03 - November 8, 2024 Homes Committes of Management Agenda PackageOZ5
ElgmCounty
Homes Committee of Management
Orders of the Day
Tuesday, November 12, 2024, 11:00 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 Homes — Committee of Management — Long -Term Care Director's
Update July 1, 2024 — September 30, 2024
6.2 Homes — Committtee of Management — Long -Term Care Operational
Report July 1, 2024 — September 30, 2024
7. Other Business
8. Correspondence
9. Closed Meeting Items
10. Motion to Rise and Report
11. Date of Next Meeting
12. Adjournment
Pages
2
5
12
Homes Committee of Management
Minutes
August 13, 2024, 11:00 a.m.
Council Chambers
450 Sunset Drive
St. Thomas ON
Members Present: Warden Ed Ketchabaw
Deputy Warden Grant Jones
Councillor Dominique Giguere
Councillor Mark Widner
Councillor Jack Couckuyt
Councillor Andrew Sloan
Councillor Todd Noble
Councillor Mike Hentz
Councillor Richard Leatham
Staff Present: Blaine Parkin, Chief Administrative Officer/Clerk (virtual)
Michele Harris, Director of Homes and Seniors Services
Andrew Case, Solicitor
Katherine Thompson, Manager of Administrative
Services/Deputy Clerk
Jenna Fentie, Legislative Services Coordinator
Stefanie Heide, Legislative Services Coordinator (virtual)
1. Call to Order
The meeting was called to order at 11.24 a.m. with Warden Ketchabaw in the
chair.
2. Approval of Agenda
Moved by: Councillor Widner
Seconded by: Councillor Leatham
RESOLVED THAT the August 13, 2024 Homes Committee of Management
agenda be approved as presented.
Motion Carried.
1
Page 2 of 29
3. Adoption of Minutes
Moved by: Councillor Hentz
Seconded by: Councillor Couckuyt
RESOLVED THAT the minutes of the meeting held on June 25, 2024 be
adopted.
Motion Carried.
4. Disclosure of Pecuniary Interest and the General Nature Thereof
None.
5. Delegations
None.
6. Reports/Briefings
6.1 Director of Homes and Seniors Services - Homes — Committee of
Management — Long -Term Care Director's Update April 1, 2024 —
June 30, 2024
The Director of Homes and Seniors Services presented the report that
provides an overview of recent updates and Ontario Health and Ministry of
Long -Term Care announcements that impact the County of Elgin's three
(3) Long -Term Care Homes. The report also provides an overview of
projects and services occurring at the Homes to support quality services
and care for residents and staff.
Moved by: Councillor Couckuyt
Seconded by: Deputy Warden Jones
RESOLVED THAT the report titled "Homes — Committee of Management
— Long -Term Care Director's Update April 1, 2024 — June 30, 2024" from
the Director of Homes and Seniors Services dated August 13, 2024 be
received and filed.
Motion Carried.
6.2 Director of Homes and Seniors Services - Homes — Committee of
Management — Long -Term Care Operational Report
The Director of Homes and Seniors Services presented the report that
provides an overview of day-to-day operations of the County's three (3)
Long -Term Care Homes as well as pertinent departmental and committee
updates and inspections for the period of April 1, 2024 to June 30, 2024.
Moved by: Councillor Widner
Seconded by: Councillor Leatham
2
Page 3 of 29
RESOLVED THAT the report titled "Homes — Committee of Management
— Long -Term Care Operational Report" from the Director of Homes and
Seniors Services dated August 13, 2024 be received and filed.
Motion Carried.
7. Other Business
None.
8. Correspondence
None.
9. Closed Meeting Items
None.
10. Motion to Rise and Report
I101rem
11. Date of Next Meeting
The Homes Committee of Management will meet again at the call of the Chair.
12. Adjournment
Moved by: Councillor Widner
Seconded by: Councillor Giguere
RESOLVED THAT we do now adjourn at 12.09 p.m. to meet again at the call of
the Chair.
Motion Carried.
Blaine Parkin, Warden Ed Ketchabaw,
Chief Administrative Officer/Clerk. Chair.
3
Page 4 of 29
ElginCounty
Report to Homes Committee of Management
From: Michele Harris, Director of Homes and Seniors Services
Date: November 12, 2024
Subject: Homes — Committee of Management — Long -Term Care Director's Update
July 1, 2024 — September 30, 2024
Recommendation(s):
THAT the report titled "Homes — Committee of Management — Long -Term Care
Director's Update July 1, 2024 — September 30, 2024" dated November 12, 2024 be
received and filed.
Introduction:
This report provides an overview of recent updates, and, Ontario Health, Ministry of
Health, and Ministry of Long -Term Care announcements which impact the three (3)
County of Elgin Long -Term Care Homes services and operations for the period of July
1, 2024 — September 30, 2024.
Background and Discussion:
Ministry Updates
On July 15, 2024, the Ministry of Long -Term Care released an update to the Entrance
Conference Checklist for Proactive Compliance Inspections. Information was circulated
to the Homes Management and Continuous Quality Improvement teams to support
inspection readiness.
