01 - June 25, 2024 Homes Committee of Management Agenda PackageOZ5
ElgmCounty
Homes Committee of Management
Orders of the Day
Tuesday, June 25, 2024, 10:00 a.m.
Council Chambers
450 Sunset Drive
St. Thomas ON
Note for Members of the Public:
Please click the link below to watch the Committee Meeting:
https://www.facebook.com/ElginCountyAdmin/
Accessible formats available upon request.
1. Call to Order
2. Approval of Agenda
3. Adoption of Minutes
4. Disclosure of Pecuniary Interest and the General Nature Thereof
5. Delegations
6. Reports/Briefings
6.1 Director of Homes and Seniors Services - Homes — Committee of
Management — Long -Term Care Director's Update January 1 — March
31, 2024
6.2 Director of Homes and Seniors Services - Homes — Committee of
Management — Policy and Procedure Manuals — Review and Revision
6.3 Director of Homes and Seniors Services - Homes — Committee of
Management — Long Term Care Operational Report
7. Other Business
8. Correspondence
9. Closed Meeting Items
10. Motion to Rise and Report
11. Date of Next Meeting
12. Adjournment
Pages
2
14
24
ElginCounty
Report to Homes Committee of Management
From: Michele Harris, Director of Homes and Seniors Services
Date: June 25, 2024
Subject: Homes — Committee of Management — Long -Term Care Director's Update
January 1 — March 31, 2024
Recommendation(s):
THAT the report titled "Homes — Committee of Management — Long -Term Care
Director's Update January 1 — March 31, 2024" dated June 25, 2024 be received and
filed.
Introduction:
This report provides an overview of recent updates, and, Ontario Health and Ministry of
Long -Term Care announcements which impact the three (3) County of Elgin Long -Term
Care Homes services and operations.
Additionally, an overview of projects and services for the residents and staff of the
Homes to support quality services and care is included in the report.
Background and Discussion:
Ministry Updates
On January 15, 2024, the Minister of Long -Term Care, Stan Cho, released a news
release regarding the launch of Ontario's new 10-person Long -Term Care Investigations
Unit. The new unit's investigators are designed as Provincial Offences Officers under
the Provincial Offences Act. The new unit is now active and working in the sector, and
will investigate allegations under the Fixing Long -Term Care Act (FLTCA) such as:
• Failing to protect a resident from abuse or neglect,
• Repeated and ongoing non-compliance,
• Failing to comply with ministry inspector's orders,
• Suppressing and/or falsifying mandatory reports, and
• Negligence of corporate directors
Page 2 of 40
On January 22, 2024, the Ministry of Long -Term Care released a memo regarding LTC
Staffing Data Collection for Q3 and 2023-24 Broader Public Sector Workforce Data
Collection for 2022.
In collaboration with the finance department, the Homes successfully completed and
submitted the staffing report prior to the February 16, 2024 deadline as well as the
Broader Public Sector Workforce Data Collection submission prior to April 22, 2024.
On January 31, 2024, the Ministry of Long -Term Care released a memo regarding
Preceptor Resource and Education Program for Long -Term Care (PREP -LTC)
Extension and Living Classroom Expansion. This investment has helped LTC Homes
support quality clinical placements over a 3 year timeframe. To build on the success of
the program the government announced extension of the program for the 2024-2025
fiscal year. All three of the County of Elgin Homes have applied and were successful in
receiving funding which has provided mentorship/onboarding education and backfill
support across the 3 Homes for nursing department clinical placements. It is
anticipated that this ongoing investment will support the recruitment and retention efforts
across our Homes.
On February 9, 2024 the Ministry of Long -Term Care released a memo regarding
Consultation of proposed amendments to Ontario Regulations 246/22 under the FLTCA,
2021. Key proposed changes include:
Staffi ng
Amending staffing qualifications for some roles specified in the Regulation to
ensure requirements are proportionate with the responsibilities and
accountabilities of the role. Roles under review include:
o Administrator
o Therapy Services Staff
o Designated Lead for the Restorative Care Program
o Designated Lead for Volunteer Program
Amendments that provide for how nursing student externs carry out certain
responsibilities in long-term care homes, including administering drugs and other
potential functions.
Permitting Registered Practical Nuses to complete RAI-MDS assessments,
particularly in instances where a resident is seeking a transfer to their preferred
long-term care home, to support regulated health professionals to work to their
full scope of practices in long-term care homes.
Pandemic Recovery and Stabilization
The proposal would broaden provisions related to the pandemic framework to
provide greater clarity to licensees on requirements in emergency situations and
de-escalation to non -emergency situations.
This would include establishing a mechanism to activate specific emergency -
related provisions in the future.
Page 3 of 40
The proposal would also require that a Home's Resident Council and Family
Council be involved in the review of existing visitor policies and any future
revisions.
Clarifying and Technical Amendments
Further clarifications related to air conditioning obligations in limited
circumstances in which a licensee would not have to install a portable or window
air conditioning unit, the circumstances when a licensee must implement the
heat -related illness prevention and management plan, and consistency in
language between the air conditioning and air temperature requirements.
On February 12, 2024, the Ministry of Long -Term Care released a memo reminding
long-term care homes of their obligations related to Section 42 and 43 of the FLTCA,
2021 Quality sections that included an overview of the requirements for the following:
The Resident and Family Survey
The FLTCA requires long-term care homes to ensure that, at least once a year, a
survey is taken of the residents, their families, and caregivers to measure their
experience with the Home and the care, services, programs and goods provided at the
Home.
• A licensee must make every reasonable effort to act on the survey results
• The results of the surveys and actions taken to improve the experience must be
documented.
• Documentation must be shared with the Residents' Council and Family Council.
• The doumentation must also be available to residents and families and during an
inspection.
All three homes conduct annual surveys and have completed the above requirements
for 2023. The 2024 annual survey is scheduled for fall.
Continuous Quality Improvement Initiative:
The FLTCA requires long-term care homes to:
• Establish an interdisciplinary quality improvement committee.
• Ensure the home's continuous quality improvement initiative is coordinated by a
designated lead.
• Annually prepare a report on the continuous quality improvement for the home
and publish on their website.
• Maintain a record of the names of the people who participated in the evaluations
of improvements in the continuous quality improvement report.
All three homes prepared and published the annual report on the Homes website as
required and have submitted a quality improvement plan (QIP) to Health Quality Ontario
for the 2024 — 2025 timeframe, prior to the deadline of March 31, 2024.
Page 4 of 40
The Continuous Quality Improvement Committee at each Home meets monthly to work
on the QIP and other key performance indicators all of which is discussed quarterly at
Professional Advisory Committee Meetings.
Bobier Villa Annual Report for 2023-2024, and, 2024-2025 Quality Improvement Plan
(QIP) Progress Report, Narrative Report and Workplan Report
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The three Homes are designated as RNAO Best Practice Spotlight Organizations
(BPSO) and Terri Benwell, Administrator for Bobier Villa and Elgin Manor, oversees the
BPSO project alongside RNAO's Long -Term Care Best Practice Implementation Coach.
Ms. Benwell had the opportunity to recently attend the RNAO BPSO launch for
organizations new to the project and participated in rapid session groups on "Preparing
to Launch" and strategies to engage organizations. The participant feedback for this
event was extremely favourable and Ms. Benwell is seen as a resource to other Homes
looking to implement the BPSO project.
On March 4, 2024, the Ministry of Long -Term Care released a memo to announce
updates on enhanced masking measures in LTC Homes. The communication
Page 5 of 40
referenced work conducted with the Chief Medical Officer of Health (OCMOH) to
monitor and assess respiratory illness in the community and LTC Homes, including
reassessing enhanced measures currently in place in LTC Homes. Based on the
recent tends and projections at that time, and the advise of the OCMOH, the Ministry
ended the enhanced masking measures effective March 4, 2024.
Based on the updated guidelines, masking in non -outbreak situations in long-term care
homes continues to be:
Required for staff, based on a point -of -care risk assessment, before every
resident interaction, and based on return -to -work protocols;
Staff may consider wearing a mask during prolonger direct resident care defined
as one-on-one within two metres of an individual for fifteen minutes or longer;
and,
Recommended for visitors and caregivers, but not required.
This information was reviewed by the IPAC managers of the Homes in collaboration
with team members; and included discussion at resident and family council. The
changes were communicated to, and implemented across, the three Homes to staff,
residents and families.
