the Administrator Dearness Home, with the

concurrence of the Managing Director, Housing, Social Services and Dearness Home, the 2016-2019 Service Accountability Agreement between The Corporation of the City of London (Dearness Home) and the Southwest Local Health Integration Network (LHIN), appended to the staff report dated March 23, 2016 as Appendix A, BE RECEIVED for information; it being noted that the above-noted Agreement will be considered by the Community and Protective Services Committee at its meeting of March 30, 2016. CARRIED.

5. Dearness Home Strategic Plan 2016-2020

USHER AND RIDLEY

That, on the recommendation of the Administrator, Dearness Home, with the concurrence of the Managing Director, Housing, Social Services and Dearness Home, the Dearness Home Strategic Plan 2016-2020 BE RECEIVED for information; it being noted that the Managing Director, Housing, Social Services and Dearness Home was requested to make a presentation at a future meeting of the Community and Protective Services Committee with respect to the above-noted Strategic Plan. CARRIED

6. Next Meeting Date June 16, 2016, 12:00 PM – Dearness Home, 710 Southdale Road East, London,

Ontario.

7. Adjournment

USHER AND PARK

That the Meeting of the Dearness Home Committee of Management BE ADJOURNED. CARRIED The Meeting adjourns at 1:11 PM. ___________________________________ J. Zaifman, Chair ___________________________________ C. Saunders, Secretary

Agenda Item # Page #

□ □ TO:

CHAIR AND MEMBERS DEARNESS HOME COMMITTEE OF MANAGEMENT

MEETING ON JUNE 16, 2016

FROM: ANGIE HEINZ

ADMINISTRATOR, DEARNESS HOME

SUBJECT:

ADMINISTRATOR’S REPORT TO THE COMMITTEE OF MANAGEMENT FOR THE PERIOD MARCH 1, 2016 TO MAY 15, 2016.

RECOMMENDATION

That, on the recommendation of Administrator, Dearness Home and with the concurrence of the Managing Director, Housing, Social Services and Dearness Home, this report related to the Dearness Home BE RECEIVED for information.

PREVIOUS REPORTS PERTINENT TO THIS MATTER

• March 23, 2016, Administrators Report January 1, 2016 to February 29, 2016

BACKGROUND

Service Provision Statistics:

Long Term Care Occupancy and Waiting List Information:

• Occupancy average for the Home for the months of January 1 to May 15, 2016 - 99.14%. • Number of individuals on the wait list: Basic Accommodation - 227; Private

Accommodation - 45

Median Days Waiting

• Private – 223 people waiting. • Basic – Less than 10 people (on average) waited for basic accommodation during the

reporting period, therefore, the Community Care Access Centre (CCAC) does not provide data for less than 10 people waiting. Note: These statistics are utilized by the Community Care Access Centre (CCAC) for the public to be aware of how many potential days of waiting to admit into Long Term Care. A basic bed can take up to a year to become available since the waitlist is much longer than the wait for a private bed.

Compliance Report/ Update: Critical Incidents – The Ministry of Health and Long Term Care (MOHLTC) has a Mandatory and Critical Incident Reporting process which requires reporting of all critical incidents in the Home. The following critical incidents were reported to the MOHLTC during the reporting period:


□ □

Mandatory and Critical Incident Reporting

Incident Type and Number (n) of Incidents

Issues Status

Falls with Fracture (1)

Resident sustained a right hip fracture while self-ambulating from washroom.

All required documentation was completed. The resident affected had their plan of care reviewed by the Falls Committee and Management team to ensure improved processes are in place to mitigate further falls.

Suspected Abuse (3): • Staff to Resident (1) • Resident to Staff (0) • Resident to Resident (2) • Other (0)

Followed City of London/ Dearness Home process for Resident Abuse and Neglect Policy and Internal process. Organization to assess and provide interventions to mitigate further harm/risk.

Investigations completed and all appropriate actions taken with staff and residents involved.

Infectious Disease Outbreak (2):

• Respiratory (1) • Gastrointestinal (1)

The respiratory outbreak on 3 West, Forest Glen, was declared on April 18, 2016 and resolved on May 2, 2016. There was minimal resident impact. The gastrointestinal outbreak on 5 West, Ash Acres, was declared on April 24, 2016, and resolved on May 2, 2016. There was minimal resident impact.

Daily surveillance and infection control measures are in place to minimize a chance of outbreak and/or duration of outbreak.

Ministry Inspections/Visits: The Ministry of Labour visited the Dearness Home on May 10, 2016 to conduct a review of the Home’s respiratory and gastrointestinal outbreaks. There were two (2) orders received:

Standards and Criteria

Ministry’s Compliance Review Findings

Nursing Home’s Compliance Plan

1. OHSA Section 32

Pursuant to O Regulation 67/93. No food, drink, tobacco or cosmetics shall be consumed, applied or kept in areas where infectious materials, hazardous chemicals or hazardous drugs are used, handled or stored. At the time of the field visit, a paper coffee cup and personal water bottles were kept at the 5th floor East nursing station where biological samples may be dropped off.

Immediate: 1. An audit of all resident home areas was completed. Staff were re-educated around appropriate storage of personal belongings, drinks and food. Long Term: 1. Regulation 67/93 will be added to the yearly mandatory staff education. Ongoing/Monitoring: 1. On-going audits (daily) to ensure personal belongings, food and drink are not kept at the nursing stations.


