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10 - May 10, 2022 County Council Agenda PackageIginProgrpesOve, by Nature TABLE OF CONTENTS Orders — Tuesday, May 10, 2022................................................................ 2 Elgin County Council Minutes — April 26, 2022............................................. 3 Delegation — SCOR Economic Development Corporation ................................ 9 ReportsIndex........................................................................................ 37 Report — Warden's Activity Report (April) and COVID-19 Update ...................... 38 Report — 2021 Annual Library Performance Measurements ............................. 42 Report — Homes — Administration Policy Updates .......................................... 55 Report — Contract Award — County Administration Building — Council Chambers 98 & Reception Upgrades Project.................................................................. Closed Session Agenda — May 10, 2022...................................................... 102 yr "i^�\NM111WIWm� Elgin @'TM'o P w nP,v t,y rVwSP,'6( e ORDERS OF THE DAY For Tuesday, May 10, 2022, 9:00 A.M. 1St Meeting Called to Order 2°d Adoption of Minutes —April 26, 2022 3rd Disclosure of Pecuniary Interest and the General Nature Thereof 4th Presenting Petitions, Presentations and Delegations Delegation: 9:00 a.m — Kimberly Earls, SCOR EDC — Future of Shortline Rail in the South Central Ontario Region 5th Motion to Move Into "Committee of the Whole Council" 6th Reports of Council, Outside Boards and Staff 7th Council Correspondence 1. Items for Consideration — none. 2. Items for Information (Consent Agenda) — none. 8th Other Business 1. Statements/Inquiries by Members 2. Notice of Motion 3. Matters of Urgency 9th Closed Meeting Items 10th Recess 11th Motion to Rise and Report 12th Motion to Adopt Recommendations from the Committee of the Whole 13th Consideration of By -Laws 14th Adjournment VIRTUAL MEETING: IN -PERSON PARTICIPATION RESTRICTED NOTE FOR MEMBERS OF THE PUBLIC: Please click the link below to watch the Council Meeting: //ww ,c,oir Ig.�InQ,.4�nf:VlElrr�ii::i.( Accessible formats available upon request. y. Elgi t Pragresaive by Na ft a e gice] I►[d9111►IVYd9111►INI MINUTES April 26, 2022 Page 1 April 26, 2022 Elgin County Council met this 261h day of April 2022 at the Masonic Centre of Elgin, 42703 Fruit Ridge Line, St. Thomas ON. The meeting was held in -person. Council Present: Warden Mary French Deputy Warden Tom Marks Councillor Duncan McPhail Councillor Bob Purcell Councillor Grant Jones Councillor Sally Martyn Councillor Dave Mennill Councillor Dominique Giguere Councillor Ed Ketchabaw Staff Present: Julie Gonyou, Chief Administrative Officer Brian Lima, General Manager of Engineering, Planning & Enterprise/Deputy Chief Administrative Officer Brian Masschaele, Director of Community and Cultural Services Michele Harris, Director of Homes and Seniors Services Katherine Thompson, Manager of Administrative Services/Deputy Clerk Carolyn Krahn, Interim Manager, Economic Development and Tourism Jenna Fentie, Legislative Services Coordinator Delany Leitch, Legislative Services Coordinator 1. CALL TO ORDER The meeting convened at 9:00 a.m. with Warden French in the chair. ADOPTION OF MINUTES Moved by: Councillor Ketchabaw Seconded by: Councillor Martyn RESOLVED THAT the minutes of the meeting held on April 6, 2022 be adopted. Motion Carried. DISCLOSURE OF PECUNIARY INTEREST AND THE GENERAL NATURE THEREOF i• •[Tip 4. PRESENTING PETITIONS, PRESENTATIONS AND DELEGATIONS None. 5. COMMITTEE OF THE WHOLE Moved by: Councillor Mennill Seconded by: Deputy Warden Marks RESOLVED THAT we do now move into Committee of the Whole Council. Motion Carried. 6. REPORTS OF COUNCIL, OUTSIDE BOARDS AND STAFF 6.1 Terrace Lodge Redevelopment Fundraising Committee Appointment — Councillor Giguere Page 2 April 26, 2022 Councillor Giguere presented the report recommending that Councillor Amarilis Drouillard from the Municipality of Dutton Dunwich be appointed to the Terrace Lodge Redevelopment Fundraising Committee. Moved by: Councillor Jones Seconded by: Councillor Purcell RESOLVED THAT the report titled "Terrace Lodge Redevelopment Fundraising Committee Appointment" dated March 29, 2022 from Councillor Giguere be received and filed; and THAT County Council appoint Dutton Dunwich Councillor Amarilis Drouillard to sit on the Terrace Lodge Redevelopment Fundraising Committee for the remainder of 2022. Motion Carried. 6.2 Library, Museum, and Archives Service Updates — December 2021 to March 2022 — Director of Community and Cultural Services The Director of Community and Cultural Services presented the report outlining the service and project updates for the Elgin County Library, Museum, and Archives for the period of December 2021 to March 2022 relative to the province's COVID-19 re -opening framework. Moved by: Councillor Martyn Seconded by: Councillor Giguere RESOLVED THAT the report titled "Library, Museum, and Archives Service Updates — December 2021 to March 2022" dated April 1, 2022 from the Director of Community and Cultural Services be received and filed. Motion Carried. 6.3 Homes — Nursing and Maintenance Department Policy Manual Review and Revisions — Director of Homes and Seniors Services The Director of Homes and Seniors Services presented the report recommending that County Council approve the revisions to the Nursing and Maintenance policy manuals for the Elgin County Long -Term Care Homes. Moved by: Councillor Mennill Seconded by: Councillor Jones RESOLVED THAT the report titled "Homes — Nursing and Maintenance Department Policy Manual Review and Revisions" dated April 13, 2022 from the Director of Homes and Seniors Services be received and filed; and THAT County Council approve the County of Elgin Homes and Seniors Services Nursing and Maintenance Department policy manual review and revisions for 2022. Motion Carried. 6.4 Homes — Pharmacy Services — Amending Agreement — Director of Homes and Seniors Services The Director of Homes and Seniors Services presented the report recommending that County Council authorize the Warden and Chief Administrative Officer to sign an amending agreement with CareRx Pharmacy for the ongoing provision of pharmacy services for the Elgin County Long -Term Care Homes. Moved by: Councillor Martyn Seconded by: Deputy Warden Marks Page 3 April 26, 2022 RESOLVED THAT County Council approve the changes in operating procedures and/or services with an authorization for execution of an amending agreement prepared by the County Solicitor which incorporates those changes; and THAT the Warden and Chief Administrative Officer be authorized to sign the amending agreement with CareRx Pharmacy Inc. for the ongoing provision of pharmacy services; and THAT the report titled "Homes — Pharmacy Services — Amending Agreement" dated April 19, 2022 from the Director of Homes and Seniors Services be received and filed. Motion Carried. 6.5 Elgincentives Program Review — Interim Manager of Economic Development and Tourism The Interim Manager of Economic Development and Tourism presented a review of the County of Elgin's Elgincentives Program. Moved by: Councillor Mennill Seconded by: Councillor Jones RESOLVED THAT the County of Elgin continue funding and administering the Elgincentives Community Improvement Plan with two (2) intakes per year and refocused priorities, targeted marketing, and updated evaluation criteria; and THAT staff be directed to continue to work with the Local Municipal Partners to conduct an annual review of the Elgincentives program to ensure program alignment with community need; and THAT during the annual budget review process, Council identify the extent to which they will participate in the Elgincentives financial incentives programs; and THAT the $80,000 from the former property tax vacancy rebate program be used to fund the 2022 Elgincentives program. Motion Carried. 