A G E N D A DEARNESS HOME COMMITTEE OF MANAGEMENT Meeting to be held on Tuesday, September 4, 2018, commencing at 12:00 PM, at Dearness Home, 710 Southdale Road E, London N6E 1R8. Committee Members: Councillors H.L. Usher (Chair), A. Hopkins (Vice Chair), T. Park, V. Ridley, and J. Zaifman, and C. Saunders (Secretary). I. CALL TO ORDER
1. Disclosures of pecuniary interest(s), if applicable. II. CONSENT ITEMS
2. 3rd Report of the Dearness Home Committee of Management
3. Administrator’s Report to the Committee of Management for the Period May 1, 2018 to July 31, 2018.
III. SCHEDULED ITEMS IV. ITEMS FOR DIRECTION V. DEFERRED MATTERS/ADDITIONAL BUSINESS VI. CONFIDENTIAL VII. NEXT MEETING DATE
November 14, 2018 at 12:00 p.m., Committee Room #4, City Hall. VIIl. ADJOURNMENT
MINUTES OF THE 3RD MEETING OF THE DEARNESS HOME COMMITTEE OF MANAGEMENT Meeting held on Wednesday, May 23, 2018, commencing at 12:01 PM in Committee Room #4, 2nd floor, City Hall. PRESENT: Councillors H.L. Usher (Chair), A. Hopkins, T. Park, V. Ridley, and J. Zaifman, and L. Rowe (Acting Secretary). ALSO PRESENT: S. Datars Bere, A. Hagan, B. Hall (Extendicare), E. Marion-Bellemare, L. Marshall and J. Westbrook. 1. Disclosures of Pecuniary Interest
None were disclosed. 2. Minutes of the 2nd Meeting of the Dearness Home Committee of Management ZAIFMAN AND RIDLEY That the Minutes of the 2nd Meeting of the Dearness Home Committee of Management,
from its meeting held on March 21, 2018, BE RECEIVED. CARRIED 3. Administrator’s Report to the Committee of Management for the Period March 1, 2018 to
April 30, 2018 HOPKINS AND ZAIFMAN
That, on the recommendation of the Administrator, Dearness Home, with the concurrence of the Managing Director, Housing, Social Services and Dearness Home, the report dated May 23, 2018, entitled “Administrator’s Report to the Committee of Management for the Period March 1, 2018 to April 30, 2018”, BE RECEIVED for information. CARRIED
4. Next Meeting Date That it BE NOTED that the next meeting of the Dearness Home Committee of
Management will be held September 19, 2018, 12:00 PM, at the Dearness Home. 5. Adjournment
ZAIFMAN AND RIDLEY That the meeting of the Dearness Home Committee of Management BE ADJOURNED. CARRIED. The meeting adjourns at 12:30 PM. ___________________________________ H.L. Usher, Chair ___________________________________ L. Rowe, Acting Secretary
Agenda Item # Page #
□ □ TO:
CHAIR AND MEMBERS
DEARNESS HOME COMMITTEE OF MANAGEMENT MEETING ON SEPTEMBER 4, 2018
FROM: BRAD HALL
ADMINISTRATOR, DEARNESS HOME
SUBJECT:
ADMINISTRATOR’S REPORT TO THE COMMITTEE OF MANAGEMENT FOR THE PERIOD MAY 1, 2018 TO JULY 31, 2018.
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 21, 2018, Administrator’s Report November 16, 2017 to February 28, 2018 • May 23, 2018, Administrator’s Report March 1, 2018 to April 30, 2018
BACKGROUND
Service Provision Statistics:
Occupancy Average January 1, 2018 to
July 31, 2018
Occupancy Average for
Previous Year (2017)
98.4% 98.34%
Number of Individuals on Waiting List as of
September 16, 2017
Number of Individuals on Waiting List as of January 22, 2018
Number of Individuals on Waiting List as of March
21, 2018 Basic – 275 Private - 52
Basic – 271 Private - 39
Basic – 278 Private - 47
Agenda Item # Page #
□ □ 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
An injury that results in a resident transfer to hospital:
• Falls with Fracture (3)
Fractures include a right hip, a left hip and a pelvic fracture.
All required documentation was completed. The residents 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. Fall Statistics:
• 22.2% of residents fell in May.
• 23.4% of residents fell in June.
• 19.7% of residents fell in July.
• 42.6% of residents who fell were found on the floor (unwitnessed).
• 82.3% had no injury.
• 17.7% had temporary injury.
• 1.6% were transferred to hospital.