Additional updates were made to IPAC measures and supported with an updated
COVID-19 Guidance Document as follows:
• Continuing to build IPAC programs in LTC;
• Encouraging staff, residents and caregivers to get vaccinated, and stay up to
date with vaccination to prevent severe illness;
• Ensuring ready access to therapeutics;
• Self -monitoring for symptoms and staying hoem when sick;
• Ensuring adequate supplies of PPE; and,
• Conducting IPAC audits
On March 27, 2024, the Ministry of Long -Term Care released a memo to announce
supplemental Construction Funding Subsidy for 2024.
The government has introduced a time -limited supplemental Construction Funding
Subsidy (CFS) for eligible operators to support the cost of developing or redeveloping
long-term care beds. The supplemental CFS provides up to an additional $35 per bed
per day to the existing CFS for 25 years for eligible projects. Not -for -profit operators
can convert up to $15 of the supplemental CFS into a construction grant payable at the
start of construction.
The supplemental CFS is available to eligible not -for -profit and for -profit operators who
can demonstrate readiness to start construction and obtain the ministry's approval to
construct by November 30, 2024.
Page 6 of 40
A report to council will be forthcoming to provide council with additional and specific
details and to obtain direction/guidance from council on potential opportunities for the
County of Elgin long-term care homes regarding the CFS announcement.
Ministry of Long -Term Care (MLTC)/Ontario Health (OH) West Reporting
Long-term care homes have weekly, quarterly, annual, and other time -sensitive
reporting and document execution/submission obligations and requirements which are
completed within the authority of the delegation bylaw.
Reporting and documents submitted for the three County of Elgin Homes during
January 1 — March 31, 2024 within the delegation of authority bylaw include the
following:
• Each home continues to complete the Long -Term Care Home (LTCH) data
submission (L9 Form) weekly to provide details regarding bed vacancies, bed
rate changes, etc.
• Each home continues to submit, in consultation with finance and human resource
department staff quarterly staffing reports to the Ministry
• 2023/2024 One -Time Funding for Equipment and Training appendix executed
and submitted to OH West January 30, 2024 for all 3 Homes
o Each home received funding for doppler and intravenous pump and
related training
• Ontario Health West Region 2024 Short -Stay Respite Bed application and
Survey Form completed February 2024
o Bobier Villa, Elgin Manor and Terrace Lodge approved to maintain one
respite bed/Home for 2024
• Schedule E — Form of Compliance Declaration for Bobier Villa, Elgin Manor and
Terrace Lodge submitted February 29, 2024, as required within the Long -Term
Care Home Service Accountability Agreement (indicating compliance with the
provisions of the Connecting Care Act, 2019)
• CCA s. 22 Notice and Extension of Long -Term Care Home Service
Accountability Agreement (L-SAA) — Multi- Home ("Extending Letter") executed
and submitted to OH West March 20, 2024 to extend current L-SAA one year
until March 31, 2025
• CCA s. 22 Notice and Extension of Multi -Sector Service Accountability
Agreement (M-SAA) ("Extending Letter") executed and submitted to OH West
March 20, 2024 to extend current M-SAA one year until March 31, 2025
• In -Year Reallocation of Funds — Fiscal 2023 -24 within the Multi -Sector Service
Accountability Agreement (M-SAA) executed and submitted to OH West on
March 22, 2024 to support additional adult day program equipment (bed,
cabinets, office furniture, client chair) for both homes; and upgrades to Terrace
Lodge Adult Day Program office and overnight space
• 2023- 2024 One -Time Increase to Long -Term Care Home Funding Attestation
executed and submitted to OH West for each Home
• Schedule F — Form of Compliance Declaration for Bobier Villa and Terrace
Lodge Adult Day Program is to be submitted by June 30, 2024, as required within
the Multi -Sector Service Accountability Agreement (MSAA) for the period of April
Page 7 of 40
1, 2023 to March 31, 2024. To the best of staffs' knowledge and understanding
the St. Thomas -Elgin Adult Day Program at Bobier Villa and Terrace Lodge has
satisfied the requirements of Schedule F — Form of Compliance Declaration and
recommends that this form be signed indicating compliance with the provisions of
the Connecting Care Act, 2019 and other local obligations, with one
exception. The obligation regarding Equity and Indigenous health training and
workplan is underway, ongoing and expected to be complete by no later than
December 31, 2024. Staff recommend that the Committee of Management
authorize staff to sign and submit Schedule F- Form of Compliance Declaration
for the MSAA for the period of April 1, 2023 to March 31, 2024 indicating the one
exception.
Agreements Executed
• Point Click Care (PCC) and Corporation of the County of Elgin to support
implementation of eHealth Ontario project "Clinical Connect" through PCC
econnect access; executed February 29, 2024
• Gail Kaufman Carlin and Corporation of the County of Elgin (Terrace Lodge)
Operational Consultant to support Terrace Lodge Redevelopment Project — one
year agreement executed March 25, 2024
• Wellness & Mobility Inc. and Corporation of the County of Elgin (all 3 Homes) —
agreement for the provision of Mobile Imaging services (x-ray, doppler,
ultrasound)
• Dutton Co-operative Child Care Centre Inc. and Corporation of County of Elgin
(Bobier Villa) — temporary emergency evacuation Memorandum of
Understanding executed February 27, 2024
• St. Joseph's Health Care London (Southwest Centre for Forensic Mental Health
Care) and Corporation of the County of Elgin (all 3 Homes) — temporary
emergency evacuation Memorandum of Understanding executed March 25, 2024
Project Updates
Staff Schedule Care
The Homes have been working diligently with support from the finance and human
resources department to implement Staff Schedule Care software.
As with any software implementation there were some adjustments and "growing pains"
but the following achievements have been successfully implemented to support
efficiencies and timely accurate schedules and shift replacement:
• Integration of SSC with Dayforce for payroll, vacation and other purposes
• Schedule development utilizing "autofill" feature
• Utilization of the "wizard" for shift replacement (managers, clerical staff,
registered staff)
Preparations for "mass messaging" began this quarter and any necessary adjustments
to the call out sorting levels are being determined and implemented. It is anticipated that
final project sign off will be achieved in the next quarter.
Page 8 of 40
Pharmacy Transition
The Homes transitioned to the new pharmacy provider and technology with Advantage
Care Pharmacy (ACP) in January and February 2024. Extensive front line registered
staff, management and physician training was conducted to support successful
onboarding. The ACP team remains highly supportive of any staff/resident needs and
the next step for implementation is pharmacy led medication reconciliation.
Mobile Imaging
The Homes transitioned to the new mobile imaging provider in January 2024. Minimal
impact to processes was required but it is worth noting that Wellness & Mobility Inc. has
been successful in meeting all mobile imaging requirements, including ultrasound which
was previously a challenge within the southwest.
Financial Implications:
The Homes are appreciative of the following announcements to support the provision of
care and services in our three Homes.
One -Time Funding for Equipment and Training
On January 8, 2024, the ministry released a news release announcing the total
allocation for local priorities funding for the 2023/24 fiscal year. $35 million has been
allocated for 2023/24. The funding is provided to help long term care homes purchase
specialized equipment and train staff to provide more specialized care, so that more
homes can admit residents who have complex needs but no longer require acute care
in hospitals. All three of our Homes are pleased to report that they were approved for
funding to support the purchase of, and training for, dopplers and intravenous therapy
pumps/equipment.
Bobier Villa 1 doppler, 1 IV pump and associated training - $9,320
Elgin Manor — 2 dopplers, 1 IV pump and associated training - $10,122
Terrace Lodge - 1 doppler, 1 IV pump and associated training - $9,976
On February 21, 2024, the Ministry of Long -Term Care released a memo to announce
that, effective March 1, 2024, LTC Home licensees will receive an adjustment of funding
provided for staffing investments aimed at direct hours of care for residents.
Licensees began receiving this funding in fixed monthly payments as of April 1, 2023 to
support:
A provincewide average of three hours and 42 minutes of daily direct care
provided by nurses and personal support workers (PSWs) per resident by March
31, 2024 as we continue to move towards a provincewide average target of four
hours of daily direct care by March 31, 2025.
A provincewide average target of 36 minutes of daily direct care provided by
allied health professionals (AHPs) per resident by March 31, 2024.
Page 9 of 40
The ministry committed to making funding adjustments (top -up) for the fiscal year
beginning April 1, 2024 and including the month of March 2024.