6.6 Elgincentives 2021 Year End Review — Interim Manager of Economic Development and Tourism The Interim Manager of Economic Development and Tourism presented the report detailing the 2021-year end review of the Elgincentives program. Moved by: Councillor Ketchabaw Seconded by: Deputy Warden Marks RESOLVED THAT the report titled "Elgincentives 2021 Year End Review" dated March 29, 2022 from the Interim Manager of Economic Development and Tourism be received and filed. Motion Carried. 6.7 2021 County Road Maintenance Agreement — Financial Reporting — General Manager of Engineering, Planning & Enterprise/Deputy CAO and Manager of Transportation Services The General Manager of Engineering, Planning & Enterprise/Deputy CAO presented the report summarizing county road maintenance expenditures as reported by Elgin's member municipalities for the 2021 calendar year as required by the Road Maintenance Agreement. Moved by: Councillor Mennill Page 4 April 26, 2022 Seconded by: Councillor Jones RESOLVED THAT the report titled "2021 County Road Maintenance Agreement — Financial Reporting" dated March 25, 2022 from the General Manager of Engineering, Planning & Enterprise/Deputy CAO and the Manager of Transportation Services be received and filed. Motion Carried. 6.8 East Road — Multi -Use Path Funding Request — General Manager of Engineering, Planning & Enterprise/Deputy CAO and Manager of Transportation Services The General Manager of Engineering, Planning & Enterprise/Deputy CAO presented the report outlining options for East Road in response to a request received from the Municipality of Central Elgin. Moved by: Councillor Jones Seconded by: Councillor Giguere RESOLVED THAT the report titled "East Road — Multi Use Path Funding Request" dated April 14, 2022 from the General Manager of Engineering, Planning & Enterprise/Deputy CAO and the Manager of Transportation Services be received and filed. Motion Carried. 6.9 Donation Policy 1.1 — Chief Administrative Officer The Chief Administrative Officer presented a draft Donation Policy for Council's review and approval. The policy will ensure that informed decisions are made regarding the acceptance of gifts to benefit Elgin County and the donor, and that such gifts are receipted in accordance with the Canada Tax Revenue Agency (CRA) and the Income Tax Act. Moved by: Councillor Giguere Seconded by: Councillor Mennill RESOLVED THAT the report titled "Donation Policy No. 1.1." dated March 29, 2022 from the Chief Administrative Officer be received and filed. Motion Carried. 6.10 Response to Ukrainian Crisis— Chief Administrative Officer The Chief Administrative Officer presented the report as a response to the motion brought forward by Councillor McPhail at the March 22, 2022 requesting recommendations regarding a possible financial contribution from Elgin County to the Canadian Red Cross in light of the humanitarian crisis in Ukraine. Moved by: Councillor Purcell Seconded by: Councillor Jones RESOLVED THAT the report titled "Response to Ukraine Crisis" dated March 22, 2022 from the Chief Administrative Officer be received and filed; and THAT Council support the humanitarian crisis in Ukraine through non -financial means such as raising the Ukrainian Flag at the Elgin County Heritage Centre and undertaking a communications strategy to raise public and staff awareness about the ongoing crisis. Motion Carried. COUNCIL CORRESPONDENCE Page 5 April 26, 2022 7.1 Items for Information (Consent Agenda) 7.1.1 Letter from the Minister of the Solicitor General confirming the County of Elgin's compliance with the Emergency Management and Civil Protection Act (EMCPA) for 2021. 7.1.2 St. Thomas -Elgin Coalition to End Poverty Year in Review. Moved by: Councillor Jones Seconded by: Councillor Giguere RESOLVED THAT Correspondence Items #7.1.1-7.1.2 be received and filed. - Motion Carried. E: 9111:IA:A:1Iby1►14:1 8.1 Statements/Inquiries by Members None. 8.2 Notice of Motion None. 8.3 Matters of Urgency None. 9. CLOSED MEETING ITEMS Moved by: Councillor Ketchabaw Seconded by: Councillor Mennill RESOLVED THAT we do now proceed into closed meeting session in accordance with the Municipal Act to discuss the following matters under Municipal Act Section 239 (2): In -Camera Item #1 (a) the security of the property of the municipality or local board — Security of Property In -Camera Item #2 (b) personal matters about an identifiable individual, including municipal or local board employees —Organizational Update - Motion Carried. 10. MOTION TO RISE AND REPORT Moved by: Councillor Mennill Seconded by: Councillor McPhail RESOLVED THAT we do now rise and report. - Motion Carried. In -Camera Item #1 — Security of Property Moved by: Councillor Mennill Seconded by: Deputy Warden Marks RESOLVED THAT staff proceed as directed. Page 6 April 26, 2022 Motion Carried. In -Camera Item #2 — Organizational Update Moved by: Councillor Jones Seconded by: Councillor Ketchabaw RESOLVED THAT staff proceed as directed. - Motion Carried. 11. MOTION TO ADOPT RECOMMENDATIONS FROM THE COMMITTEE OF THE WHOLE Moved by: Councillor Purcell Seconded by: Councillor Martyn RESOLVED THAT we do now adopt recommendations of the Committee of the Whole. - Motion Carried. 12. CONSIDERATION OF BY-LAWS 12.1 By -Law No. 22-20 — Confirming all Actions and Proceedings BEING a By -Law to Confirm Proceedings of the Municipal Council of the Corporation of the County of Elgin at the April 26, 2022 Meeting. Moved by: Councillor Jones Seconded by: Councillor Purcell RESOLVED THAT By -Law No. 22-20 be now read a first, second and third time and finally passed. - Motion Carried. 13. ADJOURNMENT Moved by: Deputy Warden Marks Seconded by: Councillor Ketchabaw RESOLVED THAT we do now adjourn at 11:11 a.m. to meet again on May 10, 2022 at 9:00 a.m. - Motion Carried. 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The area is roughly the size of the GTA and is home to about 1 million people. The region is intersected by 400 series highways; 401, 402 and 403. It is also intersected by CN and CP rail lines. In addition to land transportation the region is also home to international and regional airports as well as water ports along the Great Lakes. The region is within a 3-hour drive of 6 U.S. border crossings. It is the gateway of economic activity from the US to the rest of Ontario and Canada. Agriculture, manufacturing and tourism are the foundation of economic activity across the region. According to Statistics Canada in 2017, Agriculture, Manufacturing, and Tourism accounted for 14.08% of Canada's GDP and 14.71% of Ontario's. These economic sectors are reliant on reliable, cost-effective transportation corridors to continue to flourish and expand in the region. The Cayuga Rail Line Revitalization Project The Cayuga Rail Line Revitalization project is a collaboration between South Central Ontario Region Economic Development Corporation (SCOR EDC), GIO Rail, the Town of Tillsonburg, and the Counties of Oxford, Elgin, and Norfolk. The project seeks to rehabilitate approximately 23 miles of short line rail within the South Central Ontario region. More specifically, this project will revitalize the section of track beginning in the Municipality of Central Elgin (Elgin County) travelling through the Town of Tillsonburg (Oxford County) and ending in Courtland (Norfolk County). The project has the unique advantage of confirmed partnerships from local industry, municipalities, economic development organizations and others as proven by the letters of support, investment and continued commitment to the project. Service was recently reinstated (January 2022) along this line after a two-year pause following the abandonment of the line by the pervious shortline operator. Canadian National Railways (CN) had initiated the discontinuance process when SCOR EDC, the Town of Tillsonburg, and GIO Rail signed a letter of intent with the objective to ensure rail service remained in the region. Following this, GIO Rail was able to secure a 10-year lease with CN for the Cayuga rail line. This project will improve the existing supply chain performance for the manufacturing, agriculture and food sectors. The South Central Ontario Region is the gateway for trade and supply chain movement between United States and the rest of Ontario. The integration of the Cayuga Shortline rail as part of the wider