□ □ Standards

and Criteria

Ministry’s Compliance Review Findings

Nursing Home’s Compliance Plan

2. OHSA Section 32

Pursuant to O Regulation 67/93. No food, drink, tobacco or cosmetics shall be consumed, applied or kept in areas where infectious materials, hazardous chemicals or hazardous drugs are used, handled or stored. At the time of the field visit, a personal water bottle and a regular water bottle as well as a plastic food container with lunch products were kept at the 5th floor West nursing station where biological samples may be dropped off.

Immediate: 1. An audit of all resident home areas was completed. Staff were re-educated around appropriate storage of personal belongings, drinks and food. Long Term: 1. Regulation 67/93 will be added to the yearly mandatory staff education. Ongoing/Monitoring: 1. On-going audits (daily) to ensure personal belongings, food and drink are not kept at the nursing stations.

Infection Control Practices: The Home went into Respiratory Outbreak on April 18, 2016 and ended on May 2, 2016. All infection control measures were in place. The Home went into Gastrointestinal Outbreak on April 24, 2016 and ended on May 2, 2016. All infection control measures were in place. Monthly staff education and audits for hand hygiene and personal protective equipment (PPE) continue along with daily surveillance. Results are reviewed at the Home’s monthly Continuous Quality Improvement Committee (CQI). Reusable dressing trays used for wound care were replaced with disposable dressing trays to minimize the risk of infection. Metal forceps were also introduced for wound care to minimize the risk of infection. Health and Safety: The Occupational Health and Safety (OHS) Committee met monthly during the reporting period and conducted a full monthly physical review and inspection of the Home. The Committee ensured that any issues of concern were addressed so as to mitigate any further occurrences. As part of normal practice, all Supervisory Report of Injuries (SROI) are also reviewed at the OHS Committee level and results are brought to Continuous Quality Improvement (CQI) staff for review and analysis. The Committee is updated on the status of the Infection Control System for the Home. The Committee also continues to review health and safety policies annually to ensure we continue to remain current and provide best practice. During the reporting period the Committee continued with the Continuous Improvement Plan for the Home by reviewing related policies. The Committee was also made aware of the Accreditation process and roles of the Committee members were reviewed. During the reporting period the Committee was provided an update on the progress of the Mock Evacuation planned for May 26, 2016. Members of the Committee will be participating in the event, demonstrating the use of the Home’s emergency evacuation equipment such as Evacusleds.


□ □ General Updates: Recreation: Highlights in the Recreation Department include:

• The Home honoured over 200 Dearness Home volunteers who provide countless hours of service and care to the residents. Residents’ Council sponsored and gave City of London golf umbrellas as a gift to each volunteer.

• A formal three (3) course dinner was provided to residents and their families celebrating Mother’s Day in the Home. Over fifty residents, family and friends attended.

Dietary: Highlights in the Dietary Department include:

• The dietary department implemented revised Nutrition and Hydration Quality Assurance Protocols that identify residents with low food or fluid intake. Appropriate steps are then taken to address any nutritional concerns.

• Local farm produce, whenever possible, will be used in the planning and preparation for the introduction of the spring and summer menu.

• The Home is preparing for the replacement of its existing Dietary software program. • The Home revised its chemical and paper goods ordering system to ensure efficiencies.

Nursing: Highlights in the Nursing Department include:

• The Restorative Care Program and the Interdisciplinary Care Team have identified residents to be admitted into this program. Policies and a Restorative Nursing Guidebook has been reviewed and will be implemented to improve residents’ quality of life and potentially increase the Home’s Case Mix Index (CMI) resulting in Ministry of Health and Long Term Care funding.

• The Home has implemented a Reduction of Antipsychotics Task Force. Its goal is to identify residents whose antipsychotic medication can be substituted with an alternate lower risk medication with fewer side effects. The task force and the Home’s Pharmacist and medical team has developed a plan to review each Resident who has been prescribed an antipsychotic medication.

• The Home has created a Pain Committee to address pain issues separate from palliation. • The Home has recruited 16 casual nursing staff in preparation for the challenges of staffing

during the summer months. Environmental: Highlights in the Environmental Department include:

• A new Bed and Room Assessment Catalogue was created which tracks all changes and/or repairs made in all resident rooms in the Home. Information from the monthly, quarterly and annual Preventative Maintenance Program, as well as building and room audits are now being collated into this catalogue.

• Development of the Incident Management System (IMS) plan for the building continues. A tabletop walk through of the IMS plan was conducted on April 22, 2016. The tabletop exercise was a great success; there was valuable insight and suggestions gathered from the observers which included representatives from the City’s Facilities department for implementation of the plan.

• A full scale mock emergency evacuation drill is planned for May 26, 2016. The management team has been working with the City of London Security and Facilities


□ □ departments to develop this plan. Over sixty (60) volunteers have been secured for the drill and an agenda has been created to ensure the drill runs smoothly.

• 2016 building projects such as painting, flooring, and furniture have been reviewed and information is currently being gathered by the Facilities department and the Environmental Services Manager for Dearness. Plans for the roll out of the projects should begin in the coming months.