Abuse or neglect of a resident that resulted in harm or risk of harm: Suspected Abuse (2):
• Staff to Resident (1) • Resident to Resident (1)
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 for all incidents.
An Outbreak of a Reportable Disease:
• Acute Respiratory (1)
• Enteric (1)
The acute respiratory outbreak on 4 West, Pine Grove was declared on May 2, 2018 and resolved on May 8, 2018. There was minimal resident impact. The enteric outbreak on 4 West, Pine Grove was declared on July 11, 2018 and resolved on July 16, 2018. 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.
Missing Resident • Missing less than 3
hours. (1)
Resident returned to the home unharmed. Resident failed to notify staff of their outing.
All required documentation was completed. Code Yellow policy was followed.
Agenda Item # Page #
□ □ Infection Control The Dearness Home’s Public Health representative attended its Professional Advisory Committee meeting in June and provided comments around the Home’s infection control practices. Comments included that our early identification reporting of the initial suspected respiratory outbreak was very effective in preventing further transmission and reinforced the Home’s diligence with preparation for a possible influenza outbreak including reinforcement for unvaccinated staff to receive influenza vaccinations. Ministry Inspections/Visits: The Public report related to a visit by the Ministry of Health and Long Term Care on April 12, 13, 19, 20 and 23, 2018 attached as “Appendix A”. This report was not available for the May 23, 2018 Committee of Management meeting. The purpose of this inspection was to conduct a Critical Incident System Inspection related falls. There were no findings. The Public report related to a visit by the Ministry of Health and Long Term Care on April 19, 20, and 23, 2018 attached as “Appendix B”. This report was not available for the May 23, 2018 Committee of Management meeting. The purpose of this inspection was to conduct a Critical Incident System Inspection related to alleged abuse. There were three (3) written notifications (WNs) and two (2) voluntary plans of correction (VPCs) issued. The Home’s voluntary plan of correction attached as “Appendix C”. The Ministry of Health and Long Term Care visited the Dearness Home on July 19, 2018 to conduct a Critical Incident Review related to falls. The public report attached as “Appendix D”. There were no findings. The Middlesex-London Health Unit visited the Dearness Home on May 28, 2018 to conduct a Food Safety Inspection. There were no findings. The Ministry of Labour visited the Dearness Home on May 24, 2018 to conduct an Occupational Health and Safety Review regarding the Home’s respiratory outbreak on April 24, 2018. There were no findings. Health and Safety: The Occupational Health and Safety (OHS) Committee met monthly during the reporting period, and regular inspections were conducted. Health and Safety procedures continue to be reviewed annually and the committee remains on track with the annual review. Health and Safety workplace inspections were completed and timely responses to items have been addressed. The Supervisory Report of Injuries (SROIs) are also reviewed at the OHS Committee level and results are reviewed at the Continuous Quality Improvement Committee. An improved tracking of Workplace Violence Prevention has been developed and implemented. This allows for incidents related to a specific person to be recognized and the information shared with the Behavioural Supports Team. General Updates: Highlights in the Recreation Department include:
• Dearness Home received its Year 3 seal of Accreditation through the Commission on Accreditation for Rehabilitation Facilities (CARF). The next survey date is scheduled for May through June, 2019.
• The Dearness Home Auxiliary raised over $2000 from their annual Fashion Show. All proceeds directly support our residents.
• The new Chaplain started their new role August 13, 2018. • The Home’s volunteer training program was updated to include Competency Based
Training for volunteers who work with residents with Dementia. Training included Stop & Go Approach, Validation Therapy, Meeting Resident Abilities for Successful Interventions and Accessing Resources.
• Recreation Coordinators and the Manager of Community Life attended the TRO Therapeutic Recreation Ontario Conference (TRO) in Ottawa. The theme was Growing
Agenda Item # Page #
□ □ Our Profession and Re-energizing the Work We Do. The conference material provided us an opportunity to expand our practice for the residents and clients we serve as well as Wellness opportunities for Self Care to ‘re-energize’ our abilities as practitioners.
Dietary: Highlights in the Dietary Department include:
• The Dietary Department is planning the introduction of Menustream that is an extension of Synergy on Demand. This will result in the Dietary Department working virtually paperless as all resident nutritional information will be stored electronically and will be accessed via touch screens on all home areas. This system will ensure that all resident information is current at the touch of a button as well as resulting in minimizing errors.
• Staffing: A new Cook and Dietary Aide started in their roles during the reporting period. • Dietary staff received their Food Handlers certifications this quarter through in-house
training.
Nursing: Highlights in the Nursing Department include:
• Staff education continued May through July. To date, 125 staff have received their training.