The memo made reference to further details regarding 2024 — 25 LTC Staffing Increase
funding being release at a later date.
All three of the County of Elgin Homes are meeting the required targets for direct care
staff and allied health professionals.
A report regarding details and analysis of LTC funding will be included in the next
quarterly committee of management meeting agenda/package and/or through a
separate report to council.
In -Year Reallocation of Funds — Fiscal 2023 -24 Adult Day Program
On March 19, 2024, the Corporation of the County of Elgin was approved for one-time
funding through the MSAA and reallocation of funds submission and we are pleased to
advise that the following purchases and work has been completed to further support
community clients through the Adult Day Programs at Bobier Villa and Terrace Lodge:
Terrace Lodge Adult Day Program
o Overnight suite bed and mattress replacement $3658
o Painting of overnight room $1190
o Flooring replacement in overnight space $6639
o Desk, locking cabinets and shelving in office $3303
o Padded client chair with adjustable armrest $641
Bobier Villa Adult Day Program
o Locking upper cabinets to securely store client information $2917
o Locking cabinets for program storage $8842
On March 19, 2024, the Ministry of Long -Term Care released a memo and funding
policy to announce the continuation of 2024-25 funding to support Resident Health and
Well -Being (RHWB) for LTC Homes. The funding is intended to enhance resident
access to social support services provided by registered social workers (RSWs), social
service workers (SSWs) and other allied health professionals (AHPs) to increase overall
health, well-being and quality of life in LTC Homes. The AHP list was updated to include
positions that provide social support services and includes, but is not limited to, the
following examples:
• RSW and SSW staff
• Religious or spiritual support staff
• RAI M DS staff
• Rehab/Active Living and Therapeutic Support Staff (physiotherapy staff)
• Restorative aides
• Recreationist staff
• Occupational therapy staff
• Activity directors
Page 10 of 40
• Volunteer coordinators
• Medical directors, Nursing and Nutrition Managers
• Behavioural Support Ontario (BSO) Staff
• Hair dressing staff
• Foot care, respiratory therapy staff
To date, the Homes have been utilizing the RHWB funding with allied health
professionals excluding RSW/SSW due to challenges securing RSW services
(unsuccessful request for proposal outcomes in prior years). The County of Elgin
Homes recently re -issued a request for proposal for RSW and SSW services and is in
the process of finalizing an award/agreement which will support resident health and
well-being across the Homes.
On March 27 and March 28, 2024, the Ministry of Long -Term Care released memos to
announce long-term care funding updates for the 2024-25 fiscal year.
The summary included:
Level of Care (LoC) Funding
o 6.6% increase to LoC funding. Full details were not been released at this
time.
Staffing Supplementary (4 Hours of Care) Funding
o Up to $1.82 billion which includes up to $1,673,005,700 for nurses and
PSWs and up to $148,160,200 for Allied Health Professionals. Eligible
expenses include salaries, wages, benefits, and hours for both new and
existing direct care staff.
o For 2024/25 homes will receive the following amount:
■ Nurse and PSW Staffing Supplement: $1,822.02 per bed, per
month
Allied Health Professional (AHP) Staffing Supplement: $161.35 per
bed, per month
Our three homes have budgeted for 3 hours and 42 minutes of direct care. Once the
funding letters are received outlining the details of funds for each home, the direct care
hours planned will be reassessed to support reaching and sustaining the required hours
of direct care.
Supporting Professional Growth (SPG)
o The government is continuing to provide SPG funding and is providing $10
million to support education and training of staff members. Homes will
receive $10.91 per month
Personal Support Worker Permanent Wage Enhancement (PSW PWE)
o The government is continuing to provide PSW PWE for eligible PSWs
providing publicly funded personal support services in LTC Homes subject
to the April 1, 2024 funding policy
A report regarding details and analysis of this LTC funding will be included in the next
quarterly committee of management meeting agenda/package and/or through a
separate report to council.
Page 11 of 40
On March 27, 2024, Ontario Health West announced a 2023-24 One -Time Increase to
Long -Term Care Home Funding. The investment translates to a one-time $2543 per
bed payment and is intended to provide financial support for LTC Homes to help relieve
financial pressures and address key priorities.
Details regarding the use of the funding include the following:
• Homes that are not yet compliant in meeting the Ontario Fire Code requirements
must utilize the funding to support this requirement;
• Other eligible expenditures include deferred maintenance, bed
development/redevelopment, staffing; and,
• Funding may be applied against eligible expenditures in the Other
Accommodation or any other Level of Care funding envelopes in accordance with
the Guidelines of Eligible Expenditures for Long -Term Care Homes;
• Unused funding may be retained by the licensee provided the licensee does not
use this funding for ineligible expenditures;
• Licensees are to report separately in the 2023/24 annual and quarterly reports
and subsequent reports on the expenditures funded from this initiative
Homes were required to submit an attestation to Ontario Health West attesting to and
confirming the understanding of the use, reporting and auditing of the funds. The
attestation for each home was submitted by the Director of Homes and Seniors
Services within the required timelines as per the delegation authority bylaw.
A report regarding details and analysis of this one-time funding will be included in the
next quarterly committee of management meeting agenda/package and/or through a
separate report to council.
Alignment with Strategic Priorities:
Serving Elgin
Growing Elgin
Investing in Elgin
® Ensuring alignment of
❑ Planning for and
® Ensuring we have the
current programs and
facilitating commercial,
necessary tools,
services with community
industrial, residential, and
resources, and
need.
agricultural growth.
infrastructure to deliver
programs and services
® Exploring different ways
® Fostering a healthy
now and in the future.
of addressing community
environment.
need.
® Delivering mandated
® Enhancing quality of
programs and services
® Engaging with our
place.
efficiently and effectively.
community and other
stakeholders.
Page 12 of 40
Local Municipal Partner Impact:
The announcements from Ministry of Long -Term Care and Ontario Health support the
quality of care and support positive outcomes at the three County of Elgin long-term
care homes as we provide care and services to the residents of our homes and
community clients.
Communication Requirements:
Information has been communicated to the appropriate departments, resident council,
family council, residents, staff and visitors as required.
Conclusion:
The long-term care homes management team continues to be thankful for the support
from Council, the Chief Administrative Officer, the Senior Management Team, and the
staff in all departments as we work collaboratively to maintain and improve the quality of
services and care for our residents, families, staff and communities.
All of which is Respectfully Submitted
Michele Harris
Director of Homes and Seniors Services
Approved for Submission
Blaine Parkin
Chief Administrative Officer/Clerk
Page 13 of 40
ElginCounty
Report to Homes Committee of Management
From: Michele Harris, Director of Homes and Seniors Services
Date: June 25, 2024
Subject: Homes — Committee of Management — Policy and Procedure Manuals —
Review and Revision
Recommendation(s):
THAT the report titled "Homes — Committee of Management — Policy and Procedure
Manuals — Review and Revision" from the Director of Homes and Seniors Services
dated June 25, 2024 be received and filed.
Introduction:
Departmental policy and procedure manuals ensure consistency and quality in the
services provided by Elgin County Homes and Seniors Services; and, are reviewed
annually, and with legislative changes, to ensure inclusion of best practice and
alignment with current legislation.
Background and Discussion:
Policies within the Homes Manuals for Administration, Dietary, Housekeeping &
Laundry, Infection Prevention and Control, Maintenance, Nursing, and Program and
Therapy departments were reviewed by the Director of Homes and Seniors Services
and the respective departmental managers and the applicable policy manuals have now
been finalized to align with the Fixing Long -Term Care Act (FLTCA), 2021 and Ontario
Regulation 246/22 with the following updates:
Policy Manual
Policy #/Name
Revision
Revisions
Date
Administration —
3.15.01 Code White
Dec.
Updates to legislation — from
Section 3
2023
LTCHA to FLTCA; minor
procedural updates and testing
frequency
3.15.05 code orange
Dec.
minor procedural updates and
2023
contact information
3.15.07 code black
Dec.
Minor procedural updates
2023
Page 14 of 40
3.15.09 Code Purple
Dec.
minor procedural updates and
2023
contact information
3.15.10 code grey —
Dec.
Updated testing timelines
gas leak
2023
3.15.11 code grey —
Dec.
Minor wording updates
air quality
2023
3.20 boil water
Dec.
Updated testing timelines
2023
3.21 and A
Dec.