Accreditation:

• The Home received confirmation from the Commission on Accreditation of Rehabilitation Facilities (CARF) that two (2) surveyors will review the Adult Day Program and Long Term Care for two (2) days; June 23 and 24, 2016. As part of the preparation for Accreditation, staff champions are in training along with all stakeholders. Weekly information and updates are in progress as we prepare the Home for this exciting event to showcase the amazing services and care provided here.

Adult Day Program (ADP) & Wellness Centre:

• The program’s current capacity is 98% as of May 15, 2016. • London Area Adult Day Programs, Community Care Access Centre (CCAC) and the South

West Local Health Integration Network (SWLHIN) have streamlined waitlist times and reviewed client priority relevance and listing (priority 1, 2 or 3) for admissions to Adult Day Programs.

Homemaking Program:

• The Homemaking Program is at capacity (currently serving 55 registered clients) with over 116 clients on our waitlist.

RECOMMENDED BY: CONCURRED BY:

ANGIE HEINZ ADMINISTRATOR, DEARNESS HOME

SANDRA DATARS BERE MANAGING DIRECTOR HOUSING, SOCIAL SERVICES AND DEARNESS HOME

CC: A. Zuidema, City Manager K. Murray, Manager Financial & Business Services L. Marshall, Solicitor P. Foto, Manager, Employee and Client Relations K. Stanley, Human Resources Service Partner B. Hall, Regional Director, Extendicare Assist


□ □ TO:


MEETING ON JUNE 16, 2016 FROM: ANGIE HEINZ


SUBJECT:

ACCREDITATION

RECOMMENDATION



BACKGROUND

The attached as Appendix A and Appendix B are presentations that provide further information on the upcoming Accreditation Survey. Accreditation signals a service provider's commitment to continually improving services, encouraging feedback, and serving the community. This standard of excellence ensures fiscal savings, a marketing advantage, reduces exposure to risk and ongoing access to an international network. Dearness Administration initiated an Accreditation Review process in 2015, in order for the home (LTC Services and Adult Day Program) to successfully achieving accreditation status (expected in 2016). Through this process, it was determined that accreditation would be sought through Commission on Accreditation of Rehabilitation Facilities (CARF) International Accreditation. The City of London Dearness Home was last accredited by Accreditation Canada in 2007. On June 23rd and 24th, 2016, Surveyors CARF International is an internationally recognized Accrediting body. Both Accreditation Canada and CARF International are currently equally used in Long Term Care. CARF International was selected for the Dearness Home as their standards are more congruent with the Long Term Care model that focuses on a more holistic approach to resident care in Long Term Care Homes whereas Accreditation Canada is a more hospital based model. CARF International structures its program to ensure performance improvement and resident-centred quality care. RECOMMENDED BY: CONCURRED BY:


SANDRA DATARS BERE MANAGING DIRECTOR HOUSING, SOCIAL SERVICES AND DEARNESS HOME


Accreditation

As you are already aware, it is the goal of the Dearness Home team to become accredited by 2016. As an organization that values accreditation, the Dearness Home already strives to be innovators and leaders in the field of care for our residents who live here and our clients who attend the Adult Day Program & Wellness Centre.

What does the CARF acronym mean? Commission on Accreditation of Rehabilitation Facilities.

1

• CARF International accreditation provides a visible symbol that assures the public ofa provider's commitment to continually enhance the quality of services andprograms with a focus on the satisfaction of the persons served.

• 3 Year Accreditation: organization satisfies each of the CARF Accreditation Conditionsand demonstrates substantial conformance to the standards.

Appendix A

Accreditation- Why CARF International?

• Both Accreditation Canada and CARF International arecurrently equally used in Long Term Care.

• CARF International was selected for the DearnessHome as their standards are more congruent with theLong Term Care model that focuses on a more holisticapproach to resident care in Long Term Care Homes.

• Accreditation Canada is a more hospital based model.CARF International structures its program to ensureperformance improvement and resident-centredquality care.

CARF International Standards

3

Section 1: ASPIRE to Excellence

Assess the EnvironmentA. LeadershipSet StrategyC. Strategic PlanPersons Served and Other Stakeholders- Obtain InputD. Input from Persons Served and Other StakeholdersImplement the PlanE. Legal RequirementsF. Financial Planning and ManagementG. Risk ManagementH. Health and SafetyI. Human ResourcesJ. TechnologyK. Rights of Persons ServedL. Accessibility

CARF International Standards-cont.

4

Review ResultsM. Performance Measurement and ManagementEffect ChangeN. Performance Improvement

Section 2. Care Process for the Person Served A. Program/Service StructureB. Congregate Residential Program

Section 3. Program Specific StandardsA. Adult Day ServicesD. Person-Centered Long Term Care Communities

Appendix A – Required Written DocumentationAppendix B – Operational Time Lines

CARF International Standards-SAMPLE

5

There were 189 standards.1.H.5. There are written emergency procedures:a. For:(1) Fires(2) Bomb threats.(3) Natural Disasters.(4) Utility failures.(5) Medical emergencies.(6) Violent or other threatening situations.

b. That satisfy:(1) The requirements of applicable authorities.(2) Practices appropriate for the locale.

c. That address, as follows:(1) When evacuation is appropriate.(2) Complete evacuation from the physical facility.

CARF International Standards-SAMPLE

6

CONTINUED…(3) When sheltering in place is appropriate.(4) The safety of all persons involved. (5) Accounting for all persons involved.(6) Temporary shelter, when applicable.(7) Identification of essential services.(8) Continuation of essential services.(9) Emergency phone numbers.(10) Notification of the appropriate emergency authorities.