transportation network, will significantly improve the fluidity of the transportation of goods along these traditional supply lines creating opportunity and ensuring flow of goods and products across North America. Additionally, the project will support long term economic activity, jobs and strong supply lines, providing safe, and reliable movement of materials and products between transport trucking, air/marine shipping supplying global clients. This project will also streamline regulatory delays and red tape ensuring an efficient transport system throughout the region. The future of rail and shortline rail in particular across North American is optimistic. Over the last 18 months supply lines have been challenged and businesses producing consumer goods have been drastically affected. Ensuring that we have a consistent, reliable mode of transportation at the regional level that connects seamlessly to the wider transportation corridor is critical for continued retention and expansion of current users and for further investors. South Central Ontario Region's extensive manufacturing and agricultural sectors are committed to long term usage of shortline rail as part of their supply chain model into the future. This project will address the urgent need to invest in transportation opportunities in an efficient and cost-effective manner. It will provide increased frequency and reliability of supply shipments to businesses who rely on highway and rail for production inputs. This will create improved assets for the communities where the businesses are located but also across the entire region, thereby providing social and economic development sustainability and security in communities along the line. Development of the project and improvements to the Cayuga Shortline Rail will reduce costs and provide logistical stability for shipments through the region to end users. An essential component of this important supply chain and logistics corridor is a healthy shortline rail. Scope The scope of the project is to create and maintain an on -going viable shortline rail operation serving businesses along the rail corridor. This will continue to support existing business reliant on rail and to further utilize this asset for future economic development opportunities. The Shortline Rail Project is planned as a business retention and expansion opportunity along the 43 km (27 mi) of existing shortline rail track across the counties of Elgin, Oxford and Norfolk. There are approximately 1,150 acres of industrial lands comprising 49 occupied lots and 23 vacant lots. The majority of lands travelled through are agricultural, however there are significant existing and future industrial lands along the line that would be ripe for development and investment. The rising cost of land and lack of availability of industrial land in larger centres such as the GTHA are causing businesses to seek alternate regions for affordability for land development. However the expectation of stable, transportation networks and options are still expected. Throughout the South Central Ontario Region economic development professionals have seen a drastic increase in interest in lands and a strong interest in lands with access to rail. Industrial Sites Along Project Site Norfolk County 193.31 68 11 1 Oxford County 6091,71 458.8 18 s Tillsonblurg 60931 458.8 18 8 Elgin County 665.14 387.69 22 12 Aylmer 15531 87.05 11 6 Bayhalm 53.02 53.02 2 2 Central Elgin 247,.62 247.62 4 4 Malahid'e 209.19 01 5 0 Total 1,468.16 914.49 51 Updated December, 2020 21 Business Users Historically users along this line have been anchor businesses within wider supply chains in both agricultural and manufacturing sectors. A survey was conducted with businesses currently located along the line to determine the usage of rail, estimated car volumes, estimated car values and connection integration of these business within a wider supply chain. To date we have several entities that have committed to car increased car volumes with a vision to progressively higher volumes year over year for the life of the project and beyond. These increased volumes could only be maintained if the identified upgrades are made along the track. Currently, the rail operates at a decreased capacity which places restrictions on both car weight and frequency. This project would serve to alleviate both of those issues. Investments in the track would bring weigh capacity up to those of Class 1 rail lines 286,000 Ibs which would then provide for increased frequency of traffic as well. A survey was conducted with business along the track to ascertain impacts that could be expected to occur without the project upgrades. As the table demonstrates there are a significant number of jobs that would be at risk in addition to increase logistics costs incurred by business and loss of revenue to the region. Company Total revenue Size of Number of loss if Total revenue Logistics Current access facility employees shortline loss without costs due to to rail (Sgft.) (FTE) service shortline shortline loss infrastructure remains service ($) ($) suspended N Company 49-acre 75 0-5% None currently $250,000- Private siding A site but could 300,000 into building impact future development plans Company 5-acre 15 16-20% N/A N/A Private siding g site into property Company 173,000 160 6-10% $910,000 $850,000 Private siding C into building Company 200,000 10 16-20% $1,000,000- $100,000- Private siding p $2,000,000 $200,000 into property Company 400,000 80 21-25% $5,000,000 $50,000 Private siding E into property Company 60,000 46 0-5% $0 $50,000 Major F transload site (i.e. CN intermodal) Company 80,000 16 0-5% $0 $0 Siding in close G proximity to your business Totals 402 $7,910,000 $1,450,000 We further conducted informational research to determine the approximate value of goods per car. Although this figure can vary widely from business to business and load to load, businesses reported on past car values. Some businesses reported fairly consistent car values as seen in the table below while others reported wider variances. One business in particular noted that the lowest car value estimate was $70,000 and the highest car value estimated at $1.4 million. Approximately 26% of car volumes are anticipated to be valued at over $1 million, with the remainder having a value of approximately $70,000. Thus, we project the rail line will move a minimum of $477,000,000 during its third year of operations. Railcar Projections - Cayuga Subdivision Business Case Comparison of Original 2021 Forecast to Current Mar 31, 2022 Forecast Year 2021 Original Market Study (Adjusted) Updated Forecast Current Forecast (Mar 30, 22) 2022 (Yr 1) 490 300 2023 (Yr 2) 595 750 2024 (Yr 3) 705 3950 1500 2025 (Yr 4) 1485 2250 2026 (Yr 5) 1500 3000 Projected 5 Year Volume (Total) 4775 3950 7800 63% Labour Market Information / Workforce In addition to direct cost benefits as reported by businesses in the above table any cost -benefit calculations would be remiss if workforce influences were not considered. Currently truck driver jobs are According to a 2018 Service Canada report pre -pandemic, "Transport truck drivers, over the period 2019-2028, new job openings (arising from expansion demand and replacement demand) are expected to total 119,900 , while 96,600 new job seekers (arising from school leavers, immigration and mobility) are expected to be available to fill them', which clearly shows a deficit in labour to fill needed positions. This has been significant exacerbated by the pandemic. This job shortage creates, delays, higher costs in labour for transport companies (which are often passed along to customers) and uncertainty regarding availability of logistics. An alternative option in the form of rail would go far to mitigate this issue. ' https://www.jobbank.gc.ca/marketreport/outlook-occupation/10552/ca REPORTS OF COUNCIL AND STAFF May 10, 2022 Council Reports — ATTACHED Warden French — Warden's Activity Report (April) and COVID-19 Update Staff Reports — ATTACHED Library Coordinator — 2021 Annual Library Performance Measurements Director of Homes and Seniors Services — Homes — Administration Policy