December 7, 2015

The Government of Ontario Continues To Fail Seniors And Their Families: Highlights of the 2015 Report of the Auditor General

Laura Camarra

 

Laura Camarra

The London region was singled out in the report as having the highest increase in complaints against long-term care homes, up by 47% in 2014 as compared to 2013. This is also in stark contrast to the average across the province, which saw a 13% increase in complaints against long-term care homes between 2013 and 2014. The Ministry could not explain why the London region had the highest increase in complaints as compared to other regions. However, based on the quality-of-care indicators set out by the Canadian Institute for Health Information, long-term care homes in the London region were below the provincial average for 8 out of 9 indicators in 2013/2014.

For a more fulsome picture of the state of long-term care homes across the province, please see the Report linked below.

Value for Money:

  • There are approximately 630 long-term care homes (“homes”) in the province, providing care to approximately 77,600 residents, most of whom are over the age of 65;
  • Of the 630 homes, the vast majority (360) are for-profit homes, with the rest operating as not-for-profit homes;
  • In the 2014/2015 fiscal year, funding by the province to homes totalled $3.6 billion;
  • Most residents make a co-payment between $1,800 and $2,500 per month, depending upon the type of room they occupy (basic, semi-private or private);
  • The Long-Term Care Homes Act, 2007 (“the Act”), governs homes in the province.

Inspections:

  • In 2011, the Ministry introduced comprehensive inspections, the goal of which was to assess residents’ satisfaction and homes’ compliance with the Act;
  • There are 4 types of inspections:
    • Comprehensive inspections;
    • Complaint inspections;
    • Critical-incident inspections;
    • Follow-up inspections;
  • Inspection timeliness and effectiveness varies across the province. In 2014, Hamilton and Toronto took almost twice as long to complete the entire inspection process, and Hamilton issued, on average, 75% more compliance orders than London.

Comprehensive Inspections

  • The Ministry can inspect complaints, critical incidents and/or follow up on compliance orders during a comprehensive inspection;
  • In 2014, the Ministry performed 2,630 inspections, 201 more than in 2013, the increase mainly in comprehensive inspections;
  • Comprehensive inspections involve 3-4 inspectors examining a home over an eight-day period, has two stages and involves 31 inspection protocols, five of which are mandatory (medication, infection prevention and control, residents’ council and family council interviews, and dining observation).

Complaint Inspections

  • The Ministry receives complaints from residents, their family members and the public. Homes are also required to immediately forward any written complaints they receive to the Ministry;
  • The Ministry must review every complaint it receives and decide if an inspection is warranted;
  • In 2014, the Ministry received a 13% increase in complaints, from 2910 in 2013 to 3,300 in 2014. The London region had the most significant increase, of 47%. In addition, 8 of 9 quality-of-care indicators at homes in the London region were below the provincial average in 2013/2014;
  • If an inspection is required, the Ministry assigns a risk level (high, medium or low):
    • High-risk cases are those that involve alleged improper care, abuse, neglect, unlawful conduct, or retaliation by the homes’ staff – Anything that places a resident in serious (or significant risk of serious) harm and in immediate jeopardy if the Ministry or home fails to intervene. The Act stipulates that high risk cases must be inspected immediately;
    • Medium risk cases involve any alleged violation of the law that results in moderate (or risk of moderate) harm to a resident. The Ministry aims to inspect medium-risk complaints within 30 days;
    • Low risk cases involve minimal (or risk of minimal) harm to a resident. The Ministry aims to inspect low-risk complaints within 120 days;
  • On average, it takes 1-2 inspectors over a 2 day period to perform a complaint inspection;
  • In 2014, the Ministry inspected 1,810 complaints;
  • The number of cases requiring inspection also increased by 31%, from approximately 1,600 cases in 2013 to 2,100 cases in 2014. Of those cases requiring inspection, 2% were high risk, 53% were medium risk and 45% were low risk;
  • As of March 31, 2015, the Ministry had about 960 complaints outstanding, an increase of almost 70% since December 2013.

Critical Incident Inspections

  • Homes must immediately report critical incidents to the Ministry, such as: fire, neglect or abuse of residents, improper care, misuse of residents’ money, unlawful conduct, unexpected or sudden death, residents missing for more than three hours, missing residents who return with an injury or adverse change in condition, outbreaks of reportable communicable diseases, and contamination of drinking water supply;
  • Homes must report other critical incidents within 1 business day, such as: resident falls resulting in significant change in condition that requires a hospital visit, failures of the home’s security or other major systems for more than 6 hours, missing medication;
  • The Ministry reviews every critical incident reported to decide if an inspection is warranted. In 2014, the Ministry inspected approximately 2,030 critical incidents;
  • As of March 31, 2015, the Ministry had 1,840 critical incidents outstanding, an increase of more than 2.5 times since December 2013;
  • In 2014, the Ministry determined that approximately 3, 340 critical incidents should be inspected (from 2,040 in 2013);
  • In 2014, the majority of critical incidents requiring inspection were in the abuse and neglect category, a number which increased by 90% from 930 cases in 2013 to approximately 1,750 cases in 2014.