Intent Statement:Established emergency procedures that detail appropriate actions to be taken promotesafety in all types of emergencies.

Being prepared and knowing what to do help the persons served and personnel to respondin all emergency situations, especially those requiring evacuation. The evacuation processguides the personnel to assess the situation, to take appropriate planned actions, and tolay the foundation for continuation of essential services.

ACCREDITATION PREPARATIONHow are we getting ready?

Weekly Tips are posted around the Home; discuss with each other; ask questions

The CARF board in the staff room, Lobby & Adult Day Program has updates as we prepare for the

surveyors.Key Communications:

TIP OF THE WEEK/LOUPE/INFO BOARDS/Huddles/Newsletters/TV TOUR/Town

Hall Meetings7

SAMPLEACCREDITATION – June 23 & 24, 2016

TIP # 2WHAT IS ACCREDITATION & WHY IS IT IMPORTANT?• Compares our services with national standards of excellence for

quality and safety.• Guides our ongoing quality improvement process.• Includes an on-site survey by a team from CARF Accreditation

International.• Helps staff to become more informed and involved with important

quality and safety processes in our home.• The Ministry of Health and Long Term Care will increase Dearness

Home funding $0.33/resident/day.What might a surveyor ask?

– How have you been involved in the accreditation process?– How were you prepared for the on-site survey?

8

9

ACCREDITATION PREPARATIONJune 9th will host a CARF Team

Champs prep day –

CHAMPS:Adult Day Program: Mary B, Dee D, Rose Marie MRecreation: Patty Lynn DVolunteers: Susan DDietary: Cindy C, Christie MRN: Sue SPSW: Bettina P, Lynn B, Leonor G, Susan NRPN: Ildi O, Sue K, Cathy S, Lisa G, Laura BHousekeeping/Maintenance/Laundry: Joanne H, Dave M, Ruth

Accreditation

10

CARF Survey Dates of Thursday, June 23rd - Friday June 24th

Welcome with me our 2 Surveyors:Jed. D. JohnsonAs, M.S.W., M.B.A., Administrative Surveyor, Team Coordinator/Report Compiler, Easter Seals, Inc. Chicago, IL

Patsy H. Long, B.S., ADM, RNProgram SurveyorWarrington, PA

http://www.carf.org/home

http://www.carf.org/home

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ACCREDITATION PREPARATION

Schedule - SeeHandout

12

ACCREDITATION PREPARATION

Questions??

CARF SURVEY - Long Term Care (LTC) and Adult Day Program & Wellness Centre (ADP) Date: Thursday June 23/16

Day 1 Time Activity and Location Includes Location

1

8:00 -8:30 am

Survey Team Arrives – Welcome Jed & Patsy Survey team arrives after breakfast at hotel and sets up materials in working room provided for survey.

Angie Heinz - Administrator Melanie Camara – Director of Care Gail Johnson - Consultant Cheryl Gilmour – Manager Community Life

Lobby Welcome 4th floor Multipurpose

8:30-9:00 am

Survey Team Orientation Session Admin Surveyor/ Program Surveyor Long Term Care/ Adult Day Program & Wellness Centre

Topic: Introduction of Survey team, information about CARF International, goals of the site visit and generally setting expectations and process

Angie Heinz - Administrator Melanie Camara – Director of Care Gail Johnson – Consultant Cheryl Gilmour – Manager Community Life Simon Ojeerally – Assistant Director of Care Kelly Elgie – Manager CQI/Education/Compliance Elena Ellis – Assistant Director of Care Graeme Wood – Social Worker Ben Gibson – Manager of Environmental Services James Drummond – Dietary Manager Nora Rexhvelaj – Manager Accounting/Reporting Jackie Harwood – Admin Assist Dee Decock- Team Assistant

Adult Day Program & Wellness Centre

9:00 – 9:30 am

Tour: Admin Surveyor/ Program Surveyor Long Term Care/ Adult Day Program & Wellness Centre

Cover the programs/ areas being accredited

Maureen Mooney – Resident Council President Roy Leidelmeijer – Resident Council Vice President Rick Gregory- Family Council President/Volunteer Angie Heinz - Administrator Cheryl Gilmour – Manager Community Life

Adult Day Program & Wellness Centre Lobby Oakdale 2nd Floor Admin 5th Floor

9:30 -10:00 am

Orientation to Workroom, documentation, intranet, designated printer for surveyor use.

Please note: please ensure room has access to a confidential printer

Cheryl Gilmour – Manager Community Life with Jed/Patsy

4th floor Multi Purpose & Clinical Conference Rooms

Appendix B



2

10:00-12:00 pm

Meeting- Admin Surveyor Long Term Care/ Adult Day Program & Wellness Centre 10:00-10:45- Leadership, Input of Persons Served, Risk Management, Financial Planning, Billing process, Legal Requirements, Technology for organization 10:45-11 – BREAK 11:00-11:30- HR focus, orientation, training and education, hiring, Volunteer management 11:30-12:00- Review of Employee Files & Volunteer Files

Nora Rexhvelaj – Manager Accounting/Reporting Angie Heinz - Administrator Cheryl Gilmour – Manager Community Life

Susan Drouin – Volunteer Coordinator Kara Stanley – HR Partner Kelly Elgie – Manager CQI/Education/Compliance