Updates — Resident Rights, Resident Abuse, Mandatory and Critical Incident Reporting, Requests and Concerns, Staff Reporting and Whistle Blower Protection General Manager of EPE/Deputy CAO — Contract Award — County Administration Building — Council Chambers & Reception Upgrades Project l RECOMMENDATION: REPORT TO COUNTY COUNCIL FROM: Mary French, Warden DATE: May 2, 2022 SUBJECT: Warden's Activity Report (April) and COVID-19 Update THAT the report titled "Warden's Activity Report (April) and COVID-19 Update" dated May 2, 2022 from Warden French be received and filed. INTRODUCTION: This report provides a high-level summary of the County's response to the pandemic as well as a list of events and meetings I attended and organized on behalf of County Council. DISCUSSION: COVID-19 Update On March 21, 2022 the Province of Ontario lifted the majority of remaining COVI D-19 restrictions including lifting the requirement to wear face coverings in indoor settings. A Ig:II�...a,; ([2�....a�...a":u«�;; 1, of the COVID-19 vaccine is now available at a recommended �';�aii ui fill ��.... . . interval of five months (140 days) after a third dose for those who are: 60 years old or older First Nation, Inuit and Metis individuals aged 18 and over or a non -Indigenous household member aged 18 and over County Operations County of Elgin operations have now returned to pre -pandemic levels. Staff continue to self -screen before entering County workplaces and the Vaccination Verification Policy remains in effect. 2 Municipal Emergency Rescinded On April 8, 2022, the County of Elgin in conjunction with its Local Municipal Partners and the City of St. Thomas rescinded the municipal emergency that had been in place since March 2020. On March 17, 2020 the Province of Ontario declared an Emergency under the Emergency Measures and Civil Protection Act. This allowed the province to implement and enforce the necessary emergency orders to protect the health and safety of Ontarians during the COVID-19 pandemic. In response to this declaration, the County of Elgin, the City of St. Thomas, and Elgin County's seven (7) Local Municipal Partners also declared emergencies at the municipal level. Over the course of March 2022, key public health and health system indicators across Ontario remained stable or improved. Ontario cautiously and gradually eased public health and workplace safety measures. As restrictions lifted provincially, the Elgin County Emergency Operations Centre (EOC) comprised of representatives from Elgin Country, the City of St. Thomas, and all seven (7) of Elgin's Local Municipal Partners, decided to simultaneously end the emergency declarations in their respective jurisdictions. National Day of Mourning — April 28, 2022 On Thursday April 28 a flag was raised at the Elgin County Heritage Centre to recognize the National Day of Mourning commemorating workers who have been killed, injured or suffered illness as a result of work place incidents or exposures. I also attended an event at Pinafore Park to honour the occasion. The most recent statistics from the Canadian Labour Congress indicate that approximately 1,000 workers are killed in Canada each year and even more suffer life altering injuries and illnesses while on the job. The County of Elgin honours the lives that have been lost, mourn with the families, friends and communities that have been adversely affected, and recommit to ensuring that work places in Elgin County and across the country are places to safely earn a living. Work place deaths, injuries and illnesses are preventable and it is the responsibility of governments and employers to ensure that legislation, programs, and health and safety protocols are in place and strictly adhered to in order to ensure the safety of workers in our organizations and communities. For more information and resources associated with the National Day of Mourning visit the Canadian Centre for Occupational Health and Safety - ulln.p,;�...II u,��i. Warden's Charity Gala I am delighted to announce that the Warden's Charity Gala featuring the 'These Hands' Art Show and Auction raised $25,000 in support of the Terrace Lodge Fundraising Campaign. The event was held at the Aylmer Old Town Hall on April 29, 2022 and featured the photography included in the 'These Hands: Touching Memoirs of Seniors in Our Community' book. I would sincerely like to thank the generous sponsors, donors and event attendees for making the event a success. Events/Meetings Attended by Warden: • Elgin County Council (April 6, 26) • Legion Regional Conference Port Stanley (April 9) • Elgin County Emergency Operations Centre Meeting (April 1) • National Day of Mourning Event Pinafore Park (April 28) • SCOR EDC Meeting (April 14) • SWIFT AGM (April 29) • Warden's Charity Gala (April 29) FINANCIAL IMPLICATIONS: The financial impact of COVID-19 and the County's response efforts are reported to Council on a monthly basis. There are no other financial implications to report at this time. ALIGNMENT WITH STRATEGIC PRIORITIES: Serving Elgin ® Ensuring alignment of current programs and services with community need. ® Exploring different ways of addressing community need. ® Engaging with our community and other stakeholders. Growing Elgin ® Planning for and facilitating commercial, industrial, residential, and agricultural growth ® Fostering a healthy environment. ® Enhancing quality of place. Investing in Elgin ® Ensuring we have the necessary tools, resources, and infrastructure to deliver programs and services now and in the future. ® Delivering mandated programs and services efficiently and effectively. 3 2 Additional Comments: Elgin County Council's response efforts and the continuity of essential projects and services align with Elgin County Council's Strategic Plan 2020- 2022. LOCAL MUNICIPAL PARTNER IMPACT: Elgin County continues to work with and find ways to collaborate with Elgin's municipal partners. COMMUNICATION REQUIREMENTS: A brief synopsis will be included in the Council Highlights document that is posted to the website and distributed to local Councils. CONCLUSION: As we return to a life without COVID-19 restrictions, the County of Elgin has been able to return, after two years, to normal operations. We have also been able to host and attend more in person community events. I remain optimistic that positive conditions will continue, however, the County is committed to following any advice that may be received from SW PH or the Province of Ontario over the next several months. All of which is Respectfully Submitted Warden Mary French CC3 O o J o� L W O Oail N C� N CC3 Q L 0 4 L CL i A� WL. = V- N U V) O U cz N 1.-1 N M ,:I- U') Cfl I- N N N L V v � O c E N E a..+ O = z 0 � M d' ui LU 00 z 2 C) 0 go.,r z . C) to 0a) ., Z9 z U CL A Z5 Lf) :Oc R C*i W Vq R , � C\j ? DO Z C\l 1"" 0 x C) 2 "20 0 LU UJ U) > uj z 0 Ln 44 LL co 0 5: OL 5: 0 0 s LO r1l ca C. 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([A N O N L E > O z O Q N J O O U w N O O U— O J O O 70 m O U— m a Q w� 0 O U U O N rft■ V 0) CY) 0 4� C) C) 0) C N 04 'r- (1) g W Ig (1) 0) E > 0 0 > m 0 co > 0 m it 0� . �R CO 0 . IC, co OR >1 4t co V) co 0 a 0 u cq C) N C) CN C E > T- 0 0 0 0 0Cd 0) r La co I- LO 00 c CL 6 LO w an LN (D (D 'D 4- o 0 0 0 0 U) M 0 0 = C V m u M 0 U 0 m u 4) Q > 0. 0 I= a ,gyp ,gip m 4an. m 0. u 4 uCL (n E 0 2 c U) C4- C: 0 0) (3) = E m -2 'zr E CL Co 0 �F- .9 " 0) 0— m L- 6 CL .2 75 L) E > .r a) 0 0- 0 1-1 0 CL 0.— 0 C)_ 4- 0 0 0 m 0 >, cn CL E W C)JCL .0 C: U) m co a �5 8 W 0 0- c 0 as x 0 0 m Lu W U) a) — C14 co ca U .D O N c� 70 O O Q O - . o d' co 2 1 M C0 1 RECOMMENDATIONS: REPORT TO COUNTY COUNCIL FROM: Michele Harris, Director of Homes and Seniors Services DATE: May 4, 2022 SUBJECT: Homes — Administration Policy Updates Resident Rights, Resident Abuse, Mandatory and Critical Incident Reporting, Requests and Concerns, Staff Reporting and Whistle Blower Protection THAT the report titled: "Homes — Administration Policy Updates — Resident Rights, Resident Abuse, Mandatory and Critical Incident Reporting, Requests and Concerns, Staff Reporting and Whistle Blower Protection" dated May 4, 2022 be received and filed; and, THAT Council approve the County of Elgin Homes and Seniors Services Administrative Policy Manual updates to ensure alignment with current Ministry of Long -Term Care legislation. 