Added debrief, testing and
Outbreaks,
2023
evaluation verbiage; added
epidemics and
additional reference
pandemic supplies
3.22 Pandemic Plan
Dec.
Additional references; minor
2023
procedural updates
3.16 Loss of
Dec.
Updates re: 2nd elevator at TL
essential services
2023
3.15.06 Code Green
Dec.
Minor word updates
2023
Administration —
1.0 Mission, Vision
Dec.
Minor word updates
Section 1
and Values
2023
1.3 Mandatory and
Dec.
Minor word updates, reference
Critical incident
2023
updates
Reporting
1.4 Smoking —
Dec.
Minor wording updates; reference
Residents, Staff and
2023
updates
Visitors
1.5 Doors in a Home
Dec.
Minor wording updates
2023
1.6 Key and Fob
Dec.
Minor wording updates to align
access
2023
with legislation
1.9 Education Plan
Dec.
Minor wording updates and
2023
corrected legislation titles
1.10 New employee
Dec.
Minor updates to align with
orientation
2023
legislation and legislation titles
corrected
1.11 Gifts from
Dec.
legislation titles corrected
Resident and Family
2023
to Staff
1.13 Record
Dec.
legislation titles corrected
Management,
2023
Retention and
Destruction
1.15 Complementary
Dec.
Removing duplicate info (case
and Alternative
2023
studies)
Therapies;
Complementary and
Alternative
Page 15 of 40
Medicines -Natural
Health Products
1.18 Employee
Dec.
legislation titles corrected
Records
2023
1.21 Wander Alert
Dec.
Minor wording updates and
System
2023
legislation titles corrected
1.25 Pet Visitation
Dec.
Update Most Responsible Person
2023
1.30 Telephones
Dec.
Updated with guidelines to permit
and/or Electronic
2023
staff to carry/access devices on
Devices — Staff Use
floor for scheduling related needs
only
1.31 Social Worker
Dec.
Updated legislation; policy name
Role policy change
2023
change to Social work role; minor
name
wording updates to incorporate
Social Worker (SW) and Social
Services Worker (SSW) roles
1.32 Social Worker
Dec.
Incorporate SSW and update
Services
2023
legislation titles
1.34 Student
Dec.
Update to correct legislation titles;
Educational
2023
updated to include Human
Placements &
Resources department
orienetation
involvement in agreements
1.36 Operational
Dec.
Minor wording updates to reflect
Scheduling Cohorting
2023
current/future needs/requirements
Plan
1.35 Visitors and
Dec.
Policy Name Change, updates to
Absences During
2023
align with legislation
Pandemic
Administration
4.5 Policy Review
Dec.
Updated to reflect delegated
Section 4
2023
authority for Director to approve
4.1 Continuous
Dec.
Updated to specifically state the
Quality Improvement
2023
requirements to be included in the
Program
annual report — related to
compliance inspection
4.3 Continuous
Dec.
Updated to refer to the annual
Quality Improvement
2023
report requirements as outlined in
Committee
policy 4.1 as per compliance
inspection
4.8 Annual Program
Dec.
Updated to include'/4
Evaluation
2023
evaluation/review to work towards
annual program evaluation
Administration -
2.6 orientation of a
Dec.
Updated with correct legislation
Section 2
resident
2023
titles
2.9 Admission and
Dec.
Updated with correct legislation
Discharge
2023
titles and from LHIN/CCAC to
Page 16 of 40
Home and Community Care
Support Services
2.10 Absences and
Dec.
Updated reference
Types of Absences
2023
2.11 Resident Abuse
Dec.
Updated MLTC reporting
2023
reference document
2.15 Resident
Dec.
Removed fan; minor wording
Personal Furniture
2023
update r/t television wall mount
2.30 Private Duty
March
Reviewed by legal; Updated to
Companions
2024
require vulnerable sector Criminal
reference check; updated policy
requirements and insurance from
$2M to $5M
Program and
1.9 Social hour
Dec.
Grammatical corrections
Therapy
Program
2023
Services
1.11 Continuous
Dec.
Grammatical corrections
Quality Improvement
2023
2.1 Assessment and
Dec.
Updated from 72 hours to within 5
Documentation
2023
days of admission
2.5 A Community Out
Dec.
Grammatical corrections
Trip Form Appendix
2023
A
3.2 Memorial
Dec.
Update to state "could include the
Services and
2023
preparation" of media
Condolences
presentations and/or messages of
remembrance; each Home
services may be slightly different
4.0 Hair Care
Dec.
Grammatical corrections
Services Delivery
2023
5.1 Family Council
Dec.
Grammatical corrections
2023
6.1 Volunteer
Dec.
Reference to volunteer orientation
Orientation
2023
handbook changed to volunteer
and student handbook
6.1 A Volunteer
Dec.
Deleted — now on line and updated
orientation manual
2023
regularly — referenced in policy
appendix A
Maintenance
2.3 ER Calls,
Dec.
Updated Director of Engineering
Maintenance Dept
2023
Services contact information
Dietary
2.6 Nourishment
Dec.
Minor update to reflect current
Carts
2023
practice related to special snacks
2.8 Pleasurable
Dec.
Updated wording to reflect
Dining
2023
appropriate dining room
types/height based on resident
need
Page 17 of 40
2.17 Food Service
Dec.
Terminology correction
Temperatures
2023
4.6 Diet order policy
Dec.
deleted therapeutic diet orders
and temp/trial diets
2023
other than regular and gluten free
now that we are using a liberalized
approach
4.6.1 medical
Dec.
Updated to change from LHIN to
directive for writing
2023
Home and Community Care
diet order
Support Services
4.14 Diabetes food
Dec.
Deleted modified diabetic diet and
replacements
2023
replaced with diabetic
interventions
4.19 Enteral Feeding
Dec.
Updated to best practice guidance
2023
regarding blocked feeding tubes
and IPAC considerations
4.21 Detailed Food
Dec.
Sample details food and fluid
and Fluid Intake
2023
intake record form added
Record
4.29 Nutrition And
Dec.
Updated to align with legislative
Skin Integrity
2023
requirements. Also updated fluid
and protein guidelines and added
the PURS score
5.8.22 New Policy
March
New Specific policy for Terrace
Cleaning of Cold
2024
Lodge related to new equipment
Food Server
Phase 2 of redevelopment project
Section 1, 3, 6 &7
No
Dietary
changes
Housekeeping
Section 1, 3,4,5,6
No
and Laundry
changes
2.0 Housekeeping
Dec.
Updated process if unable to
Best Practice
2023
complete checklist of duties during
scheduled shift (contingency plan)
2.3 Cleaning of
March
Updated for cleaning of open
Entrances, Hallways,
2024
ceilings in Terrace Lodge soiled
Reception Areas &
utility rooms quarterly
Lounges
2.8 Washing of Walls
Dec.
Minor word update in procedure
2023
4.24 Laundry room
March
Updated for linen chute cleaning
cleaning
2024
7.3 Tub Room
Dec.
Name change to Tub and Spa
cleaning
2023
Room Cleaning; IPAC updates
7.9 C-diff
Dec.
Update to disinfectant type and
2023
spelling error correction
Nursing
Sections A, G, H2O,
No
P, R
changes
Page 18 of 40
Section B
Bed Safety —
Dec.
Update to the bed assessment
Prevention of
2023
criteria/reasons; addition of
Entrapment
reference for entrapment
mitigation products
Bladder Scanner
Dec.
NEW policy to support the use of
2023
bladder scanner equipment
Cleaning Showers
Dec.
Updated with contact time for
2023
solution
Section D
Death — Pronouncing
Dec.
Updated to coroner's Act/memo
of
2023
requirements — additional
notifications; added references
Death of a Resident
Dec.
Updated to coroner's Act/memo
2023
requirements — additional
notifications; added references
Section E
Enteral Feeding
Dec.
Updated to align with dietitian
2023
recommendations and Best
Practice; updated references
Section F
Feeding Residents
Dec.
Policy name change to Supporting
2023
Residents with Meals (Food and
Fluid Intake)
Section M
Medication
Dec.
New policy to align with legislation
management
2023
and pharmacy policy and
procedure.
Mechanical Lifts —
March
New policy to align with occupancy
Slings — labelling,
2024
plan policy and procedure
laundering, storage
checklist requirements
Section I
Injections —
Dec.
Updated to best practice —
Intramuscular
2023
technique
Section N
Nurse Call System
Dec.