On July 15, 2024, the Ministry of Health released a memo related to the survey request
for the 2024-2025 influenza and COVID-19 vaccine administration in long-term care
who plan to partner with external providers for the administration of influenza and/or
COVID-19 vaccine(s). The three County of Elgin Homes have the capacity and will be
providing vaccinations without external support.
On July 31, 2024, the Ministry of Long -Term Care released follow up communications
related to the Alignment with the Health and Supportive Care Providers Oversight
Authority (HSCPOA) for the Class of Personal Support Workers (PSW). The Act will
allow PSWs to voluntarily register with the new HSCPOA effective December 1, 2024.
Page 5 of 29
The ministry intends to continue to consult on proposed amendments to Ontario
Regulation 246/22 this fall and winter to align its staffing qualifications with the
registration pathways within the HSCPOA. In the interim, the current PSW qualification
requirements within section 52 of the Ontario Regulation 246/22 continue to apply.
On August 14, 2024, the Ministry of Long -Term Care released a memo reiterating the
Fixing Long -Term Care Act requirements related to long-term care homes establishing
Family Councils and the role that they play in representing the interests of families and
residents along with a review of sections 65 -67 of the Act. This information was
shared with the management team, including the Managers of Program and Therapy
whom provide support to the Family Councils of the three Homes.
On August 14, 2024, the Ministry of Health released a memo regarding Ontario's High -
Risk Older Adult RSV Vaccine Program 2024-2025 and the importance of vaccinating
high -risk groups, including LTCH residents. The Infection Prevention and Control
Managers across the three Homes worked collaboratively with the Homes Medical
Directors and Director to develop and implement a medical directive to support vaccine
administration for residents.
Information regarding the Ontario Seniors Dental Care Program and Application was
received from Southwestern Public Health and communicated to residents and
substitute decision makers of our Home. The Homes current contracted dental care
provider supports is registered with the program which supports affordable access to
dental care for residents of our Homes.
On September 11, 2024, the Ministry of Long -Term Care released a memo providing
further information regarding prpoposed amendments to Ontario Regulation 246/22.
The Ministry has been working with key partners and stakeholders to support
enhancements, greater flexibility in staffing and stability within the sector. Proposed
amendments include:
• Amending section 52 of the Regulation to fully align with the registration
pathways for PSWs under the HSCPOA
• Adding a permanent exemption to section 52 to provide LTCH licensees flexibility
in leveraging resident support personnel
• Amendments to registered dietitian requirements to enable health human
resource flexibility while upholding resident care
If approved, the ministry would propose that the amendments come into force on
December 1, 2024 to align with the HSCPOA, and all other amendments would come
into force on January 1, 2025.
Ministry of Long -Term Care and Ontario Health West Reporting
Long -Term Care Homes continue to have weekly, quarterly, annual and other one-time
sensitive reporting and document extension/submission obligations and requirements
which are completed within the authority of the delegation bylaw.
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Reporting and documents submitted for the three County of Elgin Homes during the
timeframe of July 1 — September 30, 2024, within the delegation bylaw include the
following:
Each home continues to complete the 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. Staffing reports were
submitted prior to the deadline of August 16, 2024 for all 3 Homes.
Agreements Executed
The following agreements have been developed and executed in consultation with legal
services, the procurement team, and, as required, the CAO, and align with the authority
of the delegation bylaw.
Laboratory services — Sole Source, only one provider available to provide
scheduled phlebotomy services, specimen collection, ECG, and pick/updelivery
for long-term care homes.
o Agreement signed July 8, 2024 with LifeLabs and each of the three
Homes — Bobier Villa, Elgin Manor and Terrace Lodge.
o Costs are submitted to Ministry of Long -Term Care and fully funded
through the Ministry phlebotomy funding.
o Total costs are less than $15,000 annually.
Registered Nurses Association of Ontario (RNAO) Clinical Pathways and Point
Click Care (PCC)
o Agreements signed July 31, 2024 to support the launch of RNAO clinical
pathways. The three County of Elgin LTCH's are part of Cohort 7 to
implement six clinical pathways/clinical support tools to support quality
resident care and services over a three-year period.
o An agreement was signed with both RNAO for the usage of clinical
pathway support tools and project support; and, an agreement with Point
Click Care for access to the assessments and project related PCC
updates.
o Software and access costs are funded through the Integrated Technology
System funding (former clinical support tools/medication safety technology
funding).
Southwestern Public Health and Corporation of the County of Elgin — Provincial
COVID-19 Vaccine Solution Letter of Agreement signed on August 12, 2024
supporting the provision of COVID-19 vaccine to the three County of Elgin
Homes. Vaccine administration documentation requirements are met via
documenting within the "Covax" provincial system.
Point Click Care (PCC) Single Sign On Agreement signed on September 10,
2024 to provide additional cyber security measures for all staff utilizing PCC.
Project Updates
Page 7 of 29
E-connect project implementation has been paused due to a PCC system issue.
It is anticiptated that implementation efforts will resume by year end.