• The Home scheduled Personal Support Workers (PSW’s) from select resident home areas for U-First training. U-First is a training program that helps frontline staff, mostly PSW’s, to develop a common knowledge base, language, values and approach to caring for people with Alzheimer’s disease and other dementias. It serves to develop an understanding of associated behavior changes and how to work as a team to develop individualized support strategies.
• The Home offered Cardiopulmonary Resuscitation (CPR) recertification training for twenty two (22) of our staff in collaboration with our oxygen and respiratory care provider, ProResp.
• Rexall Pharmacy hosted education on Pain Management in the Elderly in June. The training focused on the challenges associated with pain management for the elderly, effective pain assessments, and pharmacological and non-pharmacological treatment options.
• In response to the success of the Comfort Rounds trial in March, on June 1st the Home permanently instituted Comfort Rounds for identified frequent fallers. The June and July falls statistics show that of our frequent fallers identified in May, who were subsequently placed on the program in June, 50% had no falls (100% reduction) and 20% had an 80% - 90% reduction in falls. The remaining 30% saw no increase or decrease in falls.
• Six Sigma White Belt training certification was provided to one of the Home’s Assistant Directors of Care. The White Belt level is the first level of certification that provides the trainee with information about basic concepts of Six Sigma. It allows the trainee to assist with change management within the Home, implement lean practices, and assist with productivity and performance improvement.
• One of the Home’s Assistant Directors of Care completed their Gerontological Nursing Certification (GNC(c)). This certification identifies them as possessing specialized knowledge and skills in the field of gerontology and is granted by the Canadian Nurses Association.
• In June the Home ordered twenty four (24) new Pressure IQ Evolve mattresses. These new specialty mattresses are designed for the prevention and treatment of stage I - IV pressure ulcers. Pressure ulcers are a serious risk and concern for the residents of Long Term Care as they can have a significant negative impact on quality of life for our residents.
• On July 26, 2018, the Home hosted a Java webinar entitled Embracing Diversity. The webinar was organized by the Bruyère Centre for Learning Research and Innovation (CLRI) in Long-Term Care. Representatives from all areas of the Home attended including recreation, dietary, and nursing. The webinar explored strategies to increase inclusiveness in Long Term Care programs and how to put embracing diversity into action.
Agenda Item # Page #
□ □ Environmental: Highlights in the Environmental Department include:
• Planning for additional upgrades to the building management system has already begun through the City’s Facilities Department.
• Electrical upgrades to improve efficiency and reduce costs is being reviewed for 2018 year end.
• The parking lot improvements are expected to be completed August 31, 2018. The rear parking lot will be replaced. The front staff and visitor parking lots will be patched and relined.
• All of the resident bedside tables have now been replaced and additional floor lifts were purchased and are in use.
• Roof repairs has been completed. The replacement of the Home’s hot water heaters is anticipated replacement by the end of 2018.
• Preliminary planning has begun to upgrade all washroom fixtures throughout the Home.
RECOMMENDED BY: CONCURRED BY:
BRAD HALL ADMINISTRATOR, DEARNESS HOME
SANDRA DATARS BERE MANAGING DIRECTOR HOUSING, SOCIAL SERVICES AND DEARNESS HOME
CC: M. Hayward, City Manager K. Murray, Manager Financial & Business Services J. Brown, Financial Business Administrator L. Marshall, Solicitor A. Hagan, Manager, Labour Relations K. Stanley, Human Resources Service Partner A. Loft, Director of Operations, Extendicare Assist
Appendix A
Appendix B
Min
istr
y
Nurs
ing
Com
plia
nce R
evie
w F
indin
gs r
efle
ct
the M
inis
try o
f H
ealth’s
fin
din
g b
ased o
n M
inis
try s
tandard
s a
nd c
rite
ria
for
of
Hom
es
resid
ent
care
and n
urs
ing h
om
e s
erv
ices.
Com
plia
nce P
lans r
efle
ct
the h
om
e’s
corr
ective a
ctio
n p
lans t
o r
each
Hea
lth
B
ranch
com
plia
nce w
ith t
he M
inis
try’s
sta
ndard
s.