Update Terrace Lodge contact info
2023
r/t system change
Section S
Skin Care and
Dec.
Updated Appendix B to reflect use
Wound Management
2023
of clinical support tool within PCC
versus paper assessments
Infection Control
1.2 IC Committee
Dec.
Updated committee membership
(IC)
2023
and addition of role of reporting to
Section 1
Quality Improvement committee
quarterly
1.3 IC Coordinator
Dec.
Updated to include hand hygiene
2023
program implementation
1.4 Role of SWPH
Dec.
Updated to include all publicly
and OWH IPAC Hub
2023
funded vaccinations
1.6 Education
Dec.
Updated to include hand hygiene
2023
education to include visitors, staff,
residents; added mask fit testing
1.10 IC Audit
Dec.
Updates to timelines and most
Program
2023
responsible persons
Page 19 of 40
Section 2
2.2a Routine
Dec.
Provision of PPE for visitors;
Practices
2023
identification of symptomatic
residents in shared rooms
2.2b Routine
Dec.
Updated references, Point of care
Practices —
2023
risk assessment, symptoms, etc.
Additional
Precautions
2.3 Hand Hygiene
Dec.
Policy name change to "Hand
2023
Hygiene Program; addition of
verbiage r/t acrylic nails, nail
polish, hand/wrist jewelry;
additional guidance re: Alcohol
based hand rub; guidance re:
hand hygiene when caring for
residents with C-diff; updates to
hand hygiene education program;
design standards r/t hand washing
sinks
2.4 Immunization —
Dec.
Title Change to include RSV and
Residents (Influenza,
2023
Shingrix; add requirements for
Pneumovax,
RSV and shingrix vaccination r/t
,Antiviral and COVID
consent, medical directive, etc.
2.5.1 Influenza
Dec.
Updated verbiage to best practice
Vaccine Consent
2023
Form — County of
Elgin Staff
2.5.2 Influenza
Dec.
Updated to align with current and
Vaccine Refusal
2023
best practice
Form
2.6 Management of
Dec.
Updated to include reporting
Fainting and
2023
responsibilities to SWPH r/t
Anaphylactic
anaphylaxis episodes
Reactions
2.7 Storage &
Dec.
Updated with contingency plan for
Handling of Publicly
2023
failure of vaccine fridge/electricity
funded Vaccines
outage
2.8 Surveillance
Dec.
Updates r/t N95 mask direction
Resident
2023
2.8 a Surveillance —
Dec.
Updated with return to work
Staff
2023
guidance r/t covid
2.8 c — Screening
Dec.
Updated education requirements
and surveillance of
2023
for visitors
visitors
2.9 Linen/Laundry
March
Updated for linen chute protocols
Storage & Handling
2024
2.13 Equipment
Dec.
Updates related to cleaning
Cleaning,
2023
shower chairs and the use of
Page 20 of 40
Disinfection,
hoppers r/t IPAC guidance
Sterilization protocol
updates
2.21 PPE Face
Dec.
Updates to use of masks
Shields/Protective
2023
according to current legislation
Eyewear, Masks and
and best practice
Respirators
2.24 Universal
Dec.
Policy name change to "Resident
masking for
2023
Masking for Source Control";
Residents
updated to resident masking only
when symptomatic/outbreak and
by assessment and choice;
additional reference
2.25 Respiratory
Dec.
Updated verbiage re: source
Hygiene and
2023
control masking, N95 for COVID
Etiquette
and point of care risk assessment
2.26 Staff
Dec.
Updated with resource for specific
Immunization
2023
risk situations
Section 3
3.1 Screening and
Dec.
Updated minor verbiage to align
Surveillance of
2023
with current guidance
Infection — New
Admissions
3.3 Surveillance —
Dec.
Updated tracking forms; minor
Daily and Monthly;
2023
wording update to reflect
system for reporting
electronic/paper tracking
3.3 a daily LTC
Dec.
Use new versions; deletion of prior
surveillance tool
2023
tool/resources
(residents)
3b LTC surveillance
toolkit;
3c IPAC surveillance
tracking tool
3d LTC surveillance
training — front line
statff
3.4 a SWPH
Dec.
SWPH has provided a new
Reportable Disease
2023
list/form — updated to policy
List and Reporting
manual
Form
4.5 Isolation
Dec.
Added additional purpose, Point of
Precautions
2023
care risk assessment, reference to
related policies 2.2 a and b; and
additional PIDAC reference
4.6 Isolation
Dec.
Updated to reference appropriate
Guidelines
2023
policies versus duplication of
information and/or risk of not
updating all applicable policies
4.7 Identification of
Dec.
Updated verbiage r/t signage
Isolation Room
2023
Page 21 of 40
4.10 Isolation —
Dec.
Updated visitor education
Resident Visitor
2023
requirements to align with current
Education
directives
4.26 Legionella
Dec.
Added reference from Ministry
2023
memo
Section 5
5.1 Outbreak
Dec.
Minor procedural updates to align
Contingency Plan
2023
with current reporting
requirements (electronic versus
phone/fax)
5.2 Resident and
Dec.
Minor procedural updates to align
Staff Surveillance —
2023
with current reporting
Line Listing
requirements (electronic versus
phone/fax)
5.3 Outbreak
Dec.
Minor update in regards to
Management —
2023
communication —
General
persons/organizations to be
included
5.3a Quick
Dec.
Updated to 2023 Version
Reference to
2023
Outbreak Control and
Management
5.4 Outbreak
Dec.
Updated to be inclusive of role of
management — Roles
2023
IPAC lead and to align with current
and Responsibilities
requirements as they evolve
5.11 Covid-19
Dec.
Updated guidelines to most recent
outbreak
2023
directives/guidance documents re:
preparedness plan
isolation timeframes, masking, etc.
Section 6
Acute Respiratory
Dec.
Minor updates to current
Infection (ARI)
2023
directives/guidance
Financial Implications:
It is imperative that staff ensure that the requirements of the FLTCA, 2021 and Ontario
Regulation 246/22, including policy review and implementation, are met to support
compliance and appropriate funding to the LTCH's.
Alignment with Strategic Priorities:
Page 22 of 40
Serving Elgin
Growing Elgin
Investing in Elgin
® Ensuring alignment of
❑ Planning for and
❑ Ensuring we have the
current programs and
facilitating commercial,
necessary tools,
services with community
industrial, residential, and
resources, and
need.
agricultural growth.
infrastructure to deliver
programs and services
❑ Exploring different ways
® Fostering a healthy
now and in the future.
of addressing community
environment.
need.
® Delivering mandated
® Enhancing quality of
programs and services
❑ Engaging with our
place.
efficiently and effectively.
community and other
stakeholders.
Local Municipal Partner Impact:
N/A
Communication Requirements:
The revised policy changes are minor in nature and have been communicated to staff,
residents, families/visitors, volunteers and contracted workers as required within the
FLTCA, 2021, and, as required, through the online Surge learning education portal.
Conclusion:
The administration, dietary, housekeeping & laundry, infection prevention and control,
maintenance, nursing, and, program and therapy manual policy revisions align with the
FLTCA, 2021, related Regulations and best practices to support resident and staff
safety and service delivery.
All of which is Respectfully Submitted
Michele Harris
Director of Homes and Seniors Services
Approved for Submission
Blaine Parkin
Chief Administrative Officer/Clerk
Page 23 of 40
ElginCounty
Report to Homes Committee of Management
From: Michele Harris, Director of Homes and Seniors Services
Date: June 25, 2024
Subject: Homes — Committee of Management — Long Term Care Operational Report
Recommendation(s):
THAT the report titled "Homes — Committee of Management — Long -Term Care
Operational Report" from the Director of Homes and Seniors Services dated June 25,
2024 be received and filed.
Introduction:
This report provides an overview of day-to-day operations of the three (3) County of
Elgin Long -Term Care Homes along with pertinent departmental and committee
updates and inspections for the period of January 1, 2024 to March 31, 2024.