RNAO Clinical Pathways implementation will support quality resident care and
service delivery; and, is anticipated to support future positive Ministry inspection
outcomes.
o Clinical support tool implementation
o Three (3)-year project with year 1 focus including Admission Assessment,
Delirium Assessment, and Resident and Family Centred Care
Assessment
o Training began in September 2024 and "go live" date will be March 2025
o Staff training costs will be funded through ministry one-time funding
o PCC updates will be implemented by Home staff with the support of Point
Click Care
o Policy and procedure and assessment updates will be developed and
implemented to streamline processes, reduce duplication, standardize
assessments and align with legislative requirements
RNAO Best Practice Guideline Launch "Developing and Sustaining Leadership"
o Completion of Gap Analysis
o Registered staff training planned for early 2025
Policy and Procedue Updates
The following policies and procedures were reviewed and revised by the Director of
Homes and Seniors Services in collaboration with the respective departmental
managers to align with the Fixing Long -Term Care Act (FLTCA), 2021 and Ontario
Regulation 246/22.
Policy
Policy #/Name
Revision
Revisions
Manual
Date
Administrati
1.35
August
Updated to align with July 2024 MLTC
on — Section
Visitors and
2024
updates — essential caregiver access
1
Resident
and age of essential caregivers updates
Absences
During a
Disease
Outbreak,
Epidemic or
Pandemic
3.8 Terrace
July 2024
New Policy — policy and procedure to
Lodge Pool,
support the resumption of aquatic
Emergency
programming
Action Plan
Nursing
Section C
Catheter
August
Updated to best practice and IPAC best
policies —
2024
practice; deletion of irrigation policy as
1. Catheter
best practice and evidence no longer
Care — Daily
recommends intermittent irrigation
2. Catheter
irrigation —
deleted
Page 8 of 29
3. Catheter —
intermittent
4. Catheter —
indwelling
5. Catheter-
suprapubic
Section H
Heat Related
August
To align with legislation - air
Illness
2024
conditioning verbiage updates related
Prevention and
to situations in which air conditioning is
Management
not required and related monitoring and
Plan
interventions
Maintenance
2.14 Pool
August
Classification of pool updated for rental
Maintenance
2024
agreement/public use Class A; and
Class B for Life After Stroke (LAS)
Adult Day Program (ADP) clients
2.14 A Pool
August
Updated to current version of Public
Log book
2024
pool inspections and records logbook
2.15 HVAC
August
Updated to include July 1, 2024
2024
legislative updates — inspections,
additional interventions to reduce heat
and humidity
Program
1.13 Terrace
September
WhisperGLIDE wheelchair swing.
and
Lodge only
2024
New policy to support implementation
Therapy
New —
of wheelchair swings at Terrace Lodge
WhisperGLIDE
as part of the "Comforts of Home"
Wheelchair
fundraising project.
Swing
Financial Implications:
On July 12, 2024 the Ministry of Long -Term Care announced that the funding for the
"Hiring More Nurse Practitioners (HMNP) in Long -Term Care" initiative would be
provided as base funding going forward for all homes approved for funding under the
HMNP program. The HMNP initiative was announced on October 5, 2022 as a three-
year investment to hire and retain NP's in the LTC sector.
The County of Elgin Homes investigated the potential of the HMNP opportunity in 2022
but found that the allotted funding amount was insufficient to attract and retain NP's
without additional investment.
On July 31, 2024, the Ministry of Long -Term Care announced that they will be adopting
a new mandatory standard for quarterly resident assessments, advised by the Canadian
Institute for Health Information (CIHI). The current RAI-MDS 2.0 Assessment
Instrument and Continuing Care Reporting System (CCRS) will be replaced by the new
interRAI Long -Term Care Facilities (LTCF) Assessment Instrument and Integrated
interRAI Reporting System (IIRS) in Ontario Long -Term Care Homes by April 1, 2026.
A call for early adopters was received on August 23, 2024, and on September 24, 2024,
the Ministry of Long -Term Care announced that a total of 50 early adopter Homes will
be implementing the LTCF beginning fall 2024. The transition for most Homes will
occur in the 2025-26 fiscal year (April 1, 2025 — March 31, 2026) with additional
opportunities to volunteer for subsequent phases of the transition.
Page 9 of 29
Elgin County Homes will be following communications and updates regarding the LTCF
closely and will work with Point Click Care to ensure appropriate updates to
assessments are implemented. The Director, Administrators, Managers of Resident
Care and MDS-RAI coordinators will be working closely with our partners to make any
necessary adjustments in policy, procedure, assessments, and auditing to
support/maintain current Case Mix Index (CMI) during, and following, the transition,
which ultimately may impact Level of Care Funding.
On August 22, 2024, the Ministry of Long -Term Care released a memo regarding
funding for the 2024-2025 (April 1, 2024 — March 31, 2025) Comprehensive Minor
Capital Fund. Eligible long-term care homes will receive funding towards Infection
Prevention and Control (IPAC) Minor Capital funds for minor capital improvements
directly linked to improved IPAC practices, Long -Term Care Minor Capital funding to
maintain and extend the life of LTCHs, and Falls Prevention Equipment Fund as base
funding targeted to help reduce the number of falls and fall related injuries in LTCHs
and promote increased mobility and enhanced safety and quality of life for LTC
residents.
As part of 2024 budget planning, in consultation with finance department, the Homes
budgeted based on prior years funding. With the August 22, 2024 announcment, a
analysis of budgeted versus actual funding was conducted and is outlined in the table
provided below. The Homes approach to minor capital spending was conservative
while awaiting the funding announcement and spending will not exceed actual funding.