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. On April 11, 2022, the Fixing Long -Term Care Act (FLTCA), 2021, and Ontario Regulation 246/22 were proclaimed replacing the former legislation which included the Long -Term Care Homes Act, 2007 and Ontario Regulation 79/10. DISCUSSION: All Elgin County Homes and Seniors Services policy and procedure manuals are under review to ensure alignment and compliance with current Ministry of Long -Term Care legislation. The Ministry of Long -Term Care (MLTC) has provided timelines for policy review, revisions and implementation of legislative changes; and, this work is being prioritized by Homes management staff. 2 The Homes Policy Manual for Administration is under review by the Homes Administrators and Director of Homes and Seniors Services. The following policy and procedures have been revised to align with the FLTCA, 2021 and Ontario Regulation 246/22: • 1.3 Mandatory and Critical Incident Reporting — updated section numbering related to FLTCA/Reg; minor wording updates, and addition of failure to report section • 2.1 Resident's Bill of Rights — updated section numbering related to FLTCA/Reg; minor wording updates, and addition of two (2) residents rights (palliative care philosophy approach to care; and, recognition of caregiver support to the well- being and quality of life of residents) • 2.3 Requests and Concerns — updated section numbering related to FLTCA/Reg; minor wording updates, addition of procedure for situations whereby a concern cannot be investigated/resolved within ten (10) business days; and, information to be included in the written response • 2.11 Resident Abuse — updated section numbering related to FLTCA/Reg; minor wording updates to enhance the importance of immediate reporting; and, addition of resident support and program evaluation requirements • 2.12 Staff Reporting and Whistle Blower Protection — updated section numbering related to FLTCA/Reg; and, minor wording updates 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: Serving Elgin ® Ensuring alignment of current programs and services with community need. ❑ Exploring different ways of addressing community need. ❑ Engaging with our community and other stakeholders. Growing Elgin ❑ Planning for and facilitating commercial, industrial, residential, and agricultural growth. ® Fostering a healthy environment. ® Enhancing quality of place. Investing in Elgin ❑ Ensuring we have the necessary tools, resources, and infrastructure to deliver programs and services now and in the future. ® Delivering mandated programs and services efficiently and effectively. 3 Additional Comments: LOCAL MUNICIPAL PARTNER IMPACT: None. COMMUNICATION REQUIREMENTS: The revised policy changes will be communicated to staff, residents, families/visitors, volunteers and contracted workers as required within the FLTCA, 2021. Mandatory staff education (onsite) will be completed, and, through the online Surge learning education portal. CONCLUSION: The administration 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 Approved for Submission Michele Harris Julie Gonyou Director of Homes and Seniors Services Chief Administrative Officer /lr��r, ElHOMES AND SENIORS SERVICES d G iwn�P Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 1 of 10 PURPOSE: To ensure the duty and obligation to report mandatory and critical incidents which may have occurred or have occurred under the Fixing Long -Term Care Act, (FLTCA) , 2021 and Ontario Regulation 246/22 are met and within reporting timeframe requirements. PROCEDURE: Reportable incidents are defined as either "Critical or Mandatory" and fall within the reporting guidelines of the FLTCA. 1. When a critical incident occurs, the Administrator/Director of Homes and Seniors Services (or designate) shall take the necessary steps to ensure the required care and comfort to residents and/or others. 2. When a critical incident occurs, the Administrator/Director of Homes and Seniors Services (or designate) shall ensure: a. The on-line critical incident reporting process is initiated. b. That the immediate report of incidents listed in subsection 115 (1) of the Regulation occurs either during normal business hours Monday - Friday 8:30 a.m. - 4:30 p.m. or by using the Ministry of Long -Term Care (MLTC) after-hours emergency contact, (1-888-999-6973). 3. When a critical incident occurs requiring critical or mandatory reporting to the MLTC, the Director of Homes and Seniors Services will determine if the situation requires reporting to the Chief Administrative Officer for the Corporation who in turn shall report to the Warden of County Council. Mandatory and Critical Incident Reporting Requirements and Definitions: Mandatory Report Immediately upon having reasonable grounds to suspect this has occurred or may occur. Page 1 of 10 /lr��r, ElHOMES AND SENIORS SERVICES d G iwn�P Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 2 of 10 Appendix A — (document is pending MLTC update to FLTCA, 2021 and ON Reg. 246122) Reporting Requirements: LTCHA Subsection 28(1)-(Mandatory Reports) Must be reported Immediately: • Improper or incompetent treatment or care of a resident that resulted in harm or risk of harm to the resident. • Abuse of a resident by anyone or neglect of a resident by the licensee or staff that resulted in harm or a risk of harm to the resident. Also refer to Administration Policy # 2.11, Resident Abuse. • Unlawful conduct that resulted in harm or a risk of harm to a resident. • Misuse or misappropriation of a resident's money. • Misuse or misappropriation of funding provided to a licensee under this Act or the Local Health System Integration Act, 2006 or the Connecting Care Act, 2019. Critical Incident Immediately report; full report within 10 days of becoming aware of the incident or at an earlier date if required. Appendix B — (document pending MLTC update to FLTCA, 2021 and ON Reg. 246122) Regulation, under O Reg 246122 subsections 115(1), (3) Must be reported immediately: • An emergency, including fire, unplanned evacuation or intake of evacuees. • An unexpected or sudden death, including a death resulting from an accident or suicide. • A resident who is missing for three hours or more. Also refer to Administration Policy: # 1.20 Missing Resident. • Any missing resident who returns to the home with an injury or any adverse change in condition regardless of the length of time the resident was missing. Also refer to Administration Policy: # 1.20 Missing Resident Page 2 of 10 /lr��r, ElHOMES AND SENIORS SERVICES d G iwn�P Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 3 of 10 Regulation, under O Reg 246122 subsections 115 (3) Must be reported within one business day after the occurrence of the incident, followed by the required report. • An outbreak of a disease of public health significance or communicable disease as defined in the Health Protection and Promotion Act. • Contamination of the drinking water supply. • A resident who is missing for less than three hours and who returns to the home with no injury or adverse change in condition. Also refer to Administration Policy: # 1.20 Missing Resident. (includes resident who is found outside the home, on the home's property) • An environmental hazard that affects the provision of care or the safety, security or well- being of one or more residents for a period greater than six hours, including: ■ A breakdown or failure of the security system ■ A breakdown of major equipment or a system in the home ■ A loss of essential services, or ■ Flooding • A missing or unaccounted for controlled substance. • Subject to subsection (4), see below, an incident that causes an injury to a resident for which the resident is taken to a hospital and that results in a significant change in the resident's health condition. o Where an incident occurs that causes an injury to a resident for which the resident is taken to a hospital, but the licensee is unable to determine within one