15 Personnel Files (both ADP & LTC) 5 Volunteer Files (both ADP & LTC)

4th floor- Clinical Conference Room

Meeting: Program Surveyor Long Term Care 10:00-10:30- Interview with Medical Director 10:30-10:50- Interview with Clinical Consultant Pharmacist, Director of Care & Accreditation Consultant 10:50-11:05- BREAK 11:05-11:25- Interviews with Front Line Staff Program Surveyor 11:25-12:00- Program Surveyor to review Resident Charts

Dr. Nancy McKeough - Medical Director Luis Viana – Pharmacist Melanie Camara – Director of Care Gail Johnson – Consultant

PSW: Bettina Poortinga, Lynn Birkby, Leonor Goos, Susan Nakayenga, Mary Brekelmans Recreation: Patty Lynn Dilling Housekeeping: Dave McCormick Dietary: Cindy Clark, Christie Mills Maintenance: Ruth Steinbach Laundry Jo-anne Hepburn

Closed Charts(5 LTC/2ADP), Resident/Client Charts (20 LTC, 10 ADP)

4th floor- Multi Purpose Room



3

12:00 – 12:40 pm

Lunch and documentation review NOTE: If possible Program Surveyor to have lunch with residents.

12:45-1:15 pm

Surveyor Meeting: Admin Surveyor Meeting: Strategic Planning, Performance Improvement Long Term Care/ Adult Day Program & Wellness Centre

Angie Heinz - Administrator Cheryl Gilmour – Manager Community Life Melanie Camara – Director of Care Kelly Elgie – Manager CQI, Education, Compliance Gail Johnson – Consultant


Program Surveyor Family Interviews – Long Term Care Topic: Input from Persons Served, Rights of Persons Served Depending on Time, Admin Surveyor may join in on this meeting.

Rick Gregory- Family Council President Louisa Anzic- Family Council Member Dorothy MacDonald – Family Council Member Lori Neemuth – Family Member


1:15- 1:45pm

Maintenance/Physical Plant & Food Services- Admin Surveyor Follow up on any sections that require clarification from earlier meetings.

Ben Gibson – Manager of Environmental Services James Drummond – Dietary Manager

4th Floor Clinical Conference Room

Adult Day Program & Wellness Centre Interview: Input from Persons Served Program Surveyor Adult Day Program & Wellness Centre

2-3 Clients Viki Clarke - Caregiver Andrew Habib - Caregiver


1:45-2:15 pm

Surveyor Meeting: Program Surveyor Program Surveyor to Interview Clinical Team – Long Term Care

Simon Ojeerally – ADOC Infection Control Lead RN – Sue Sang RPN – Ildi Orosi, Laura Bali Sue Kirkpatrick – Behavioural Support Lead RPN Graeme Wood - Social Worker Lisa Galbraith – RAI Coordinator RPN Cathy Simons – Wound Care & Continence RPN Victoria Craig – Dietitian




4

Stakeholder Meeting: Admin Surveyor Long Term Care/ Adult Day Program & Wellness Centre

Colin VanDeWetering - Respiratory Therapist; Western ProResp Inc. Larry Needham – Physiotherapist, Achieva Health Joanne Dow – Public Health Nurse, Infectious Disease Control; Middlesex London Health Unit Stacey McKell – Transit Manager, Boys & Girls Club of London Transportation Paul Knauer – Chaplain, Dearness Home

4th Floor Clinical Conference Room

2:15-2:45 pm

Surveyor Meeting: Program Surveyor Residents- Includes a diverse group - Long Term Care Topic: Input from Persons Served, Rights of Persons Served

Maureen Mooney – Resident Council President Roy Leidelmeijer – Resident Council Vice President Karen Johnson – Resident Council Rep Bertha Halbot – Resident Council Rep Jean Brown - Resident

4th floor Multi-purpose Room

Surveyor Meeting: Admin Surveyor Topic: Health & Safety, Accessibility Planning Long Term Care/ Adult Day Program & Wellness Centre

Ben Gibson – Manager of Environmental Services Angie Heinz - Administrator Cheryl Gilmour – Manager Community Life Gail Johnson – Consultant

4th Floor Clinical Conference Room & Physical Plant

2:45-3:15pm

Surveyor Meeting: Program Surveyor Program Surveyor to Interview Care Team – Adult Day Program

Rose Marie McGaw – Recreation Coordinator Mary Brekelmans – PSW Dionne Decock – Team Assistant Cheryl Gilmour – Manager Community Life Angie Heinz – Administrator

4th floor Multi-purpose Room

2:45-3:15pm

Documentation Review- Admin Surveyor 4th Floor Clinical Conference Room

3:15-4:00pm

Documentation Review- Admin Surveyor/ Program Surveyor


4:00-4:30 pm

Surveyor Meeting- Documentation Review Topic: Review of day, information needs, check-in point for any needs at this time.

Angie Heinz - Administrator Cheryl Gilmour – Manager Community Life Gail Johnson – Consultant

4:30-4:45 End of Day Wrap Up with Team

Angie Heinz - Administrator Melanie Camara – Director of Care Gail Johnson – Consultant



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Cheryl Gilmour – Manager Community Life Simon Ojeerally – Assistant Director of Care Kelly Elgie – Manager CQI/Education/Compliance Elena Ellis – Assistant Director of Care Graeme Wood – Social Worker Ben Gibson – Manager of Environmental Services James Drummond – Dietary Manager Nora Rexhvelaj – Manager Accounting/Reporting Jackie Harwood – Admin Assist

5:00 pm Survey team exits Note: If possible, team continues to review documents from 5:00-6:00 if needed. Will verify at end of day wrap up with Accreditation Lead – Cheryl Gilmour.

