Summary of Recommendations
1. RNAO strongly urges the Ministry of Health and Long-Term Care to legislate and fund a minimum of 3.5 hours of nursing and personal care for residents of long-term care homes, attached to average acuity. Greater acuity would require more hours of care.
2. RNAO strongly urges the Ministry of Health and Long-Term Care to require by regulation and fund a minimum of 0.5 hours of activation and recreational programs that promote socialization, engagement in social activities, mental and physical stimulation for residents of long-term care homes.
3. RNAO urges the Ministry of Health and Long-Term Care to establish by regulation a staff mix in long-term care homes of one nurse practitioner (NP) per large facility, 20 per cent registered nurses (RN), 25 per cent registered practical nurses (RPN) and 55 per cent personal support workers (PSW), supported by adequate funding.
4. RNAO recommends that the definition of “nursing care” in Part I, section 1, be clarified to mean skilled nursing given by an RN or an RPN, and a definition be added for “personal care”, meaning personal care given by an unregulated worker under the supervision of an RN or RPN.
5. RNAO urges the government to stay on track with its commitment to achieving 70 per cent full-time employment for nurses and personal support workers in LTC facilities as crucial in ensuring continuity of caregiver and positive outcomes for long-term care home residents.
6. RNAO urges the government to address the inequity in wages between the acute care and community and long-term care sectors to ensure continuity of care-giver and the best quality patient care.
7. RNAO urges the Ministry of Health and Long-Term Care to commission research to update the findings of the 2001 PriceWaterhouseCooper’s report into staffing and acuity levels in Ontario’s Long-Term Care homes to allow LTC facilities to better plan staffing needs in the short and medium term.
8. RNAO urges government to quickly expand the Long-Term Care Best Practices Initiative as it has proven to be an effective support in implementing best practices for long-term care homes and staff.
9. RNAO recommends that the definitions of “abuse” in the draft regulation s.2(1) be extended to include neglect, as well as unreasonable confinement in the definition of physical abuse, removal of decision-making power in the definition of emotional abuse and subtle and intentional or unintentional abuse in the definition of emotional abuse. In addition we recommend that:
a. The definition of “neglect” in the draft regulation s.4 be expanded to include systemic neglect and the failure to make best efforts to meet and fund standards of care and staffing.
b. The Ministry of Health and Long-Term Care adopt a provincial standard for a zero tolerance policy for abuse and neglect, usingRNAO’s Preventing and Managing Violence in the Workplace Best Practice Guideline as a model of a comprehensive and strategic approach.
c. The government allocate adequate funding for staffing, mandatory education and leadership development to prevent, identify and respond to abuse and neglect.
d. The Ministry introduce whistleblower protection for those who report abuse, neglect and any other care deficiencies, in long-term care homes.
e. The regulatory college of any regulated staff be immediately notified of any alleged, suspected or witnessed incident of abuse or neglect in addition to the police notification requirement in s.18 of the draft regulation.
10. RNAO recommends that there be mandatory reporting in writing to the Ministry of incidents where a restraint is used and any changes implemented to minimize the use of restraints. This should include educational programs to understand aggression in the elderly and prevent its escalation.
11. RNAO urges the government to recognize the use of chemical restraints by extending the requirement of a minimizing restraining policy to apply to pharmacological use. This should include defined policies and procedures for obtaining informed consent from the resident or substitute decision maker prior to administration of chemical restraints.
12. RNAO recommends that the government must adequately fund the long-term care sector including ensuring adequate numbers of nurses and other health professionals. Staffing levels should permit Directors of Care to focus on leadership and operations, in addition to allowing the use of full-time rather than replacement nurses in monitoring patients in restraints.
13. The regulation should recognize an applicant’s need to age in place and be placed in a long-term care facility as close to their home, family and community as possible, if requested. Limits on waiting lists should not apply where the facility is in the applicant’s home community.
14. The regulation must clearly define the otherwise subjective term “severe capacity pressures” in s.46(4)(b) of the draft regulation.