Enforcement

  • If, after conducting an inspection, an inspector finds a home not in compliance with the Act, the inspector shall take one or more of the following five enforcement actions:
    • Issue a written notification;
    • Issue a voluntary plan of correction;
    • Issue a compliance order;
    • Issue a work and activity order; or
    • Refer the matter to the Ministry’s Program Director, who may issue an order;
  • Over the last three years, the Ministry has not issued any work and activity orders that require the home to pay for necessary work performed by the Ministry on the home’s behalf in order for them to achieve compliance;
  • In 2014, the Ministry issued 4030 written notifications, 4,450 voluntary plans of correction, 1,040 compliance orders, 0 (Nil) work and activity orders and 0 (Nil) director’s delegate orders. In the previous 3 years, only 1 Director’s order has been issue.

Follow-Up Inspections

  • If the inspection results in the home being issued an order to comply with the Act, a follow-up inspection must occur to ensure the home has complied with the order by the deadline given and the issue rectified. In 2014, the Ministry conducted 260 follow-up inspections and addressed approximately 770 compliance orders issued to homes.

General Findings of the Auditor General

  • The backlog of complaints and critical incidents more than doubled, from 1,300 as of December 2013 to 2,800 as of March 2015;
  • 40% of high-risk complaints and critical incidents that should have been inspected immediately took longer than 3 days;
  • Over 25% of high-risk complaints and critical incidents took between 1 and 9 months for inspection;
  • 60% of sample of medium-risk cases took an average of 62 days to inspect;
  • The Ministry did not prioritize comprehensive inspections based on a home’s risk level;
  • The Ministry does not provide clear guidance on how much time homes should be given to comply with orders. In 2014, inspectors in one region gave homes an average of 34 days to comply with orders relating to key risk areas (such as carrying out a resident’s plan of care, protecting residents from abuse and neglect, and providing a safe, secure and clean home) and respecting the Resident’s Bill of Rights (the Act lists 27 rights that residents are entitled to, such as the right to be treated with courtesy and respect, the right to be protected from abuse and the right not to be neglected). Meanwhile, inspectors in another region gave homes an average of 77 days to comply with similar orders;
  • Situations placing residents at risk were not followed-up by the Ministry in a timely manner to ensure resolution. Two thirds, approximately 380 of the compliance orders due in 2014, had not been followed up within the Ministry’s informal 30-day target. In 2014, on average, it took the Ministry 2 months after an order’s due date to perform a follow-up inspection;
  • As of March 2015, the Ministry had failed to follow-up with about 250 (30%) of the compliance orders due in 2014 and 20 (4%) of the orders due since 2013;
  • For follow-up inspections in 2014, orders relating to high-risk areas such as abuse, neglect, home safety, security, cleanliness, repair, plans of care, and Residents’ Bill of Rights took, on average, 89 days to be followed up with. Lower-risk orders took 74 days, on average;
  • The Ministry’s actions are not sufficient to address repeated non-compliance:
    • Homes in one region did not comply with almost 40% of compliance orders issued by the Ministry;
    • Of the over 50 different areas in which homes have failed to comply with an order, 10 areas account for nearly 50% of these cases;
    • Several areas within the top 10 are serious, “key risk areas”: failing to carry out a resident’s plan of care, failing to protect residents from abuse and neglect, failing to provide a safe, secure and clean home, and failing to respect the Resident’s Bill of Rights;
    • Even when the Ministry deemed an instance serious enough to warrant a compliance order, the homes were often not taking the necessary steps to become compliant. In 2014, the Ministry performed follow-up inspections on approximately 770 compliance orders of which 570 were due at 210 homes that year. It found that 78 homes had failed to comply with 142 (or 25%) of the 570 compliance orders. Of those 142 orders, 31 (or 22%) of them related to one of the Ministry’s key risk areas. One home failed to comply with 18 orders the Ministry had issued over the past two years;
    • The Ministry is taking too long to escalate cases of recurrent non-compliance to the Program Director for further action. As an example, from 2011 to 2014, the Ministry referred 6 homes to the Director, but only did so after at least a year of multiple, re-issued compliance orders. Despite the fact the Program Director was involved, the report noted similar issues during the comprehensive inspections at 3 out of the 4 homes in the first 6 months of 2015;
    • The Ministry seldom uses the stronger enforcement actions at its disposal, such as ordering funding to be returned or withheld, ordering a home’s management to be replaced, or revoking a home’s licence. Since 2010, the Ministry has revoked the licence of only one home;
  • The Act does not require a minimum front-line-staff-to-resident ratio at homes. In 2014, homes provided an average of 3.4 direct care hours per resident per day, while the Ontario Association of Non-Profit Homes and Services for Seniors recommends 4 hours;
  • As of March 31, 2015, 4 of 5 regional offices had complaints or critical incidents that had been outstanding for more than a year with no inspection, ranging from 2 at one office to 94 at another;
  • None of the regional offices track and monitor the number of complaints and critical incidents that are past due for inspection. For 2,000 cases that did have a risk level noted, about 1,200 (60%) were past their inspection timeframe. Close to 90% (or 1,070) of complaints and critical incidents that were overdue as of March 31, 2015 were assessed by the Ministry to be medium-risk.

 

Link to the 2015 Report of the Auditor General: Click Here

 

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