Survey Team only


□ □ TO:



FROM: ANGIE HEINZ


SUBJECT:

MINISTRY OF HEALTH AND LONG-TERM CARE RESIDENT QUALITY INSPECTION PROCESS OF LONG-TERM CARE

HOMES

RECOMMENDATION



BACKGROUND

The Ministry of Health and Long – Term Care inspection systems was developed to comply with the new Long-Term Care Homes Act (2007) (LTCHA) and it’s regulations, which was proclaimed on July 1, 2010. The attached presentation as Appendix A provides an overview of the Resident Quality Inspection (RQI) process to the Dearness Home Committee of Management as well as how the results of the Dearness Home’s 2015 RQI compares to other Long -Term Care Homes within the City of London.

The Long-Term Care Home Quality Inspection Program (LQIP) safeguards residents’ well-being by continuously investigating complaints, concerns and critical incidents, and by ensuring that all Homes are inspected at least once per year.

The purpose of LQIP is to: • Protect over 76,000 residents in Ontario’s 629 LTC Homes. • Safeguard resident rights, safety, security and quality of life. • Ensure LTC Homes comply with legislation and regulations.

This is achieved by performing unannounced inspections and enforcement measures as required, and ensuring that actions taken by the government are transparent. The Ministry of Health and Long Term Care (MOHLTC) conducts complaint, critical incident, follow-up, comprehensive and other types of inspections. Copies of the public version of inspection reports detailing all findings of non-compliance must be publicly posted in Long Term Care Homes and provided to Residents’ and Family Councils. They are also published on the Ministry’s website. To obtain a Home’s inspection report, you can request it from the Home directly or locate reports on this website. http://publicreporting.ltchomes.net/en-ca/default.aspx http://publicreporting.ltchomes.net/en-ca/homeprofile.aspx?Home=M514 http://health.gov.on.ca/en/public/programs/ltc/31_pr_inspections.aspx

Key features of LQIP include:

• Structured interviews with residents, family members and staff, direct observations of how

care is being delivered as well as specifically targeted record reviews. • The use of independently validated methods to conduct inspections that are consistent

and trigger the need to complete Inspection Protocols.

http://publicreporting.ltchomes.net/en-ca/default.aspx

http://publicreporting.ltchomes.net/en-ca/homeprofile.aspx?Home=M514

http://health.gov.on.ca/en/public/programs/ltc/31_pr_inspections.aspx


□ □ • Adapted to meet specific requirements of the Long Term Care Homes Act, 2007 (LTCHA)

and the characteristics of Long-Term Care Home residents. • Tested prior to implementation. • Use of certified inspectors in a team to support consistency. • Inspection Protocols requiring inspectors to determine whether the standards of care set

out in the LTCHA are being met. • Transparency. • Resident questionnaires and Inspection Protocols are available to Homes so they know

what is expected of them and can incorporate this into their own educational and quality improvement programs.

• Use of specially developed technology and professional training to support inspectors. • Follow-up where non-compliance is identified.

RECOMMENDED BY: CONCURRED BY:


SANDRA DATARS BERE MANAGING DIRECTOR HOUSING, SOCIAL SERVICES and DEARNESS HOME


How the Inspection Process Works

Long-Term Care Quality Inspection

Program

Appenix A

Long-Term Care Quality Inspection

Program The Ministry of Health and Long-term Care inspection system was

developed to comply with the new Long-term Care Homes Act (2007) (LTCHA) and its regulation, which was proclaimed on July 1, 2010.

Not all complaints and CI’s result in an inspection and Follow-ups are only required if an order has been issued.

The Act also states that every long-term care home shall be inspected at least once a year.

The inspectors use the specific MOHLTC Inspection Protocols to determine whether or not the Home is compliant with the Act and its regulation Inspection Protocols are tools to guide inspectors and include instructions, probes and questions to determine the status of a Home’s compliance with legislation.

Types of Inspections Resident Quality Inspections (RQI). These are the most

comprehensive inspections of a long-term care home. Comparable

to the annual inspections under the old Acts but more in-depth, the RQI

is a two-stage process.

Stage 1 – a preliminary inspection using interviews, records

and observations of 40 randomly selected residents. This stage

also includes interviews with family and staff, as well as residents’

council and family council members.

Stage 2 – an in-depth inspection based on areas triggered from

Stage 1 i.e. resident related, Home related and mandatory

protocols in order to determine compliance with the Act and

regulations.

Types of Inspections Complaint Inspections – Not all Complaints are responded to by a

visit to the home, some are handled as an inquiry by telephone.

Critical Incident Inspections –These inspections are initiated as a result of a critical incident in a Home. In these cases the inspection specifically examines whether the Home has complied with the regulations around reporting, documenting, and handling the incident. Compliance is determined for both the Act and the Regulation and includes looking at the incident itself to ensure due diligence was undertaken prior to reporting the incident and also involves reviewing the resident’s plan of care as it relates to the incident.