Background and Discussion:
Resident and Family Experience Survey 2023
The annual resident and family experience survey results for 2023 were received in
December 2023. The highlights of the survey results for each home are outlined
below:
Indicator
Bobier Villa
Elgin Manor
Terrace Lodge
% of surveys
18 participants
21 participants
33 participants
completed
(31 %)
(23%)
(33 %)
Top 3 areas of
How well staff
How well staff
How well staff
satisfaction
listen to you
listen to you
listen to you
Call bell
Call bell
Knowing who
response time
response time
to contact with
questions
Staff wear a
Staff wear a
name tag,
name tag,
Overall food
introduce
introduce
and nutrition
themselves
themselves
services
Page 24 of 40
and explain
role
and explain
role
Top 3 areas for
Contracted in
Contracted in
Contracted in
improvement
house services
house services
house services
(26 % of
(38 % of
(38 % of
respondents
respondents
respondents
dissatisfied)
dissatisfied)
dissatisfied)
Laundry
Laundry
Laundry
services (5 %
services (14 %
services (9 %
of respondents
of respondents
of respondents
dissatisfied)
dissatisfied)
dissatisfied)
Participation in
Temperature of
plan of care
food (13 %
(30% of
dissatisfaction)
respondents
dissatisfied)
Top words and
Outstanding,
Happy with the
Excellent;
comments
Very pleasant,
activity people;
friendly;
used by
Happy with
I like this place;
services
residents/family
care and
good home;
couldn't be
to describe the
support,
happy; staff
better; happy
Home
Caring
are always
here; treated
Friendly, warm
friendly and
well; staff work
kind,
caring
hard with the
Proud of our
dignity of
decision in
residents in
Bobier
mind;
awesome,
wonderful
The continuous quality improvement teams and each department has reviewed the
survey results, shared the results with resident and family council, and incorporated the
findings into development of quality improvement intiatives for 2024.
This work aligns with the Registered Nurses Association of Ontarion (RNAO) Best
Practice Spotlight Organizations (BPSO) initiatives/project work for 2023 (Person and
Family Centred Care) and 2024 (Developing and Sustaining Leadership).
Ministry of Long -Term Care (MLTC) Compliance Inspection Visit Reports
Summary
Page 25 of 40
Ministry of Long -Term Care Inspections are unannounced and last from 1 day to 2
weeks depending on the purpose of the inspection. There are several types of
inspections of long-term care homes as follows:
• Reactive Inspections which are done in response to complaints or critical incident
submissions and generally focus on the substance of the complaint or incident ;
and, follow-up inspections conducted to ensure that any compliance orders have
been addressed.
• Proactive Inspections are broad -based inspections carried out on a regular basis
to ensure a home is in ongoing compliance with the Act and Regulation.
• Other types of inspections include pre -occupancy and post -occupancy
inspections visits to a home undergoing the development/redevelopment of beds.
The Ministry of Long -Term Care implemented the "Proactive Compliance Inspection"
process in 2023; and both Bobier Villa and Terrace Lodge participated in their first
proactive compliance inspection this quarter.
Bobier Villa
MLTC inspectors visited the Home from March 6 — 15, 2024 to conduct the "Proactive
Compliance Inspection" (PCI). The inspection report was received in April 2024.
There were three "non-compliance remedied" findings during the inspection related to
the following: communication of the seven-day and daily menus which was immediately
remedied during the inspection; one bottle of alcohol based hand rub which was noted
to have been expired and which was immediately remedied during the inspection; and,
the drug destruction box located in the medication room required replacement which
was also remedied during the inspection.
There were nine areas of non-compliance whereby a written notification was issued in
the areas of timelines of response to a concern in writing versus verbal; written record
specifics related to program evaluations; dining and snack service (food temperatures
and course by course service of meals); infection prevention and control program (hand
hygiene and team structure); medication incident documentation; and, specifics related
to the 2022-2023 annual quality improvement report.
There was one compliance order related to administration of drugs (medication self -
administration) with a timeframe of May 3, 2024 to review/revise medication self-
admnistration policy, ensure all persons trained on the revised policy, conduct resident
assessment for self -administration, update care plan, and, to submit and analyze a
medication incident report. The management team met with stakeholders to complete
and meet all compliance order requirements within the required timeframe to ensure
compliance.
The management team and continuous quality improvement team developed and
implemented a plan of action to address each of the areas of non-compliance related to
the proactive compliance inspection of non-compliance.
III,: u. ......�....i .....I........................................V.........................................................5..................................�......�....Y....�.......F\I� ......
Page 26 of 40
Elgin Manor
MLTC inspectors visited the Home from Janury 30 to February 1, 2024 to conduct a
critical incident inspection related to falls prevention and management. During the
course of this inspection the inspector made relevant observations, reviewed records
and conducted interviews. The Ministry also conducted a review of infection prevention
and control practices which is done with every inspection. There were no findings of
non-compliance.
� L!Li� II i� u � � u III ° II � Y� n u � i� II II � � u �5 � �) n:,i, ,,ii 2 (,,,)24
Terrace Lodge
MLTC inspectors visited the Home from December 5 — 13, 2023 to conduct the
"Proactive Compliance Inspection" (PCI). There was one "non-compliance remedied"
found during the inspection related to communication of the seven-day and daily menus
which was immediately remedied during the inspection.
There were eight areas of non-compliance whereby a written notification was issued in
the areas of plan of care; written record specifics related to program evaluations; dining
and snack service (food temperatures and course by course service of meals); quarterly
and annual evaluation of medication management system and medication incidents;
and, specifics related to the 2022-2023 annual quality improvement report.
The management team and continuous quality improvement team developed and
implemented a plan of action to address the proactive compliance inspection areas of
non-compliance.
Iln° p!"gtuon II�`epg t 2()23.
MLTC inspectors visited the Home from February 12 — 21, 2024 to conduct an
inspection related to critical incidents regarding allegations of resident abuse and
resident fall with injury. Inspection Protocols utilized during the inspection included
infection prevention and control, responsive behaviours, prevention of abuse and
neglect, and falls prevention and management.
There were three areas of non-compliance whereby a written notification was issued in
the areas of residents rights; post fall assessment; and, pain assessment.
The management team and continuous quality improvement team developed and
implemented a plan of action to address these areas.
Critical Incident Systems Report Summary for all Three Homes
Types of Critical Incidents — January 1 — March 31, 2024 Total
Number
Page 27 of 40
— Three
Homes
Abuse & Neglect — Any alleged, suspected or witnessed abuse of a
25
resident by anyone or neglect of a resident by the licensee or staff that
resulted in harm or risk of harm to the resident, misue or misappropriation
of residents' money, misuse or misappropriation of funds provided to
licensee.
Unlawful or Improper or Incompetent Treatment or Care — Includes care of
4
a resident that resulted in harm or risk of harm to resident.
Unexpected Death — Including a death resulting from an accident or
0
suicide.
Medication Incident — Includes a medication incident or adverse drug
0
reaction in respect of which a resident is taken to hospital.
Environmental Hazard — Includes breakdown or failure of the security
1
system or major equipment or a system in the Home that affects the
provision of care or the safety, security, or well-being of residents for a
period greater than six hours
Disease Outbreak
3
Contamination of Drinking Water Supply
0
Incident that Causes Injury and Transfer to Hospital — Includes injury in
3
respect of which a person is taken to hospital resulting in a significant
change in status
Controlled Substance Missing/Unaccounted — Includes missing or
0
unaccounted for controlled substance
Written complaint
1
The above noted critical incidents have been reviewed and internally investigated. It is
important to note that the abuse and neglect critical incident reporting includes "harm or
risk of harm". Each of the three Homes have a memory care resident home area
supporting mild to severe cognitively impaired residents that may, at times, and despite
interventions, exhibit responsive behaviours resulting in "risk of harm". The Homes are
diligent in reporting responsive behaviours in the "risk of harm" category with 22 of the
25 reports falling into this category. Follow up to each incident is conducted by the
management team in collaboration with both the internal and external Behavioural
Support Ontario teams and is ongoing to develop interventions and update plans of care
to support all residents on the memory care resident home areas and throughout the
Homes.
The management team and continuous quality improvement team have developed and
implemented a plan of action to address all of the critical incident related areas,
including, but not limited to providing additional training and education as required.
One written complaint was received in this quarter in relation to the laundering of soiled
linen and the selection of clothing upon transfer to the funeral home and appropriate
follow up was completed.
Outbreaks
Page 28 of 40
Home
Number of
Timeframe of
# of Residents
Outbreaks and
Outbreak
Impacted
Agent
Bobier Villa
0
N/A
N/A
Elgin Manor
1 —seasonal
March 12 — 19,
4
coronavirus
2024
Terrace Lodge
2 outbreaks
#1 — February 14 —
#1 — 13
#1
March 4, 2024
#2 - 7
Entero/Rhinovirus
#2 March 27 — April
#2 Rhinovirus
10, 2024
Vaccinations are offered as per guidelines/directives and promoted for residents,
visitors and staff.
