Long-Term Care Home Quality Inspection Program

The Ontario government recognizes the important role of long-term care homes in providing quality care to vulnerable residents.

The Ministry of Health and Long-Term Care is working with long-term care home operators, residents and their advocates, as well as Local Health Integration Networks (LHINs) to ensure continued safety and quality of care for residents.

Inspections include confidential interviews with residents, family members and staff, as well as direct observations of how care is being delivered. Completed reports are posted publicly after personal information and personal health information are removed.

With the implementation of the LTCHA, all LTC Homes are subject to a Resident Quality Inspection (RQI) by LTC Home inspectors. An RQI inspection is a comprehensive, systematic two-stage inspection. During a Comprehensive Inspection, if deficiencies with compliance orders are discovered, a follow-up inspection(s) will be conducted.

The following Inspection Protocols are used in all Home inspections:

• Infection prevention and control practices
• Medication
• Residents’ Council Interviews
• Family Council Interviews

The Dining Inspection Protocol is also used in an Intensive Risk Focused RQI

For all Homes, a standardized sample of residents is randomly selected in advance from a provincial database. The purpose of Stage 1 is to conduct preliminary reviews of the quality of care and quality of life indicators (QCLIs) of these randomly sampled residents using a structured set of questions. This structured process ensures consistent results that are comparable across inspectors and Homes.

There are two approaches to conducting an RQI. One is an Intensive Risk Focused RQI and the other is a Risk Focused RQI. The main differences between the two types of RQIs are the number of residents randomly selected, the QCLI thresholds, the mandatory Inspection Protocols used and the number of triggered QCLIs.

In an Intensive Risk Focused RQI the random sample of residents is 40 while in a Risk Focused RQI the random sample of residents is 20. The type of RQI is based on the level of risk in the home. Every home must have an Intensive Risk Focused RQI at least once every three years.

The RQI questions cover a wide range of QCLIs. Inspectors collect resident specific information in Stage 1 from observations, interviews (with residents, family, staff), and health records. The frequency of positive and negative responses to such questions as “Do you feel staff treat you with respect and dignity?” is analyzed by comparing them to thresholds shown through research to be predictive of the presence of non-compliance. Through analysis, this enables Inspectors to assess whether deficiencies may be present that warrant inspection in Stage 2.

The extent of an in-depth Stage 2 inspection is based on results of Stage 1 interviews, observations and record reviews. If there are no potential deficiencies from Stage 1, there is no need for the Stage 2 process. Stage 2 is the inspection of the triggered QCLIs from Stage 1. This inspection is conducted by using the corresponding Inspection Protocol and by responding to the relevant questions within the Inspection Protocol(s).

These Inspection Protocols require LTC Home Inspectors to gather the information necessary to determine whether or not standards of care set out in the LTCHA , and its regulations, are in compliance.

Following are some examples of Inspection Protocols which may be triggered:

• Continence care and bowel management
• Dignity, choice and privacy
• Falls prevention
• Minimizing restraint
• Nutrition and hydration
• Pain management
• Personal support services
• Recreational and social activities
• Responsive behaviours
• Safe and secure home
• Skin and wound

Findings of non-compliance are documented within the inspection report. Inspectors have a duty under the LTCHA to identify in an Inspection Report all non-compliances found during the course of an inspection.

All inspections are unannounced (with very minor and narrow exceptions set out in s. 298 of Ontario Regulation 79/10 under the LTCHA ) and the inspection schedule is randomized and prioritized based on risk.

For each instance where ‘non-compliance’ with the legislation has been identified a decision must be made by the LTC Home inspector on the appropriate action to take, including whether to impose a sanction that is an Order.  At minimum the inspector will issue a Written Notification of Non-Compliance (LTCHA , 2007, C.8 s. 152.1).

Whether further action is required is based on an assessment of the following factors:

1. The severity of harm (or risk of harm) resulting from the non-compliance
2. The scope of harm (or risk of harm) in the home as a result of the non-compliance
3. The licensee’s past history of compliance for the last 36 months, in any Home, with requirements under the LTCHA and any service agreements.  (O. Reg. 79/10 s. 299(1))

Inspectors are required to apply the definitions of severity, scope and history of compliance (see appendix A below) when deciding on other actions that may be taken which may include:

1. Voluntary Plan of Correction (VPC) – LTCHA , 2007, C. 8, s. 152.2
   • The inspector can make a written request for the licensee to prepare a written plan of correction for achieving compliance to be implemented voluntarily.  The licensee/Home is not required to submit the plan to the ministry.  There is no required compliance date set out in the inspection report.
2. Compliance Order (CO) – LTCHA , 2007, C.8, s. 153 (1)(a) and (b)
   • The inspector may order a licensee to:
     1. do anything, or refrain from doing anything to achieve compliance with a requirement under this Act or;
     2. prepare, submit and implement a plan for achieving compliance with a requirement under this Act.
   • The licensee/Home is required to follow the Order to achieve compliance with the LTCHA within the timelines for compliance set out in the Order.
3. Work and Activity Orders (WAO) – LTCHA , 2007, C.8, s. 154 (1)(a) and (b)
   • The inspector may order a licensee:
     1. to allow employees of the ministry, or agents or contractors acting under the authority of the ministry, to perform any work or activity at the LTC Home  that is necessary, in the opinion of the person making the order, to achieve compliance with a requirement under this Act; and
     2. to pay the reasonable costs of the work or activity.
   • The licensee/Home is required to follow the Order to achieve compliance with the LTCHA within the timelines for compliance set out in the Order.
4. Written Notification and Referral to the Director (WN & Referral) – LTCHA , 2007, C.8, s. 152.4

   The inspector may issue a written notification to the licensee and refer the matter to the Director for further action by the Director

   Other Inspections
   The LQIP also includes other types of inspections, for example, where there are complaints or critical incident system reports or there is a follow-up from a previous inspection. In this case Stage 1 of the RQI or Comprehensive Inspection is not applied. The relevant Inspection Protocols are used to delve directly into the issue and determine if the Home is compliant with the LTCHA and its regulations.

   Inspection Reports:
   There are two versions of the Inspection Reports and Orders issued by the MOHLTC – one is the licensee version (LTC Home operator) and the other a public version. The public version usually follows after the licensee version, as it requires careful editing to remove as much of the personal health information (PHI) and personal information (PI) as possible.

   Licensee Report – The Licensee copy of the report is given to the licensee which contains all information related to the inspection including resident health information (confidential and not to be shared).

   Public Report - The Public copy contains all information related to the inspection with personal health information removed as much as possible.  This report is given to the Residents’ Council, and Family Council and posted in the Home.  Please note that the MOHLTC removes select information, such as identifying details, from the public version of inspection reports to ensure that LTC residents cannot be identified and in order to respect their right to privacy.

   Note:  Inspection reports are edited in an effort to strike a balance between the government’s commitment to information transparency and the need to protect and respect individual privacy, which involves taking all reasonable steps to respect the privacy of individuals by removing as much of their personal information (PI) and personal health information (PHI) as possible.

• Each of Ontario’s long-term care homes undergoes an annual inspection to ensure they comply with the Long-Term Care Homes Act, 2007 and Ontario Regulation 79/10. These inspections include interviews with residents, family members and staff as well as direct observations of how care is being delivered.
• In addition, the ministry inspects homes based on complaints from residents, their family members, staff or the public; critical incidents and mandatory reports reported by long-term care home operators; and follows up on issues that may be identified in an inspection.
• Based on recommendations from the Auditor General, a risk-focused approach to Resident Quality Inspections (RQI) was introduced in August 2016.
• Every single long-term care home continues to receive an annual inspection.
• A summary of the inspection reports detailing the findings of non-compliance must be publicly posted in long-term care homes and be provided to Residents’ and Family Councils, and are also published on the ministry’s website.
• As outlined in the Long-Term Care Homes Act and Regulation, long-term care homes are required to report critical incidents and mandatory reports to the ministry.  Any suspected or alleged neglect or abuse of residents, improper care or unexpected or sudden death require the long-term care home to notify the ministry immediately.
• The ministry responds immediately to any reports of serious harm or serious risk of harm to a resident, sending inspectors to visit the home to conduct an inspection. 
• The ministry also has a public Action Line number (1-866-434-0144) that any member of the public can call with respect to issues at a long-term care home.
• All regulated health professionals that work in Ontario, such as doctors and nurses, must hold a valid certificate of registration from a health regulatory college in order to practice the profession and present themselves as members of that profession in Ontario. Licensees must ensure that all staff members have the required qualifications.
• All long-term care home staff must undergo a criminal reference check that includes the much more in-depth vulnerable sector screen check.

Involvement of the Coroner:

• Long-term care homes are required to report all deaths in Ontario’s long-term care homes to the Office of the Chief Coroner.
• In addition, long-term care homes are required to report any unexpected or sudden death, including a death resulting from an accident or suicide, to the ministry through the Critical Incident reporting system.
• The administration staff of a long-term care home report the deaths of residents to the Office of the Chief Coroner by:
1. Completing and electronically submitting the Institutional Patient Death Record (IPDR);
2. Calling the local coroner, if required by the IPDR, which initiates an investigation; and,
3. Entering the death into the long-term care home’s Death Register.
• Based on the results of the Coroner’s investigation, the Office of the Chief Coroner makes the determination whether to launch an inquest.