024-25 Comprehensive Min cir Capitau
IHolime
Budgeted
ActuaL
Perfoirmane
BobierVitla
192,498
86,465
(16,033)
A lla"JOUir bl,e-
IEI,gjin Mainoir
129,997
99,17.E
�39,822)
UnfaVOUirabl.e
Tenrace (Lodge
176,830
148,49
(28,334)
A lla"JOUir bl.e
On September 17, 2024, the Ministry of Long -Term Care released a memo reminding
LTCHs to complete and submit the 2024 in -year occupancy report to specify resident
days and co -payment revenue for the period of January 1, 2024 to September 30, 2024.
This information will be used to inform of potential adjustments to the monthly cash flow
(payment notices) due to change in occupancy rates. Finance departmental staff
completed and submitted the report within the required timelines.
On September 27, 2024, the Ministry of Long -Term Care released a memo advising
long-term care homes to complete the "2023-2024 One -Time Funding Increase
Reporting Template" by November 1, 2024. This report was submitted with the support
of the finance department, incorporated discussion with facilities, and includes details
for actual and planned/projected usage of the funding.
Alianment with Strateaic Priorities:
Page 10 of 29
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:
The announcements from the Ministry of Long -Term Care and Ontario Health West
support the quality of care and support positive outcomes for the three County of Elgin
Long -Term Care Homes as staff and managers work collaboratively to 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 11 of 29
ElginCounty
Report to Homes Committee of Management
From: Michele Harris, Director of Homes and Seniors Services
Date: November 12, 2024
Subject: Homes — Committtee of Management — Long -Term Care Operational Report
July 1, 2024 — September 30, 2024
Recommendation(s):
THAT the report titled "Homes — Committee of Management — Long -Term Care
Operational Report July 1, 2024 — September 30, 2024" dated November 12, 2024 be
received and filed.
Introduction:
This report provides an overview of the day-to-day operations of the three (3) County of
Elgin Homes along with pertinent departmental and committee updates and inspections
for the period of July 1, 2024 to September 30, 2024.
Backaround and Discussion:
Ministry of Long -Term Care (MLTC) Compliance Inspection Visit Reports Summary
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 that a home is in ongoing compliance with the Act and Regulation.
Other types of inspections include pre -occupancy inspections and post -
occupancy inspections visits to a home undergoing the
development/redevelopment of beds.
There were no MLTC inspections at any of the County of Elgin three LTCH's during the
timeframe of July 1 — September 30, 2024.
Page 12 of 29
Critical Incident Systems Report Summary for all Three Homes
Types of Critical Incidents — July 1, 2024 — September 30, 2024
Total
Number
— Three
Homes
Abuse & Neglect — Any alleged, suspected or witnessed abuse of a
28
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
2
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
1
unaccounted for controlled substance
Written complaint
8
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 25 of the
28 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 (BSO) 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.
Eight written complaints were received in this quarter in relation to entry to the home,
potential breach of information, concerns related to care, and communications related to
dietary intake; and, appropriate follow up was completed.
Page 13 of 29
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 and
written complaints, including, but not limited to, providing additional training and
education as required.
Outbreaks
Home
Number of
Timeframe of
# of Residents
Outbreaks and
Outbreak
Impacted
Agent
Bobier Villa
0
N/A
N/A
Bobier Villa recently
celebrated 1 year
outbreak free!
Elgin Manor
2 outbreaks
#1 — July 1 — July
#1 — 22
#1 — COVID-19
18, 2024
#2 — 3
#2 — COVID-19
#2 —July 23 — July
30, 2024
Terrace Lodge
1 outbreak
July 11 — July 15,
2
Rhinovirus
2024
Infection Prevention and Control (IPAC) managers continue to participate in the IPAC
Hub and community of practice meetings. Ongoing collaboration with Southwestern
Public Health continues to support accuracy in decision -making and planning regarding
updated circulating pathogens, guidance documents and policy and procedures.
The IPAC teams across the Homes have been providing education to residents and
families and promoting the Fall COVID vaccine campaign. Some residents may be
ineligible for the fall COVID vaccine based on recent COVID infections.
Mandatory Masking
The July 2024 outbreaks at Elgin Manor and Terrace Lodge occurred during a
timeframe when Public Health was reporting increased respiratory activity, and when
masking was not mandatory.
Based on an analysis of local and regional IPAC data including respiratory activity and
outbreaks in Elgin and Oxford health care facilities, a decision was made by the Homes
management team to resume "mandatory masking" for all staff, students and volunteers
at the three County of Elgin LTCHs in early October. Masking is strongly
recommended, but not mandatory, for all visitors to the Homes. Mandatory masking will
be evaluated throughout the cold and flu season and will be adjusted, where supported
by local and regional data.
This information was communicated to resident and family council and was highly
supported by both residents and families.
Page 14 of 29
Vaccination Updates
Information and promotion of the RSV vaccine was circulated to all residents and
families and a high percentage of residents across our 3 Homes received the RSV
vaccination.
The COVID-19 vaccine was not available to residents during the month of September
while awaiting the updated COVID-19 vaccine. COVID-19 and Influenza vaccinations
will be prioritized in October and November across the 3 Homes.