The Homes Infection Prevention and Control (IPAC) managers participate in the
regional IPAC Hub meetings (through Public Health) and Community of Practice
meetings (through AdvantAge Ontario) to ensure alignment with best practices. The
Terrace Lodge Manager of Resident Care acts as a co-chair on the Community of
Practice committee with AdvantAge Ontario.
Public Health Ontario provided a long-term education resource/modules regarding
environmental cleaning which will be assigned to environmental services staff to support
enhanced cleaning measures to align with best practices.
Terrrace Lodge welcomed Arlene MacDonald as IPAC Manager on March 25, 2024.
Arlene is an asset to the Home as she brings with her certification in Infection
Prevention and Control; and has previous experience at Terrace Lodge having worked
as a Registered Nurse for five years.
Elgin Manor and Bobier Villa IPAC Managers are preparing for IPAC certification and
are anticipated to write in fall of 2024 which aligns with ministry requirements.
Additionally, the leadership team recognized the importance of sustainability and
contingency planning regarding IPAC management, and, as such has supported one
management team member and four front line registered staff registration in a ministry
approved Infection Control Program in 2024. The costs of training and backfill of staff
are supported through the Ministry of Long -Term Care IPAC funding and will support
the IPAC measures across the Homes moving forward.
Occupancy Data
Bobier Villa
Occupancy Data
January 1 — March 31,
2024
Occupancy
99 %
Admissions (Move -Ins)
5
Discharges
4
Page 29 of 40
Elgin Manor
Occupancy Data
January 1 — March 31,
2024
Occupancy
98 %
Admissions (Move -Ins)
13
Discharges
15
Terrace Lodge
Occupancy Data
January 1 — March 31,
2024
Occupancy
98 %
Admissions (Move -Ins)
6
Discharges
7
Health System Partners (i.e. Fire, Public Health, Ministry of Labour)
Bobier Villa
Monthly fire drills are conducted each month on all shifts
Bobier Villa received a public health food safety inspection on February 28, 2024.
There was one finding during the inspection, specifically that there was an
accumulation of dust around the air intake vents on the ceiliing in the main
kitchen in the area near the cooking equipment which was addressed following
inspection.
�ood I'afetyII s p�onR...11 �epg.p t ,.
Elgin Manor
• Monthly fire drills are conducted each month on all shifts.
• A Code Silver was issued during this timeframe related to a threat. A safety plan
was developed and implemented in consultation with local authorities, legal,
human resources and CAO.
• There were two fire department visits related to false alarms (resident actions).
• Elgin Manor received a public health food safety inspection on March 6, 2024.
There were no findings during the inspection.
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Terrace Lodge
Monthly fire drills are conducted each month on all shifts
The Fire Safety Plan was updated to align with changes as part of the Terrace
Lodge Redevelopment Project and approved by the local fire chief.
Page 30 of 40
• Public Health conducted a pre -occupancy inspection of the Phase 2 Home
Kitchens, Serveries and Dining Areas on April 9, 2024.
Dietary and Housekeeping/Laundry Departmental Updates
Department
Bobier Villa
Elgin Manor
Terrace Lodge
Dietary
Chocolate dipped
Welcomed a
Terrace Lodge main
strawberries
Food and
kitchen remains
served for
Nutrition
"under renovation".
Valentine's Day;
Management
Staff should be
St. Patrick's Day
Student (5
commended for
celebrated with
weeks).
having adjusted to
bangers and
New menu
reduced work spaces
mash;
development for
and revised job
Refresh of dietary
June 2024 with
routines in the main
schedules to
local fresh
kitchen to
provide 2 week
seasonal fruits
accommodate
rotation of cooks
and vegetables.
renovations.
for continuity and
Theme menus —
consistency.
Chinese New
Implementation
Year, Shrove
of
Tuesday,
interdisciplinary
Valentine's Day,
meal service
St. Patricks Day.
project to support
meal service
delivery in follow
up to the
proactive
compliance
inspection.
Food Committee
Theme meal
Kitchen tour
Monthly
planning;
provided to
encouragement for
seasonal menu
residents to see
residents to
development
"where and how
recommend meal
their daily meals
items for "Resident
are prepared" —
choice meal day"
some residents
(example - BBQ ribs
braved the walk-
on the bone, baked
in fridge/freezer;
potato, cream corn,
residents were
rice pudding with
happy to see
whipped topping)
familiar labels
they had used to
serve their own
families.
Housekeeping/laundry
New employee
Retirement of 22
Housekeeping/laundry
successfully
year employee
staff have
Page 31 of 40
transitioned to
Ongoing
experienced
dietary
streamlining of
significant change in
department from
chemical
job routines
housekeeping.
services to
throughout the project
support lean,
and should be
user friendly
commended for their
services
ability to adjust and
accommodate the
operational needs and
needs of the
residents.
Joint Health & Safety
Code Drills
Code Drills —
Monthly Code Drills
- Code Red
Missing Person,
with team members
Code White,
creating poster boards
Code Silver,
to increase staff
Regular
Code Red
awareness.
inspections
Regular
Regular inspections
inspections
Resident & Family Council Updates
Resident Council
Bobier Villa
Elgin Manor
Terrace Lodge
January
January 18
January 18
January 25
Sharing and
Sharing and
Sharing and
discussing updates
discussing updates
discussing updates
— new pharmacy;
—new pharmacy;
—redevelopment
annual satisfaction
annual satisfaction
project updates;
survey results;
survey results;
spiritual care
emergency
emergency
program;
response codes;
response codes
discussion and
new pharmacy
and IPAC updates;
agreement
communication
Eulogy Memories;
regarding shared
Resident Bill of
leadership style for
Rights and Mission
resident council;
Statement;
review of 3
Outings & Special
Resident Bill of
Event planning
Rights; new
pharmacy and
mobile imaging
communication
February
February 15
February 15
February 1
Discussion topics:
Discussion topics:
Guest speaker
Resident Bill of
Resident Bill of
regarding Terrace
Rights
Rights
Lodge "Comforts of
Treasurers Report
Silent Auction
Home Campaign"
Page 32 of 40
Concern Follow up
Outings & Special
overview and
Events
agreement to
Resident
donate Silent
Remembrances
Auction funds to
Campaign
February 27, 2024
Discussion topics:
Mechanical lifts,
nursing schedule
update; spiritual
care and recreation
and leisure
programming;
required areas of
review as per
Ontario Association
of Resident Council
guidelines; review
of 3 Resident Bill of
Rights
March
March 21
March 14
March 28
Discussion topics:
Discussion topics:
Discussion topics
Resident Bill of
Resident Bill of
Resident Bill of
Rights
Rights
Rights; spiritual
OARC membership
Outings & Special
care;
New Masking
Events
communication re:
Regulations in LTC
New Masking
construction
Resident Council
Regulations in LTC
updates front of
Configuaration
Television Services
building;
Front Door
volunteers;
Entry/Exit
program
IPAC Updates
discussion; solar
Spring COVID
eclipse, menu and
vaccine campaign
food committee and
OARC membership
Easter meal; IPAC
MLTC Inspection
update/masking
Report results
and new IPAC
manager; public
inspection report
from December
2023; annual
satisfaction survey
results
Page 33 of 40
Delayed until April
5, 2024 Manager
guest
Discussion topics;
quality
improvement plan
(QIP)
Review of 3
Resident Bill of
Rights
Family Council
Bobier Villa
Elgin Manor
Terrace Lodge
January
January 24
January 12
January 4
New family
Home Updates;
Change in
membership; Home
cable services; new
membership related
updates
pharmacy; annual
to resident changes
satisfaction survey
resulting in
Annual Satisfaction
results and action
decreased number
survey results
plan; IPAC update;
of members.
shared with family
Emergency
Meeting information
council
Response Policies;
communciated but
development of a
members unable to
resource guide for
attend January
resident care
meeting
conferences
virtually/inperson
Recruitment efforts
ongoing (posted in
the Home, sent via
email/newsletter)
related to
decreased
membership;
options to
communicate via
meetings available
in
person/phone/zoom
to support
attendance.