business day whether the injury has resulted in a significant change in the resident's condition, the licensee shall, Page 3of10 /lr��r, ElHOMES AND SENIORS SERVICES d G iwn�P Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 4 of 10 o Contact the hospital within three calendar days after the occurrence of the incident to determine whether the injury has resulted in a significant change in the resident's health condition; and o Where the licensee determines that the injury has resulted in a significant change in the resident's health condition or remains unable to determine whether the injury has resulted in a significant change in the resident's health condition, inform the Director of the incident no later than three business days after the occurrence of the incident, and follow with the report required under subsection (5) A medication incident or adverse drug reaction in respect of which a resident is taken to hospital. Significant Change — In section 115 of the Regulation, means a major change in the resident's health condition that, • Will not resolve itself without further intervention, • Impacts on more than one aspect of the resident's health condition, and • Requires an assessment by the interdisciplinary team or a revision to the resident's plan of care. [s.115(8)] Additional reporting agency requirements: Critical Incidents which pose an immediate risk to resident(s) and which may require intervention by an outside agency or agencies such as police, fire department, or medical officer of health are to be reported by the Administrator/Director of Homes and Seniors Services/Designate as follows. Police: ♦ Abuse and /or assault involving a resident, including wilful direct infliction of physical pain or injury, as well as sexual assault. ♦ Alleged fraud, theft. ♦ Bomb threats, evacuations. Page 4 of 10 /lr��r, ElHOMES AND SENIORS SERVICES d G iwn�P Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 5 of 10 ♦ Missing person, according to the facility's own disaster/search plan definition of when a person is "missing". ♦ Unusual/accidental death including suicide. ♦ Missing/misappropriated drugs. Fire Department: ♦ Fire emergency within the facility requiring partial evacuation of an area or disruption of service. Medical Officer of Health: ♦ Infectious disease at the outbreak level. ♦ Communicable diseases as per Health Protection and Promotion Act. ♦ Problems with drinking water supply (i.e. contamination) Under all circumstances, the Homes' Administrator/Director of Homes and Seniors Services are immediately informed on matters requiring immediate reporting, unexpected death, missing resident and abuse. Offence of Failure to Report The following persons are guilty of an offence if they fail to make a required report: • The licensee of the long-term care home (LTCH) or a person who manages a LTCH • If the licensee or person who manages the Home is a corporation, an officer of director of the corporation • A member of the committee of management for the Home A staff member • Any person who provides professional services to a resident in the areas of health, social work or social services work Page 5 of 10 /lr��r, ElHOMES AND SENIORS SERVICES d G iwn�P Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 6 of 10 For additional information regarding definitions of and reporting of Abuse refer to the attached Memo from the Director, Performance Improvement and Compliance Branch, February 12, 2015, Ministry of Health and Long -Term Care "Reporting Requirements Tip Sheet", and Administration Policy # 1.20. References: Ministry of Health and Long -Term Care, Director Performance Improvement and Compliance Branch, Memo dated February 12, 2015; Clarification of Mandatory and Critical Incident Reporting Requirements Fixing Long -Term Care Act, 2021 Ontario Regulation 246/22 Page 6of10 ONE, El HOMES AND SENIORS SERVICES POLICY& PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 7 of 10 Any person who esorwGre of an inclder[t that must be TepoTTPdtp the, DirecZorHinder suhsection 24t7) ref thetTQIA, 2'007ond whadoe.5 not hove acc= to the hdrnes triticDI ¢ncrdent reputing system tand who es notreporriruq on behoy of the kremsee) owukfreport using the took free Action line #or J-866-4.34-0144. Appendix S. TARLE2: Critical Incident Reporting under 0 Reg 79/10 subsections and (7) Type of incident in LTC Home Section of Haw Livensao must submit report: t* MOHLTC IDlreiftor) Reporting Time iFrame 0 Reg 79/10 Monday-Friday All other times (including 830 O.M, - 430 p,m, statutory horldays) Aa emergency, nd uding fue, unplanned irorfledialely Iniltlato and Phon,e the After Houm ImmeArliatoy, full (#part -VaUlatiun or untake of evacuees. 5abrnit the on line Critical Pager within 10 daygi mt becoming Incident System ICIS) form aware of the incident* identifying 11,l, as a `Cdlwal -death . ........... Am unexpected or sudden deathi, i-rduding . .. ... s,1G,7(1P. Immediately initiate and Phon, theAfter Hours Immediately: full report a or submit the on -fine CIS form within 10 days of txcorning suicide. identifying this as a 'Critical: aware ofthe Mddent* Inddient', — . ............. . .. . A resident echo is three hours s.1071[1)3 InimediatiOy initiate and Phone the After Hours . ........ . ImnredWely; full report or more. submit the an line CBS form Pager 4 1,9001-268,W)0 within 10 days of becoming identifying tN5 as a'Cntical aware ofthe incident - Any missing resiident who returns to the 5.107(1)4. ornmedlately initiate and Phone the After Houir,s immedWely; full repart ho,ole with an jn)ury or any adverse change submit the on-line OS form Pager a I-SVU-268-6060 within 10 days of becurnine in condilmn regardless ofthe length of 4onVf)png this as a 'Critical aware of the incident* Prime the resident was missing,. Incident', An outbreak of a reportable : disease or j 5,107l1)5, immediately 7Tnn—tjate7,;,d�p hone the After Hours Immediately; fuH repo�rt comm wea bi er disera me as defined in the subroft the on -I I no CV; form PagPr #) 800-268-rXY4 6viliJ n 10, days of becorin i np Headth Protection and Promotion Act idle ntifymg this as a 'Critical aware of the incident* Incident'. Contammz6on ofthe drinking-wateT s.107(1)6. Irn n i e d at ely 1 nftiate and Phone the After Hours Immediately; full repoft, 541PW submit the on-line CIS form Pager #1-800-26,8-0,6D withIn 10, daysof becoming identifyng this as a *Cftcal aware of the incident"` incident , , - I.. --- � ..................... . ....... ........ Page 7 of 10 ONE, El HOMES AND SENIORS SERVICES POLICY& PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 8 of 10 Type Incident iWi- 7 . ........ .. of -Section of How Licensee must submit report to MOHILN . ......... ___ . I Reporting Time Frame 0 Reg 79110 (Director) 'ilnm_ Monday -Friday Ali oa�a 8:30 a.m. - 4:30 p.m. (Inctudirkll Statat" holidays) A resident who is missing ferr Wss than three s.107(311. InitiabQ amm nd submit Ihe Same as Monday- Within one business day of the hours and who returns to the home with no oo-Fine C15 form Friday Incident; full report within 10 injury or adverse change in condificin, identifying this as a days of becoming awarp of thee i —'v'e Critical Incl,dent. _L67�312'7__Initiate incident" An environmental hazard that and subrO the Same as Monday- Within one business day of the provislon of care or the safaty,.sewdry or on-line C15 form Friday inaclent; full report, within 10 we 11 being of one or rpore resWenls for a 4QntifVi"8 ifill5r a S @ dayr of becoming aware of the nod' greater than six hours, inciuding: 'Cr4ical knddent'. incident,, . A breakdown or failure Dfthe &Pcurlty syste M • A breakdown of major equnament or a system m ifie home • A less of esseittial "Mces, or • flooding ....... .. .......... . . SAD7J3)3' nlVatL and submi.t the Same as Monday,, Within one business dayof `he substance- on,fine CIIS form I'viddy incident; full report within 10 Identifying this as a days afibeCaTning aware of Lhe Crj icai incidenk'. Incident* Subject Tos'ubiection (3.1) [see below],, an s.107(3)4_ WCate and sobirrirt tht. Same as Monday, Within one, business day -of the iincident,that c:Auses an injury to a?v'sident on -line CIS form Friday Incident, or within 3 caiendar for which the reeldent is taken to a hospital dondfvIng this as a days if unable. within I husiness I and that resufts in a significaritchange— in Tritic2g incrdurnk', day to determine whether injury fkue residents heafth condition. caused a significant change' full report within 10 days r of -T-1-initiate . .............. ...... . . . ... . . . _ _b" �_Olnillg '=­!