Fall Preparedness — Soutwestern Public Health Assessments
Each of the 3 County of Elgin Homes has been "gearing up" for "Fall Preparedness".
IPAC assessments have been completed alongside staff from Southwestern Public
Health to support the Homes preparedness for cold and flu season.
Recommendations were provided to the Homes IPAC managers by SWPH to support
readiness and work is being done to implement the recommendations.
Each Home IPAC team conducts IPAC audits and provides staff, residents and visitors
with education to support IPAC measures — hand hygiene, personal protective
equipment, passive and active screening for symptoms, etc.
Elgin Manor has developed new signage as part of the visitor education campaign.
Each Home is conducting hand hygiene audits weekly to support best practices and to
minimize the risk of infection transmission.
Occupancy Data
A 97 % occupancy rate is required to support full ministry funding. All 3 Homes continue
to work diligently to support >97% occupancy rates.
Bobier Villa
Occupancy Data excluding
respite bed
July 1 — September 30,
2024
Occupancy
99 %
Admissions (Move -Ins)
6
Discharges
6
Elgin Manor
Occupancy Data excluding
respite bed
July 1 — September 30,
2024
Occupancy
99 %
Admissions (Move -Ins)
13
Discharges
13
Terrace Lodge
Page 15 of 29
Occupancy Data excluding
respite bed
July 1 — September 30,
2024
Occupancy
99%
Admissions (Move -Ins)
7
Discharges
8
Health System Partners (i.e. Fire, Public Health, Ministry of Labour)
• Monthly fire drills and health and safety inspections are conducted each month
on all shifts at all three Homes
• Terrace Lodge had a Food Safety Inspecton in July 2024 with Southwestern
Public Health; there were no findings of non-compliance.
• Elgin Manor received a field/site visit from the Ministry of Labour, Immigration,
Training and Skills Development on August 23, 2024 to review infection
prevention and control of COVID 19 measures. No orders were issued during
the inspection.
• Bobier Villa received a field/site visit from the Ministry of Labour, Immigration,
Training and Skills Development on September 18, 2024. The inspector was
onsite regarding workers caring for residents with responsive behavours. Two
orders were issued regarding completion of the 2024 workplace violence risk
assessment; and, protection of the worker while providing care for residents with
responsive behaviours. The timeline for corrective action related to the orders
was October 4, 2024. The required actions were taken within these timelines,
however, an extension was requested and provided due to the joint health and
safety committee (JHSC) member's schedule and requirement of the JHSC
member to sign to indicate compliance.
• The Homes are each preparing for their annual fire evacuation and inspection.
This year each home is also preparing for mandatory evacuation exercises.
Dietary and Housekeeping/Laundry Departmental Updates
Department
Bobier Villa
Elgin Manor
Terrace Lodge
Dietary
Recreation and
The residents
Terrace Lodge
dietary staff
enjoyed local
main kitchen
collaboration
harvest produce
remains "under
continues to
including corn on
renovation".
support Chemed
the cob,
Staff should be
meals.
watermelon and
commended for
August — the teams
yellow beans.
having adjusted to
worked together to
reduced work
make Eggs
Theme days have
spaces and
Benedict; and, in
kept the kitchen
revised job
September they
busy with
routines in the
hosted a "Fall Fair"
traditional meals
main kitchen to
whereby residents
for Camp Day,
accommodate
enjoyed live
Country Hoedown
renovations.
entertainment and
Lunch and
Page 16 of 29
pulled pork and
Flavours of the
For the month of
homemade
Carribbean.
August residents
coleslaw.
enjoyed fresh
There were no
vegetables and
There were no
public health
fruit including
public health
kitchen
raspberries,
kitchen inspections
inspections during
strawberries,
during this
this timeframe.
blueberries,
timeframe.
peaches,
honeydew,
wax/green beans,
and corn on the
cob.
Food Committee
Relocation of the
Food committee
Residents
barbeque location
members helped
thoroughly
so that residents
inspire the
enjoyed the "BBQ
could enjoy the
flavours of each
Thursday" that
smells of BBQ
theme day.
took place from
days and watch
July through to
their food being
September.
cooked on the grill.
Housekeeping/laundry
Acknowledgement
The
The
to the
Housekeeping
Housekeeping
housekeeping
team are working
team are working
team —their
through the Public
through the Public
exceptional,
Health Ontario
Health Ontario
diligent cleaning
modules for "IPAC
modules for "IPAC
and IPAC practices
for Environmental
for Environmental
has supported zero
Cleaning in Health
Cleaning in Health
outbreaks this
Care".
Care".
quarter.
This training will
This training will
support ongoing
support ongoing
continuous
continuous
education
education
reflective of IPAC
reflective of IPAC
best practices.
best practices.
Joint Health & Safety
One additional staff
Code Drills —Code
Monthly Code
certified as a JHSC
White and code
Drills with team
member!