Follow-up Inspections – Inspectors are required to complete a follow-up inspection whenever there has been a Compliance Order issued to ensure compliance has been achieved.

Inspection Reports

Each inspection visit results in 2 reports; one of which is public and available on the MOH LTC website, and the other a confidential report, which often contains personal information and personal health information about an individual. Also, every long-term care home is required to post their recent public reports (the last two years) in a conspicuous and easily accessible location.

Each type of inspection report gives the date and type of inspection, the purpose of the visit, and the names of the inspectors and which inspection protocols were used.

The report states whether or not the Home was found to be in compliance with the Act and Regulations.

Inspection Reports/Enforcement

Actions Each non-compliance results in an Inspector issuing one of the following:

1. Written notification (WN), which states the relevant section/subsection of the Act and its regulation and the specific non-compliances related to the non-compliance.

2. Issue a written request to the licensee to prepare a written plan of correction for achieving compliance, to be implemented voluntarily.

3. Make an order under section 153 or 154.

4. Issue a written notification to the licensee and refer the matter to the Director for further action by the Director.

The additional required actions may include the following, depending on the scope, severity and history of the Home:

Voluntary Plan of Correction (VPC) – the Home is requested to voluntarily prepare a written plan of correction for achieving compliance with the specific section of the Act.

Compliance Order (CO) or Work and Activity Order –the Home is required to comply with the order by a given date.

Directors Referral (DR) – the matter is referred to the Director of the Performance Improvement and Compliance Branch for further action.

Actions/Enforcement Actions that can

be taken by an Inspector

Enforcement Actions Voluntary Plan of Correction (VPC) – the Home is requested to

voluntarily prepare a written plan of correction for achieving compliance with the specific section of the Act.

Compliance Order (CO) Order and/or Work and Activity Orders Directors Referral (DR) – the matter is referred to the Director of the

Performance Improvement and Compliance Branch for further action.

Orders: Do or refrain from doing something and/or to prepare and submit a plan for

achieving compliance. Allow MOH, agents or contractors acting under MOH to perform a work or

activity order and Licensee to pay applicable costs.

Under the Long-term Care Homes Act, the Director,

or designate, has the following powers:

Cease Admissions – direct the Community Care Access

Centre to cease admissions to the Home;

Withhold Funding – direct LHIN to withhold funding;

Mandatory Management – require the Licensee (the

holder of the provincial license to operate the Home) to

retain someone to manage or assist in managing the Home,

and;

Revocation of License – revoke or refuse to renew the

Home’s license.

Top 10 Issued @ RQIs: All non-

compliances (WN’s) June 2013 – Jan. 31, 2015

Rank Non-Compliance Description # times

issued

#of LTCHs

in which

issued

% of LTCHs in

which issued

1 LTCHSA s.6 Plan of Care 518 506 81%

2 O Reg 79/10 s.229 IPAC 427 421 67%

3 O Reg 79/10 s.8 Policies > in compliance

with LTCHA

Policies> home to comply

with own policies

352 346 55%

4 LTCHA s.15 Accommodation Services >

cleanliness and repairs of

home, furnishings and

equipment

333 327 52%

5 LTCHA s.3(1) Resident’s Bill of Rights 305 301 48%

Top 10 Issued @ RQIs: All non-

compliances (WN’s) June 2013 – Jan. 31, 2015


issued

# of LTCHs in

which issued

% of LTCHs in

which issued

6 O Reg 79/10 s. 73 Dining and Snack Service 248 242 39%

7 O Reg 79/10 s.129 Safe Storage of Drugs 234 233 37%

8 O Reg 79/10 s.17 Communication and

Response System

222 218 35%

9 O Reg 79/10 s.50 Skin and Wound Care

(required programs)

208 208 33%

10 LTCHA s.85 Resident and Family

Satisfaction

206 204 33%

Top 10 Issued @ RQIs: Compliance

Orders June 2013 -Jan 31, 2015


issued

# of LTCHs in

which issued

% of LTCHs

in which

issued

1 O Reg 79/10 s.15

(1)

Safety issues related to

bedrails

62 57 9%

2 O Reg 79/10 s.19

(1)

Generator availability and

capacity

30 30 5%

3 O Reg 79/10 s.9 Doors in the Home >

requirements

30 25 4%

4 O Reg 79/10 s.17

(1)

Communication and Response

System

29 24 4%

5 LTCH s.3 (1) Resident’s Bill of Rights 26 26 4%

Top 10 Issued @RQIs: Compliance

Orders June 2013 -Jan 31, 2015

Rank Non-Compliance Description # of times

issued

# LTCHs in

which

issued

% of LTCHs in

which issued

6 LTCHA s.6(7) Plan of Care > care provided

according to the plan of care

25 25 4%

7 LTCHA s.15(2) Accommodation Services >

cleanliness and repairs of the

home, furnishings and

equipment

25 24 4%

8 O Reg 79/10 s.8(1) Policies > incompliance with

the LTCHA

Policies > home to comply

with own policies

24 24 4%

9 LTCHA s.6(1) Plan of Care > ensure a

written plan of care for each

resident

21 21 3%

10 O Reg 79/10

s.73(1)

Dining and Snack Service 20 17 3%

RQI Inspection Results

Provincial Average

Type of non-Compliance Average # at RQI

Written Notification 12

Compliance Order 2

2015 RQI Reported Findings

(Taken from the LTC Public Website)