15. The government should adopt the recommendations of the Casa Verde coroner’s inquest, including ensuring that individuals with high medical needs, mental illness or who are prone to aggression and are a threat to themselves and others are only placed in long-term care facilities once they have been appropriately assessed, a care plan developed, and the LTC facility has regular access to specialty services such as psychogeriatricians, specialty Advance Practice Nurses or outreach consultants to support on-going care of these residents. In addition, RNAO supports inquest recommendation #22 that urges the Ministry of Health and Long-Term Care to fund specialized facilities to care for cognitively impaired residents who exhibit aggressive behaviours.
16. RNAO urges the Minister to ensure that an appropriately education registered nurse dedicated to infection control is a funding priority to ensure all long-term care facilities have the capacity to implement the infection prevention and control program consistent with best practices and professional standards.
Hon. David Caplan
Minister of Health and Long-Term Care
10th Floor, Hepburn Block
80 Grosvenor Street
Toronto, Ontario, Canada
June 5, 2009
Thank you for the opportunity to respond to the Initial Draft Regulation under the Long-Term Care Homes Act, 2007 (LTCHA)
When the Long-Term Care Homes Act, 2007 was introduced on October 3, 2006, the RNAO applauded measures to help residents of long-term care homes, including provisions for whistleblower protection and the requirement that every LTC facility have at least one RN on duty and on-site 24 hours a day, seven days a week. Significant concerns were voiced at the time by the RNAO and others that the legislation failed to commit to a minimum number of hours of nursing and personal care for residents, an omission that in our view compromises resident safety. Moreover, RNAO was concerned that the Act did not contain a stronger commitment to not-for-profit delivery, particularly for new long-term care beds.
RNAO’s concerns have not been alleviated by release of the initial draft regulation.
There is no standard of nursing and personal care or staffing in the regulation, nor is there a provincial standard for zero tolerance of abuse and neglect. Whistleblower protection is inadequate and restraint minimizing provisions are silent on the use of chemical restraints. There is little protection against inappropriate admission of residents with complex care requirements and not enough recognition of the need for people to live as close as possible to their families, communities and support systems.
One lesson of the global economic crisis is deregulation does not work, and there are many examples of lax regulation in the long-term care sector not being in the public interest. In the attached response to the initial draft regulation, RNAO focuses on the most crucial issues outlined above. However, we agree with those who suggest it is inappropriate and premature to finalize the regulations under the Long-Term Care Homes Act, 2007 prior to release of the Ontario Ombudsman’s current investigation into Ontario’s long-term care homes and his recommendations. It is vital that we take the time required to get the regulations right.
RNAO looks forward to continuing to work closely with you to develop regulations that will improve the care and quality of life of the over 75,000 Ontarians who call long-term care facilities home.
Doris Grinspun, RN, MSN, PhD(c), O.ONT.
Executive Director, RNAO
Wendy Fucile, RN, BScN, MPA, CHE
The Registered Nurses’ Association of Ontario (RNAO) is the professional organization for registered nurses who practice in all roles and sectors across Ontario. Our mandate is to advocate for healthy public policy and for the role of registered nurses in shaping and delivering health services. We welcome the opportunity to respond to the Initial Draft Regulation under the Long-Term Care Homes Act, 2007
On June 4, 2007, the Long-Term Care Homes Act, 2007, received Royal Assent. Now, two years later, the first of at least two draft regulations has been released for consultation by the Ministry of Health and Long-Term Care. Only when the regulations are approved by Cabinet and in place will the Act finally take effect.
Most of Parts I, II and III of the Act are covered in the draft regulation subject to this consultation. This includes provisions related to care plans, abuse and neglect, restraints, and admissions.
Nurses applauded the introduction of the Long-Term Care Homes Act, 2007 with its provision that long-term care facilities have at least one registered nurse on duty and on-site 24 hours a day, seven days a week. However, RNAO has stated consistently and firmly that patient care would be compromised if the Act and regulations did not prescribe a minimum number of hours of nursing and personal care for residents. It is for this reason that the RNAO is profoundly disappointed that the draft regulation completely omits any mention of minimum number of hours of nursing and personal care in long-term care homes.
If the government is to meet its commitment “to the health and well-being of Ontarians living in long-term care homes now and in the future”, set out in the Bill’s preamble, the regulation must clearly specify the minimum number of hours of nursing and personal care to which every resident is entitled.