New pharmacy,
mobile imaging and
home related
communications
sent to members
electronically and
posted in the Home
Page 34 of 40
February
As per family
February 16
February 1
council February 28
New mobile
Meeting information
meeting was
imaging provider
communciated but
postponed until
details; family
members unable to
March
council letter;
attend
resident care
conferences;
volunteering
opportunities
March
March 20
As per family
March 7
Manager vacancy
council March 15
Meeting information
and coverage; solar
meeting was
communciated but
eclipse; Ministry
postponed until
members unable to
inspection;
April
attend
IPAC/masking
updtes;
Meet the Managers
Professional
post move date
Advisory
2024; membership
Committee Meeting
encouragement
invitation; 2023
and participation
survey results and
ongoing
action plan; menu
changes and
location of display;
resident care
conferences
Program and Therapy Department Updates
Item
Bobier Villa
Elgin Manor
Terrace Lodge
Special Programs &
Pet Therapy
Pet Therapy
Auxiliary tuck shop
Event Highlights
open 6 days per
Country of Discover
Country of Discover
week beginning
(Scotland — taste
(Austraila — reptilia
January 2024
testing and Scottish
visit, outback
programming; New
dress -up; China —
Auxiliary &
Orleans — making
Chinese food &
Recreation
Mardi Gras masks;
movie)
Department
Ireland — Irish
Valentine's Tea
Bingo, Shamrock
History Talk with
cookie decorating)
Guest Speaker
New Drumming
(Irish Rovers)
Program Lead and
History Talk with
Resource
Guest Speaker
Bus outings —
(Irish Rovers)
hockey game;
Spiritual Care
Restaurant outing
Community
Valentine's
Partnerships and
Celebration
programs
Page 35 of 40
Weekly tuck shop
Easter Bunny Visits
with the Auxiiliary
Animal Vistis from
Green Theme Day
Hobby Farm
Pottery Class
Sunday Tea with
the Auxiliary
Highland Dance
Show
Animal Vistis from
Hobby Farm
New
Monthly cultural
Monthly cultural
Koffee Klatch
Initiatives/Enhanced
diversity and
diversity and
Program
Programming
inclusion programs
inclusion programs
Animal assisted
Fun & Fitness
Therapeutic
Hobby farm therapy
partnering with a
Puppetry
program
physical trainer
Jewellery making
program
Hand quilt project
Education
Food Handlers
Food Handlers
Turning Over a
Training/Food
Training/Food
New Leaf (link
Safety Program
Safety Program
between Nature
initiated February
initiated February
Access and
2024
2024
Outcomes in LTC)
Horticultural
Therapy Program
Certification
New member of
Volunteer Elgin
Network Group
Data and Security
for leaders and
volunteers
Meditation for older
people
Student Placements
None this quarter
None this quarter
Secondary School
Cooperative
Placement
Volunteer Services
14 registered active
12 registered active
17 new volunteers
volunteers with 2
volunteers with 4
in process of formal
Page 36 of 40
new during this
new during this
registration; 45
timeframe
timeframe
active volunteers;
New volunteer led
library literacy
program (Aylmer
library)
Website Taskforce
Participation and
Participation and
Participation and
Participation
support for updated
support for updated
support for updated
website
website
website
Nursing Department and Quality Improvement Updates
Department
Bobier Villa
Elgin Manor
Terrace Lodge
Mandatory
Development and
Development and
Development and
Programs &
implementation of
implementation of
implementation of
Committees
updated program
updated program
updated program
evaluation template
evaluation template
evaluation template
to support
to support
to support
compliance and
compliance and
compliance and
legislative
legislative
legislative
interpretation
interpretation
interpretation
Pharmacy
Successful
Successful
Successful
ServicesTransition
transition to
transition to
transition to
— training for
Advantage Care
Advantage Care
Advantage Care
management,
Pharmacy services
Pharmacy services
Pharmacy services
registered staff,
February 14, 2024
February 7, 2024
January 31, 2024
physicians
Mobile Imaging
Successful
Successful
Successful
Services Transition
transition to
transition to
transition to
(xray, ultrasound,
Westminster Mobile
Westminster Mobile
Westminster Mobile
doppler) — process
Medical Imaging
Medical Imaging
Medical Imaging
updates
Inc. January 29,
Inc. January 29,
Inc. January 29,
communication
2024
2024
2024
Home specific
Manager of
Implementation of
Increased
nursing/quality
Resident Care
initial coaching
frequency of team
updates
vacancy with
concepts to support
huddles for day and
internal
onboarding of new
afternoon shifts to
management team
employees
enhance
coverage during
communication,
recruitment process
decision making
and teamwork;
BSO team huddle
frequency
increased to
support knowledge
sharing and
embedded
processes
Page 37 of 40
Student
No placements
PSW placement;
No placements
placements
during this quarter;
Preceptor
during this quarter;
Preceptor
Resource and
Preceptor
Resource and
Education Program
Resource and
Education Program
(PREP) support
Education Program
(PREP) support
available
(PREP) support
available
available
Additional
One letter of
Full day onsite
IV therapy and
educational
understanding in
mechanical lift
pump training to
opportunities
place to support
"train the trainer"
support residents
education
eduation
with specific
opportunity;
medication and
Full day onsite
hydration needs;
mechanical lift
Resident Care
"train the trainer"
Coordinator
eduation;
participation in
Behavioural
Ahria Consulting
Support Ontario
"Manager as a
(BSO) internal team
Coach Learning
foundational
Series"; Full day
training
onsite mechanical
lift "train the trainer"
eduation
Administrative Department Updates
Item
Bobier Villa
Elgin Manor
Terrace Lodge
Staff Schedule
Administrative clerks
Administrative
Administrative
Care (SSC) —
and management
clerks and
clerks and
autofill, wizard,
worked diligently with
management
management
project sign off for
SSC to successfully
worked diligently
worked diligently
these
implement development
with SSC to
with SSC to
requirements
of schedules with the
successfully
successfully
use of autofill;
implement
implement
successful
development of
development of
implementation of
schedules with
schedules with
"Wizard" to support
the use of autofill;
the use of autofill;
staff/shift replacement
successful
successful
implementation of
implementation of
"Wizard" to
"Wizard" to
support staff/shift
support staff/shift
replacement
replacement
Clinical
Director of Homes and
Connect/econnect
Seniors Services
working directly with
eHealth Ontario,
Ontario Health, clinical
Page 38 of 40
connect (McMaster
University), and Point
Click Care for
onboard/implementation
setup and readiness for
all 3 Homes
Staffing Updates
Letter of Understanding
Support from
No changes
with SEIU to support
Bobier Villa
administrative clerk
administrative
temporary part time
clerk to provide
position for coverage
temporary
coverage
Director of Homes
Nominated for and
and Seniors
successful recipient of
Services
AdvantAge Ontario
Leadership Award
Education
Administrator -
Administrator -
Administrator -
Advanced Long -Term
Advanced Long-
Advanced Long -
Care Funding,
Term Care
Term Care
Budgeting and
Funding,
Funding,
Reporting full day
Budgeting and
Budgeting and
education through
Reporting full day
Reporting full day
AdvantAge Ontario
education through
education through
AdvantAge
AdvantAge
Ontario
Ontario
Terrace Lodge
Phase 2 of the
Redevelopment
Terrace Lodge
Redevelopment
Project near
completion
Financial Implications:
None
Alignment with Strategic Priorities:
Page 39 of 40
Serving Elgin
Growing Elgin
Investing in Elgin
® Ensuring alignment of
❑ Planning for and
® Ensuring we have the
current programs and
facilitating commercial,
necessary tools,
services with community
industrial, residential, and
resources, and
need.
agricultural growth.
infrastructure to deliver
programs and services
® Exploring different ways
® Fostering a healthy
now and in the future.
of addressing community
environment.
need.
® Delivering mandated
® Enhancing quality of
programs and services
® Engaging with our
place.
efficiently and effectively.
community and other
stakeholders.
Local Municipal Partner Impact:
None
Communication Requirements:
Information has been communicated to the appropriate departments, resident council,
family council, residents, staff and visitors as required.
Conclusion:
The long-term care homes management team continues to be thankful for the support
from Council, the Chief Administrative Officer, the Senior Management Team, and the
staff in all departments as we work collaboratively to maintain and improve the quality of
services and care for our residents, families, staff and communities.
All of which is Respectfully Submitted
Michele Harris
Director of Homes and Seniors Services
Approved for Submission
Blaine Parkin
Chief Administrative Officer/Clerk
Page 40 of 40