Min
istè
re
Directio
ns d
es
Les r
ésultats
de l’in
spectio
n d
e c
onfo
rmité s
ont
tiré
s d
e l’in
spectio
n e
ffectu
ée p
ar
le m
inis
tère
de la
Santé
en f
onctio
n
de
mais
ons d
e
des n
orm
es e
t critè
res d
ue m
inis
tère
pour
les s
oin
s d
ispensés a
ux p
ensio
nnaires e
t le
s e
rvic
es o
ffert
s d
ans le
s m
ais
ons
la S
anté
soin
s in
firm
iers
des s
oin
s in
firm
iers
contie
nt
les m
esure
s c
orr
ectives q
ue l’é
tablis
sem
ent
ente
nd a
dapte
r pour
se c
onfo
rmer
aux n
orm
es
du m
inis
trè
2611-5
2 (
89/1
2)
Page
1 o
f/de _
On
tari
o
Co
mp
lia
nc
e
Pla
ns
Pla
ns
de
c
on
form
ité
Nam
e a
nd a
ddre
ss o
f N
urs
ing
Hom
e/N
om
et
adre
sse d
e la
mais
on
de s
oin
s in
firm
iers
Dearn
ess H
om
e
710 S
outh
dale
Rd
London,
ON
Com
plia
nce R
evie
w D
ate
/Date
de
l’in
spectio
n d
e c
onfo
rmité
F
rom
/de
T
o/à
April 12,
2018
Com
plia
nce A
dvis
or/
Conseill
er-
inspecte
ur
Ju
lie L
am
pm
an
June 6
, 2018
Type o
f R
evie
w/G
enre
d’in
spectio
n:
Cri
tical
Inc
iden
t
Ins
pecti
on
Pla
n s
ubm
itte
d b
y/P
lan s
oum
is p
ar
Eil
een
Mari
on
-Bell
em
are
Sig
natu
re o
f P
ers
on S
ubm
ittin
g P
lan
P
lan R
eceip
t D
ate
/Date
de r
éceptio
n d
e p
lan
Sta
ndard
s a
nd
Crite
ria
N
orm
es e
t critè
res
Min
istr
y’s
Com
plia
nce R
evie
w
Fin
din
gs
Resultats
de l’in
spectio
n d
u
min
istè
re
Nurs
ing H
om
e’s
Com
plia
nce P
lan
P
lan d
es m
esure
s c
orr
ectives d
e la
mais
on d
e s
oin
s in
firm
iers
R
esponsib
le
Pers
on
Ta
rget
Date
WN
# 1
V
PC
LT
CH
A,
20
07
, c,
8,s
.20
P
olic
y t
o
Pro
mo
te
Ze
ro
To
lera
nce
In r
ela
tion to C
IS r
eport
#M
514-0
00057-1
6: T
he
licensee h
as f
aile
d to e
nsure
th
at th
e w
ritten p
olic
y to
pro
mote
zero
tole
rance o
f abuse a
nd n
egle
ct of
resid
ents
was c
om
plie
d w
ith
, in
that a s
taff
mem
ber
involv
ed in a
n a
lleged
incid
ent of
abuse w
as n
ot
imm
edia
tely
rem
oved f
rom
th
e w
ork
schedule
pendin
g
investigation.
-the H
om
e h
as a
zero
tole
rance f
or
abuse p
olic
y-a
ll sta
ff a
nd m
anagem
ent
shall
continue to r
eceiv
e a
nnual tr
ain
ing o
n the
zero
tole
rance o
f abuse p
olic
y-a
ll sta
ff a
nd m
anagem
ent
shall
continue to r
eceiv
e tra
inin
g o
n t
he z
ero
tole
rance o
f abuse p
olic
y a
t orienta
tion
-appro
priate
and tim
ely
notification to the s
chedule
rs r
egard
ing s
taff
who h
ave
been p
laced o
n the ‘D
o N
ot C
all
Lis
t’ has b
een a
chie
ved s
ince this
incid
ent in
2016
-a C
IS r
eport
will
continue to b
e s
ubm
itte
d a
s r
equired
-m
anagem
ent te
am
has e
sta
blis
hed a
pro
cedure
for
rem
ovin
g s
taff
fro
m the
work
pla
ce if/
or
when there
is a
n a
ccusation, suspecte
d, or
actu
al case o
fabuse o
r negle
ct
sin
ce this
incid
ent in
2016
Eile
en M
ario
n-
Belle
mare
, D
OC
Bra
d H
all,
A
dm
inis
trato
r
Imm
edia
te
WN
# 2
V
PC
In r
ela
tion to C
IS r
eport
#M
514-0
00057-1
6: T
he
licensee h
as f
aile
d to c
om
ply
w
ith O
.Reg 7
9/1
0, s.9
8.