-fthe onculent A niedicati'on inadent or ve. adT.&P. diW, &107fis. and submit the. Same a, Monday- WItKin one business day o4the respect of wWth a, residentsine 5 ro Friday �nndcnt; fuN report within 10 hospitaL �... ofnle'n I ving IN 5 a's a t days of becorning aware of the Critical hdclpnt�_ In,ddent* Using the Critical fnvdlent System,. the, 1611 report .. .. .. .. .. .. .. undir sub5ecNon I egulation must he made within 10 days, ofthe licensee becornrng, Pwrpre of the incident or at on carlier date if requirr, d by the Dirertor. Page 8 of 10 ElHOMES AND SENIORS SERVICES d G ira�P Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 Page 9 of 10 I "In section 107 of the id'egulation, kignrf'=nt cRrongL" rrew: s ra rrrajorchange in the resdenes health cr ndirion than , N' will not resolve. irsel 'wlthi7rr^8 J"o'r'mer iore"evi'ton, m impacts an more than an e aspect of the resident's health condition, and dui requires an assessment by the interdrstrpNna.ry team Ora revasran to the resilent`s plan raif r ore. 15,1,07�7j Reguratior,, subsection107 (3.1). Where an incident Occurs chat c'aSu.sem as it0jury+to a resident far which the resident is, taken, to aar hrns'pitaf,, but the licensee' is anabie to deteMMe within One business day whether than injury has resulted in o sfgnifkant change l7v the resrdear's condition, the licensee shaft, Contact the hospltol Vwttdk three calendar days after the accrurrence of the docldeW fez deterrMne whether the injury ha, re:satt'ed in a signrjncernt change do the residenrs heddth condition; and Where the, f censee deterrnirres that the in,iury+ bras resulte d dn' a srrdnrJ3r rnr chanede in the resident"s health condition or remains unable eo dcrermine whether the'njury has resulted in a significantchange in the residents taeofth condi'tiom, inform the director of the encrdent no later than three business days rafter the occurrence trf the inclrlent, and foirow with the report requrrerd uodersubserrtion (4) (s, ti77(1l)/ gequfaslarr subsection 10712)—repradrtingofteJ hovirs" Normal bd�si'mess hours Of ClA°fl' are E:30 a. nr. • 4:30 p; mn After normna't business hours, the drnrnediate repur"t Of the above andden'ts must be made asking, the Winistry's after-hours eanergexary <aratoet {i:e. 1.800-768-6060 SpillsActian Centre (SACI pager). 't"larspargernumber is only to be used by LTC Name licensme/s'ta fandonfyforpurause.sofafler.laoursreporting. Page 9 of 10 ✓,a;A�rr;/lr��r, ElHOMES AND SENIORS SERVICES d G iwnwP Bip YtlddW'aud'&i POLICY & PROCEDURE NUMBER: 1.3 DEPARTMENT: Administration SUBJECT: Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) APPROVAL DATE: March 2015 REVISION DATE: March 2016; Oct. 2019; April 2022 REVIEW DATE: March 2017; Dec. 2020; March 2022 � w nlY qY w1,1w'waaar1"`'lI" w w1F ,>ryfryw,oi�ry,✓,wvrr r;w �i ,rn;,m,�rporo#,>a^�9 4e �rwiWnm,wS»zryrrm r.�mw aw w 9w w , f,w , N,I fu w, ntlm: q,$ oa "k w9 f/)w m * p'y AAo"p, ffY f- ""a 4fW^ wIw 10,"w waww�4r.iw4 M'l961�'J&IiJLV IDr wwV< l l 11, 0 ➢)WA bN Fww l.,= #row OR wiu �uws fy J^,0<iwyv r�o�rra dhm,N wfw,w•ol"owiwva'wirvmY,'i �. 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F ✓ IW, aw a r rc s rr rr� e'i 2. ilh itin F. m+2,ii.. Page 10 of 10 „f�rrrr%�irr, HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.1 DEPARTMENT: Administration SUBJECT: Residents ' Bill of Rights APPROVAL DATE: Nov. 9, 1988 REVISED DATE: Oct. 2019; April 2022 REVIEW DATE: March 2015; March 2016; Mar. 2017; Dec. 2020; March 2022 Page 1 of 4 PURPOSE: To recognize each resident as an individual and incorporate his/her wishes into the plan of care. To assist residents to make informed choices about his/her care in the long-term care home. To maximize residents' independence and enhance self-esteem. Fundamental Principle: The fundamental principle to be applied in the interpretation of the Fixing Long -Term Care Act, 2021 and anything required or permitted under this Act is that a long-term care home is primarily the home of its residents and is to be operated so that it is a place where they may live with dignity and in security, safety and comfort and have their physical, psychological, social, spiritual and cultural needs adequately met. PROCEDURE: The Residents' Bill of Rights and Fundamental Principle in English and French shall be posted in a minimum size font of 16 and prominently displayed within the home. Each resident/personal representative will receive a copy of the Residents' Bill of Rights on admission. The Residents' Bill of Rights will be reviewed with the residents through resident council on a regular basis. All employees will be knowledgeable of and support Residents' Rights. The Residents' Bill of Rights which shall be fully respected and promoted include, but are not limited to the following rights contained in the Fixing Long -Term Care Act, 2021: 1. Every resident has the right to be treated with courtesy and respect and in a way that fully recognizes the resident's inherent dignity, worth and individuality, regardless of their race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity, gender expression, age, marital status, family status or disability. 2. Every resident has the right to be protected/free from abuse. 3. Every resident has the right not to be neglected by the licensee or staff. 4. Every resident has the right to proper accommodation, nutrition, care and services consistent with his or her needs. „f�rrrr%�irr, HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.1 DEPARTMENT: Administration SUBJECT: Residents ' Bill of Rights APPROVAL DATE: Nov. 9, 1988 REVISED DATE: Oct. 2019; April 2022 REVIEW DATE: March 2015; March 2016; Mar. 2017; Dec. 2020; March 2022 Page 2 of 4 5. Every resident has the right to live in a safe and clean environment. 6. Every resident has the right to exercise the rights of a citizen. 7. Every resident has the right to be told who is responsible for and who is providing the resident's direct care. 8. Every resident has the right to be afforded privacy in treatment and in caring for their personal needs. 9. Every resident has the right to have his or her participation in decision -making respected. 10. Every resident has the right to keep in his or her room and display personal possessions, pictures and furnishings in keeping with safety requirements and the rights of other residents. 11. Every resident has the right to, i. participate fully in the development, implementation, review and revision of their plan of care, ii. give or refuse consent to any treatment, care or services for which their consent is required by law and to be informed of the consequences of giving or refusing consent, iii. participate fully in making any decision concerning any aspect of their care, including any decision concerning his or her admission, discharge or transfer to or from a long- term care home and to obtain an independent opinion with regard to any of those matters, and iv. have their personal health information within the meaning of the Personal Health Information Protection Act, 2004 kept confidential in accordance with that Act, and to have access to their records of personal health information, including their plan of care, in accordance with that Act 12. Every resident has the right to receive care and assistance towards independence based on a restorative care philosophy to maximize independence to the greatest extent possible. „f�rrrr%�irr, HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.1 DEPARTMENT: Administration SUBJECT: Residents ' Bill of Rights APPROVAL DATE: Nov. 9, 1988 REVISED DATE: Oct. 2019; April 2022 REVIEW DATE: March 2015; March 2016; Mar. 2017; Dec. 2020; March 2022 Page 3 of 4 13. Every resident has the right not to be restrained, except in the limited circumstances provided for under this Act and subject to the requirements provided for under this Act. 14. Every resident has the right to communicate in confidence, to receive visitors of his or her choice and to consult in private with any person without interference. 