Brown policy
members creating
reviewed and
poster boards to
education
increase staff
Regular
provided.
awareness.
inspections and fire
drills
Regular
Violence in the
inspections and
Workplace
fire drills
Assessment
completed
Page 17 of 29
Regular
inspections and
fire drills
Resident & Family Council Updates
Resident
Council
Bobier Villa
Elgin Manor
Terrace Lodge
July
July 18t", 2024
Resident Council
July 8, 2024
- Treasurer's
Meeting scheduled
Sharing and
Report
and took place on July
discussing updates
- Bill of Rights
23rd, 2024
and memo review —
review
- Bill of Rights
redevelopment
- Family Suite
- Home's Mission
project updates, air
Update
Statement
exchange vents,
- Age -wise
- Eulogy
menu boards,
Solutions —
Memories
dessert options,
introduction of
- Admissions &
receiving dock,
Social Worker
Discharges
visitor washroom
- Program
update, entrance
Calendar
access, review of
Review
residents rights,
- Suggested
question related to
programs for
the meaning of
future
"compliance";
- Treasurer's
memo review —
Report
accommodation
- Front door
rate changes, IPAC
situation
updates and
- Front door
vaccination, and
bump
masking.
- Emergency
planning
- Outbreak
update
- Listeria concern
in media
August
Residents Council
Resident Council
August 12
Meeting scheduled
Meeting scheduled
Discussion topics:
and took place on
and took place on
Air exchange vents,
August 14t" 2024
August 22, 2024
menu boards,
- Postponement
- Resident's Bill
washroom
of August
of Rights review
response times,
Residents'
- Eulogy
OARC renewal and
Council-
Memories
payment, IV
Residents
- Admissions &
therapy, washroom
Council in
Discharge
update lobby,
agreeance.
recreation
Page 18 of 29
- Program
calendars (new
Calendar
larger size),
Review
Olympic Games
- Suggested
enjoyment,
programs for
enjoyment of local
future
fresh produce and
- Treasurer
BBQs, upcoming
Report
CQI meeting
- Request for
invitation
"dollar like
items" in the
August 29
Gift Shop
- Mel's place light
Discussion topics:
repair
Air exchange vents,
- Outdoor pole
entrance door time
repair
update, washroom
- RSV, Covid, &
response update,
Flu Vaccines
review of resident
update
rights (#17, 18, 19),
redevelopment
bowling tournament
and process for
lottery license, new
administration
clerk, update
redevelopment,
new genealogy
program, draft
September
recreation
calendars,
legislation and meal
service update, CQI
meeting update,
Emergency Codes,
draft resident and
family satisfaction
survey review;
memo
redevelopment
update Aug. 30
September
Residents Council
Resident Council
September 13
Meeting scheduled
Meeting scheduled
Discussion topics:
and took place on
and took place on
Air Exchange Vents
September 19t",
September 19t", 2024
Update, resident
2024
- Bill of Rights
council week,
- Treasurer's
review
refrigeration of
Report
personal items,
Page 19 of 29
Bill of Rights
review
Resident &
Family
Satisfaction
Survey
Purchase of
Large Hallway
Clock by
Residents'
Council
Silent Auction
in November
Eulogy
memories
- Admissions &
Discharge
- Program
Calendar
Review
- Treasurer
Report
- Suggested
program(s) for
future
- Hairdressing
services
- Annual
Satisfaction
Surveys
- Staff hiring
Fire Map, Fire Drills,
Planned annual
evacuation in October
religious and
spiritual care
update, birds nest
update,
redevelopment
memo, recreation
program update,
whisper glide swing
program and policy,
IPAC update re-
vaccination,
community outings
update, CQI
meeting date and
time, Emergency
codes cards and
poster, resident and
family satisfaction
survey
September 26
Discussion topics:
Air exchange vents
update, lift
batteries, resident
rights review (#20,
21, 22), OARC
membership
update, IV therapy,
religious and
spiritual care, birds
nest update, large
tree in courtyard,
camera monitoring
front entrance,
shower room,
family council
invitation cards,
IPAC update — flu
season and
vaccinations, IPAC
masking
conversation,
shingles
vaccination,
resident and family
satisfaction survey,
visitor policy, memo
— enhanced
Page 20 of 29
masking and IPAC
measures
Family
Bobier Villa
Elgin Manor
Terrace Lodge
Council
July
Family Council
Family Council
Monthly
Meeting scheduled
Meeting scheduled on
on July 17t" 2024,-
July 12t" 2024
Meeting information
no members in
- Cancelled as
communciated but
attendance, Family
per Family
members unable to
Council meeting
Council due to
attend
minutes posted and
outbreak
virtually/inperson
sent to members.
Recruitment efforts
ongoing (posted in
the Home, sent via
email/newsletter);
options to
communicate via
meetings available
in
person/phone/zoom
to support
attendance.
August
Family Council
Family Council
Monthly
Meeting scheduled
Meeting scheduled
Meeting information
on August 21st,
and took place on
communciated but
2024, no members in
August 9t"7 2024
members unable to
attendance, Family
- Home Updates
attend
Council meeting
- Introduction of
minutes posted and
Social worker in
sent to members.
the Home
Information sent
- Introduction of
electronically to
Quality
members
Improvement
Co-ordinator
- Capital projects
- IPAC updates
- Glove
Dispenser's in
Residents'
Rooms
September
Family Council
Family Council
Monthly
Meeting scheduled
Meeting scheduled
Meeting information
on September 18t"
and took place on
communciated but
2024, no members in
September 13t"7 2024
members unable to
attendance, Family
- Home updates,
attend.