Every
lic
ensee o
f a long term
care
hom
e s
hall
ensure
that
the a
ppro
priate
polic
e f
orc
e
is im
media
tely
notified o
f any
alle
ged, suspecte
d o
r
-the H
om
e h
as a
zero
tole
rance f
or
abuse p
olic
y-a
ll sta
ff a
nd m
anagem
ent shall
continue to r
eceiv
e a
nnual tr
ain
ing o
n the
Resid
ent B
ill o
f R
ights
and the z
ero
tole
rance o
f abuse p
olic
y-a
ll sta
ff a
nd m
anagem
ent shall
continue to r
eceiv
e tra
inin
g o
n the R
esdie
nt
Bill
of
Rig
hts
and z
ero
tole
rance o
f abuse p
olic
y a
t orienta
tion
-a C
IS r
eport
will
continue to b
e s
ubm
itte
d a
s r
equired
-m
anagem
ent te
am
has b
een e
ducate
d r
egard
ing c
onta
cting the p
olic
eif/w
hen there
is a
n a
ccusation, suspecte
d, or
actu
al case o
f abuse o
r negle
ct
-the im
port
ance o
f appro
priate
, a
ccura
te, and tim
ely
docum
enta
tion r
egard
ing
Eile
en M
ario
n-
Belle
mare
, D
OC
Bra
d H
all,
A
dm
inis
trato
r
Imm
edia
te
Appe
ndix
C
M
inis
try
N
urs
ing
Com
plia
nce R
evie
w F
indin
gs r
efle
ct
the M
inis
try o
f H
ealth’s
fin
din
g b
ased o
n M
inis
try s
tandard
s a
nd c
rite
ria
for
o
f H
om
es
resid
ent
care
and n
urs
ing h
om
e s
erv
ices.
Com
plia
nce P
lans r
efle
ct
the h
om
e’s
corr
ective a
ctio
n p
lans t
o r
each
H
ea
lth
B
ranch
com
plia
nce w
ith t
he M
inis
try’s
sta
ndard
s.
M
inis
tère
D
irectio
ns d
es
Les r
ésultats
de l’in
spectio
n d
e c
onfo
rmité s
ont
tiré
s d
e l’in
spectio
n e
ffectu
ée p
ar
le m
inis
tère
de la
Santé
en f
onctio
n
de
mais
ons d
e
des n
orm
es e
t critè
res d
ue m
inis
tère
pour
les s
oin
s d
ispensés a
ux p
ensio
nnaires e
t le
s e
rvic
es o
ffert
s d
ans le
s m
ais
ons
la
Santé
soin
s in
firm
iers
des s
oin
s in
firm
iers
contie
nt
les m
esure
s c
orr
ectives q
ue l’é
tablis
sem
ent
ente
nd a
dapte
r pour
se c
onfo
rmer
aux n
orm
es
du m
inis
trè
2611-5
2 (
89/1
2)
Page
2 o
f/de _
On
tari
o
Co
mp
lia
nc
e
Pla
ns
P
lan
s d
e
co
nfo
rmit
é
Nam
e a
nd a
ddre
ss o
f N
urs
ing
Hom
e/N
om
et
adre
sse d
e la
mais
on
de s
oin
s in
firm
iers
D
earn
ess H
om
e
710 S
outh
dale
Rd
London,
ON
Com
plia
nce R
evie
w D
ate
/Date
de
l’in
spectio
n d
e c
onfo
rmité
F
rom
/de
T
o/à
A
pril 12,
2018
Com
plia
nce A
dvis
or/
Conseill
er-
inspecte
ur
Ju
lie L
am
pm
an
June 6
, 2018
T
ype o
f R
evie
w/G
enre
d’in
spectio
n:
Cri
tical
Inc
iden
t
Ins
pecti
on
Pla
n s
ubm
itte
d b
y/P
lan s
oum
is p
ar
Eil
een
Mari
on
-Bell
em
are
Sig
natu
re o
f P
ers
on S
ubm
ittin
g P
lan
Pla
n R
eceip
t D
ate
/Date
de r
éceptio
n d
e p
lan
Sta
ndard
s a
nd
Crite
ria
N
orm
es e
t critè
res
Min
istr
y’s
Com
plia
nce R
evie
w
Fin
din
gs
Resultats
de l’in
spectio
n d
u
min
istè
re
Nurs
ing H
om
e’s
Com
plia
nce P
lan
P
lan d
es m
esure
s c
orr
ectives d
e la
mais
on d
e s
oin
s in
firm
iers
R
esponsib
le
Pers
on
Ta
rget
Date
witnessed incid
ent of
abuse
or
negle
ct of
a r
esid
ent th
at
the lic
ensee s
uspects
may
constitu
te a
crim
inal off
ice.
incid
ents
has b
een e
sta
blis
hed s
ince this
incid
ent fr
om
2016
Appendix D