HOME WN's VPC's CO's DR's WAO's # Inspector

Visits

Marion Villa21 14 5 0 0 17

Meadow Park 17 11 4 0 0 16

Earls Court Village 16 14 2 0 0' 30

McGarrell Place 15 14 0 0 0 5

Mount Hope 12 10 1 0 0 9

PeopleCare

- Oak Crossing 11 8 0 0 0 4

Westmount Gardens 11 8 0 0 0 9

Chelsey Park 10 9 0 0 0 7

Kensington Village 10 7 0 0 0 14

Glendale Crossing 9 6 2 0 0 16

Henly Place 6 3 0 0 0 15

Dearness Home 5 2 2 0 0 10

Chateau Gardens 4 2 0 0 0 6

Elmwood Place 4 2 0 0 0 6

McCormick Home 2 2 0 0 0 4

Extendicare London 1 1 0 0 0 5


□ □ TO:



FROM: ANGIE HEINZ


SUBJECT:

DEARNESS HOME LEVEL 4 EVACUATION

RECOMMENDATION

That, on the recommendation of the Administrator, Dearness Home, that this report BE RECEIVED for information.


BACKGROUND

The Incident Management System IMS team at Dearness conducted a live test of the evacuation plan on May 26, 2016. The attached presentation as Appendix A provides a summary of the planning, execution and results of the mock evacuation event at Dearness Home. The Province of Ontario has identified the need to implement an approach to emergency management that would permit ministries, communities, organizations, institutions, and industry to operate more cohesively. They also recognized that such a system should acknowledge existing emergency management systems and take advantage of their strengths in developing a standardized, Province wide approach. The Incident Management System (IMS) was found to be the most appropriate basis to accomplish these outcomes. In addition to the creation of the IMS, the Long-Term Care Homes Act, 2007, (LTCHA), and its Regulation (O.Reg. 79/10), governs the Long Term Care Homes (LTCH) in Ontario and sections 87 and 230 outline the requirement to create, train, implement and test an emergency plan for the Home. As such the Dearness Home, working with Corporate Security and Emergency Management Team, developed the IMS plan for the Home. The purpose of the plan is to pre-plan a level 4 evacuation (Code Green) of the Dearness Home in the event of a worst case scenario.

SUBMITTED BY: RECOMMENDED BY:

BEN GIBSON MANAGER OF ENVIRONMENTAL SERVICES, DEARNESS HOME


CC: S. Datars Bere, Managing Director Housing, Social Services and Dearness Home A. Zuidema, City Manager K. Murray, Manager Financial & Business Services L. Marshall, Solicitor P. Foto, Manager, Employee and Client Relations K. Stanley, Human Resources Service Partner B. Hall, Regional Director, Extendicare Assist

IMS Planning

and

Mock Evacuation Drill

May 26, 2016

Appendix A

Background

• Recently, Ontario has identified the need to implement an

approach to emergency management that would permit

ministries, communities, organizations, institutions, and industry

to operate more cohesively.

• It was recognized that such a system should acknowledge

existing emergency management systems and take advantage of

their strengths in developing a standardized, Province wide

approach.

• The Incident Management System (IMS) was found to be the

most appropriate basis to accomplish these outcomes.

• There is also a legislated requirement in the Long Term Care

Homes Act, 2007, (LTCHA), and its Regulation (O.Reg. 79/10),

sections 87 and 230 that outlines the requirement to create, train,

implement and test an emergency plan for the Home.

IMS Planning

• Over the past several months working with the Corporate

Security and Emergency Management team, the IMS plan was

developed for the Home.

• The aim of the plan is to pre-plan a level 4 evacuation (Code

Green) of Dearness Home to South London Community Centre,

in the worst case scenario.

Mock Evacuation

• Part of the IMS plan and a requirement of the LTCHA, is to

demonstrate the evacuation process.

• On May 26, 2016 Dearness Home conducted a live mock full

evacuation of the Home.

• The process involved 60 outside volunteers to act as “stand ins”

for our residents, 25 staff members to act as the evacuators,

family volunteers, additional staff members to support the

process and of course the IMS team made up of the

Management team.

• The process was to evacuate all 5 floors of the Home from the

top down, taking into consideration the safety of residents and

volunteers.

• There were wheelchairs and evacusleds used to simulate the

diversity of abilities within the Home.

• It was a top down process, evacuating the secure units last and

using only one elevator as the means of egress.

0

5

10

15

20

25

30

5th floor 4th floor 2nd floor 3rd floor 1st floor

East time

West time

Total floor Time

A variety of methods to time the evacuation were used;

• 5th floor was timed as a whole, but evacuated separately

• 4th floor was timed and evacuated separately

• 2nd floor, East and West were evacuated at the same time, one

time recorded

• 3rd floor was timed and evacuated separately

• 1st floor had its own time as there is no West side.

• Total time to evacuate was 1 hour 28 minutes!

• That time can only improve with the use of all three elevators as

well as the process of evacuating both East and West at the

same time.

• There were some addition suggestions from our observers on

how to make changes for when the drill is run the next time.

• Those suggestions will be incorporated into the IMS plan and

into drills that are run in the future.

Overall the process was well received and was an excellent learning

experience for all involved!

a g e n d a dearness home committee of management · a g e n d a . dearness home committee of...

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