Council meeting
specifically
Page 21 of 29
minutes posted and
related to front
sent to members.
door access
- IPAC Updates
including
communications
of outbreaks
- Introductions to
new Resident
Care
Coordinator and
Education &
Quality
Improvement
Coordinator
- Director Memo
of Family
Council
- Annual Family
& Residents
Satisfaction
Survey
- Upcoming
Quarterly
Continuous
Quality
Improvement
Meeting
Crafter's Market on
November 23rd, 2024
Program and Therapy Department Updates
Item
Bobier Villa
Elgin Manor
Terrace Lodge
Special Programs &
Country of
Celebration of the
Mistyglen
Event Highlights
Discover: Canada,
commencement of
Creamery and
Greece, Paris
the Summer
Farm Outing
Olympics
Celebration of the
Ruby's Cookhouse
commencement of
Bus Outing —
Order -in
the Summer
Shaw's Ice
Olympics
Cream,Mackies,
Aylmer Burger
Boston Pizza
Stand Order -in
Watermelon Social
Lemonade Social
Celebration of Life
Walkers Dairy Bar
Cooking
Outing
Demonstration with
Fitness with Larry
Recreation: Make
Aylmer Bandshell
your own Pizza
Concert in the Park
Page 22 of 29
Bus Trip — GTs in
Port Stanley,
Palassads Bowling
in London and
Magnolia Outing to
Port Glasgow;
London Majors
Game, Sparta Tea
room
Fitness with Larry
Art Class with
Krista
Historian Pete
Sheridan —Johnny
Cash
Pet Therapy visits
Sunday Tea with
Bobier Villa
Auxiliary Group
Croc-A-Doodle:
Painting Ceramics
Daycare visits from
Dutton Daycare
Country of
Discover: Paris
including Parisian
breakfast
Country Fall Fair —
open to residents &
families. Fall Fair
included popcorn &
games, music
entertainment and
dinner
Resident & Family
Collaboration event
in memory of
resident passing —
family paid for
Art Therapy with
Krista
Country of
Discover:
Caribbean Day
which included a
Mocktail Tiki Bar
and Life Music from
Golden Harps Steel
Drum Band
History Talk with
Guest Speaker
(Pete Sheridan)
Weekly tuck shop
with the Auxiiliary
Reduced
programming
during month of
July related to
outbreak activity
with Spicer's
Bakery
Refreshments
Aylmer Fair Entries
— prize ribbons
ranging from
participation up to
1st place!
Aylmer Art in the
Park Participant
Local Car Show at
Terrace Lodge
featuring Pop Shop
Pop and Snacks
Page 23 of 29
entertainment and
ice cream sundae
bar
New
Celebration of the
Hire of the Golden
Terrace Lodge
Initiatives/Enhanced
Summer Olympics
Harps Steel Drum
Olympic Games
Programming
in Paris
Band
and Medal Tracking
French inspired
Animal Farm
Gorgeous
Cooking
Therapy by Little
Grandma Photo
Demonstration with
Hobby Hill Farm
Shoot
MSS Chris and
Recreation Team —
Reduced due to
Gorgeous Grandpa
making crepes
outbreak activity
Photo Shoot
featuring a Model T
Heart for Music
Ford
Application
submitted to
New Genealogy
enhance our music
Program with
based
Volunteer Supprot
programming at
Bobier Villa
Gift Shop
Preparedness and
County Fall Fair
Purchases
New Large Print
Calendars
Education
Recreation staff
Recreation staff
Whisper Glide
completed their
completed their
Swing training and
Food Handlers
Food Handlers
policy
Training/Food
Training/Food
implementation
Safety Program
Safety Program
Mental health First
during this time
during this time
Aid Training for
period.
period.
Seniors
Volunteer Services
14 registered active
16 registered active
52 active
volunteers; 2 new
volunteers; 2 new
volunteers
since last quarter
since last quarter
Gift Shop Volunteer
Campaign
Nursing Department and Quality Improvement Updates
Department
Bobier Villa
Elgin Manor
Terrace Lodge
Mandatory
All mandatory
Work to increase
RNAO clinical
Programs &
teams and
committee
pathway awareness
Committees
programs in place;
membership.
communication
continue to build
membership.
Page 24 of 29
Behavioural
RNAO clinical
Supports Ontario
pathway awareness
(BSO) team
communication
onboarding 2 new
members.
Comfort rounds
initiated on all new
admissions x 7
days to flag high
risk residents.
Home specific
Catheter and
Catheter and
Ongoing increased
nursing/quality
hydration focus
hydration focus.
frequency of team
updates
huddles for day and
Focus on
afternoon shifts to
falls, change in
enhance
status, pain,
communication,
documentation
decision making
related to prior
and teamwork;
inspection
BSO team huddle
outcomes.
frequency
increased to
support knowledge
sharing and
embedded
processes.
Catheter and
hydration focus.
Student
2 groups of Year 3
PSW students and
PSW students and
placements
RN students —
RPN students
RPN students
planning for
placements in
October 2024.
Additional
CMHA 15 minute
CMHA 15 minute
CMHA 15 minute
educational
education sessions
education sessions
education sessions
opportunities
for all staff onsite
for all staff onsite
for all staff onsite
Letters of
RNAO Best
RNAO Best
understanding in
Practice Guideline
Practice Guideline
place to support
Champion Training
Champion Training
education
ongoing
ongoing
opportunity
RNAO Best
Management team
Management team
Practice Guideline
members across all
members across all
Champion Training
departments
departments
ongoing
engaged in
engaged in
Page 25 of 29
Management team
Indigenous Cultural
Indigenous Cultural
members across all
Awareness Safety
Awareness Safety
departments
Training and
Training and
engaged in
Equity, Diverstity,
Equity, Diverstity,
Indigenous Cultural
Inclusion and Anti-
Inclusion and Anti -
Awareness Safety
Racism training
Racism training
Training and
Hydration forms
Equity, Diverstity,
Hydration forms
Inclusion and Anti-
New catheter
Racism training
New catheter
policies
policies
Continence
refresher education
and inservices with
provider
Quality Indicators
Key Performance
Bobier Villa
Elgin Manor
Terrace Lodge
Indicator
Falls
April — June
7%
9.6%
24.4%
July — September
11 %
15.3%
20%
Daily Physical
Restraints
April — June
0%
0%
1.1 %
July — September
0%
2%
2.2%
Worsening
Pressure Ulcer
(Stage 2-4)
April — June
1 %
3.0%
8.6%
July — September
1 %
2%
6.1 %
Antipsychotics
without a
supporting
Diagnosis
April — June
3%
23.8%
3.8%
July — September
6%
21 %
2%
Administrative Department Updates
Item
Bobier Villa
Elgin Manor
Terrace Lodge
Staff Schedule
New clerical staff
New clerical staff
New clerical staff
Care (SSC)
onboarded —
onboarded — refresher
onboarded —
refresher
education provided to
refresher
education
support scheduling and
education
provided to
robocall; education
provided to
support
support
Page 26 of 29
scheduling and
recordings available for
scheduling and
robocall;
future use.
robocall;
education
education
recordings
recordings
available for
available for
future use.
future use.
Clinical
Training and
Training and
Training and
Connect/econnect
onboarding
onboarding delayed
onboarding
delayed related to
related to PCC issue —
delayed related to
PCC issue —
awaiting resolve.
PCC issue —
awaiting resolve.
awaiting resolve.
Reimbursement of
fees during the
delay.
Staffing Updates
Retirement of
Homes Quality
Vacancy for
long-term full time
Improvement/education
administrative
administrative
role filled by former
clerk filled —
clerk employee in
Resident Care
successful
September.
Coordinator.
onboarding for
Former part time
full-time role.
clerk accepted full
Elgin Manor RPN,
time role.
accepted the full time
Successful
Resident Care
onboarding for
Coordinator role.
part time role.
Education
Several Managers
Several Managers
Several Managers
enrolled in the
enrolled in the
enrolled in the
"Manager as a
"Manager as a Coach
"Manager as a
Coach Learning
Learning Sessions
Coach Learning
Sessions across
across the Homes and
Sessions across
the Homes and
prior attendees are
the Homes and
prior attendees
implementing small
prior attendees
are implementing
work groups to support
are implementing
small work groups
ongoing
small work groups
to support
implementation of
to support
ongoing
concepts at the Home
ongoing
implementation of
level
implementation of
concepts at the
concepts at the
Home level
Home level
Director,
Director,
Director,
Administrators,
Administrators,
Administrators,
Managers of
Managers of Resident
Managers of
Resident Care
Care and Quality
Resident Care
and Quality
Improvement lead
and Quality
Improvement lead
attended 2 day RNAO
Improvement lead
attended 2 day
Clinical Pathways
attended 2 day
RNAO Clinical
RNAO Clinical
Page 27 of 29
Pathways launch
launch for Cohort 7 in
Pathways launch
for Cohort 7 in
September
for Cohort 7 in
September
September
Wellness
Wellness Moments
Wellness
Moments with
with CMHA for all staff
Moments with
CMHA for all staff
in July/August — 15
CMHA for all staff
in July/August —
minute sessions to
in July/August —
15 minute
introduce health care
15 minute
sessions to
wellness strategies;
sessions to
introduce health
additional training
introduce health
care wellness
planned.
care wellness
strategies;
strategies;
additional training
additional training
planned.
planned.
Diagnostic
All 3 Homes
All 3 Homes submitted
All 3 Homes
Equipment
submitted
application for software
submitted
Funding
application for
and equipment to
application for
Application
software and
support resident care
software and
equipment to
and services; awaiting
equipment to
support resident
response from Ontario
support resident
care and services;
Health to submission.
care and services;
awaiting response
awaiting response
from Ontario
from Ontario
Health to
Health to
submission.
submission.
Terrace Lodge
Phase 3 of the
Redevelopment
Terrace Lodge
Redevelopment
Project well
underway.
Director finalizing
occupancy plan
for submission to
Ministry; pre-
occupancy
inspection and
move day
anticipated to be
spring 2025.
Financial Implications:
None
Page 28 of 29
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.
Local Municipal Partner Impact:
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 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 29 of 29