15. Every resident who is dying or who is very ill has the right to have family and friends present twenty-four hours per day. 16. Every resident has the right to designate a person to receive information concerning any transfer or any hospitalization of the resident and, to have that person receive that information immediately. 17. Every resident has the right to raise concerns or recommend changes in policies and services on behalf of themself or others to the residents' council, family council, the licensee, staff members, government officials or any other person inside or outside the home, without interference and without fear of coercion, discrimination or reprisal, whether directed at the resident or anyone else. 18. Every resident has the right to form friendships and relationships and to participate in the life of the long-term care home. 19. Every resident has the right to have his or her lifestyle and choices respected. 20. Every resident has the right to participate in the Residents' Council. 21. Every resident has the right to meet privately with his or her spouse in a room that assures privacy. 22. Every resident has the right to share a room with another resident according to their mutual wishes, if an appropriate accommodation is available. 23. Every resident has a right to pursue social, cultural, religious and other interests, to develop their potential and to be given reasonable assistance by the home to pursue these interests and to develop their potential. 24. Every resident has the right to be informed in writing of any law, rule or policy affecting the services provided to the resident and of the procedures for initiating complaints. „f�rrrr%�irr, HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.1 DEPARTMENT: Administration SUBJECT: Residents ' Bill of Rights APPROVAL DATE: Nov. 9, 1988 REVISED DATE: Oct. 2019; April 2022 REVIEW DATE: March 2015; March 2016; Mar. 2017; Dec. 2020; March 2022 Page 4 of 4 25. Every resident has the right to manage his or her own financial affairs unless the resident lacks the legal capacity to do so. 26. Every resident has the right to be given access to protected areas outside the home in order to enjoy outdoor activity, unless the physical setting makes this impossible. 27. Every resident has the right to have any friend, family member, caregiver or other person of importance to the resident attend any meeting with the licensee or the staff of the home. 28. Every resident has the right to be provided with care and services based on a palliative care philosophy. 29. Every resident has a right to ongoing and safe support from their caregivers to support their physical, mental, social and emotional wellbeing and their quality of life and to assistance in contacting a caregiver or other person to support their needs. References Fixing Long -Term Care Act, 2021 Ontario Regulation 246/22 „f�rrrr%�irr, HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.3 DEPARTMENT: Administration SUBJECT: Requests and Concerns APPROVAL DATE: April 2004 REVISED DATE: March 2015 APPROVAL DATE: Sept. 2011 REVISED DATE: March 2011 REVISED DATE: March 2016; March 2017; Oct. 2019; Mar. 2022; April 2022 REVIEW DATE: Dec. 2020 Page 1 of 4 PURPOSE: To provide an effective process to receive and address requests/concerns ensuring a prompt response, follow-up and accountability. PROCEDURE: Resident/Personal Representative and Staff Awareness: 1. On admission a resident/personal representative will be informed as to the formal requests/concern process. 2. A copy of the request/concern policy is kept in the Public Information binder. Copies of the procedure are available upon request. 3. Staff shall receive instruction on the process for a request/concern brought forward by a resident/personal representative/visitor, upon hire and annually thereafter. Informal Requests/Concerns: 1. Requests/concerns should be taken to the Registered Staff on Duty and/or Department Manager for immediate response and resolution. Should the resolution be unsatisfactory, residents/personal representatives are asked to move to the next step in the Complaint/Request Resolution Process (Form Adm #2.3b) Staff Responsibility and Accountability: 1. Should staff receive a verbal request/concern that cannot be immediately resolved, the information should be documented on the "Request/Concern Response Form” (Form Adm #2.3a) and forwarded to the respective Department Manager. The Request/Concern Response Form is for Interdepartmental Use Only and is completed only by staff. Use of this form does not constitute receipt of a written complaint. „f�rrrr%�irr, HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.3 DEPARTMENT: Administration SUBJECT: Requests and Concerns APPROVAL DATE: April 2004 REVISED DATE: March 2015 APPROVAL DATE: Sept. 2011 REVISED DATE: March 2011 REVISED DATE: March 2016; March 2017; Oct. 2019; Mar. 2022; April 2022 REVIEW DATE: Dec. 2020 Page 2 of 4 2. The request/concern shall be responded to within 10 days of receipt to include a possible plan of action. 3. All actions shall be documented including dates, follow-up and timeframes, final resolution, complainant response and date of feedback provided to resident/personal representative/visitor. 4. The documented record of the verbal requests/concern is reviewed and analyzed for trends at least quarterly; a. request/concern forms are taken to the Continuous Quality Improvement Team meetings for review and analysis and determine action as appropriate, b. the results of the review and analysis are taken into account in determining what improvements are required in the home; and incorporated in to the annual Quality Improvement Plan (QIP) , c. a written record is kept of each review and of the improvements made in response, d. Subsection (2) of section 26 of the Fixing Long -Term Care Act, 2021 does not apply with respect to verbal complaints that the home is able to resolve within 24 hours of the request/concern being received. Resident/Personal Representative/Visitor: 1. Residents/Personal Representatives/Visitors are encouraged to follow the Request/Concern Procedure however may forward a concern/complaint to the Ministry of Health and Long -Term Care at any point in the complaint process. 2. All formal written requests/concerns (and required documentation provided for in ON. Reg. 246/22) received from the resident/personal representative/visitor concerning the care of a resident or the operation of the long-term care home shall be immediately submitted electronically via the Ministry of Long -Term Care Critical Incident Reporting system (during Ministry normal business hours, or outside of normal business hours, using the Ministry's after hours emergency contact method); investigated, resolved where „f�rrrr%�irr, HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.3 DEPARTMENT: Administration SUBJECT: Requests and Concerns APPROVAL DATE: April 2004 REVISED DATE: March 2015 APPROVAL DATE: Sept. 2011 REVISED DATE: March 2011 REVISED DATE: March 2016; March 2017; Oct. 2019; Mar. 2022; April 2022 REVIEW DATE: Dec. 2020 Page 3 of 4 possible, and response provided to the complainant and MLTC within 10 business days of the receipt of the complaint. 3. For those complaints that cannot be investigated and resolved within 10 business days of receipt of the complaint, an acknowledgement of receipt of the complaint including the date by which the complainant can reasonably expect a resolution, and a follow up response that complies with shall be provided as soon as possible in the circumstances. 4. The response provided to a person who made a complaint shall include: • The MLTC toll -free telephone number for making complaints about homes and its hours of service and contact information for the patient ombudsman under the Excellent Care for All Act, 2010 • And, explanation of, what the licensee has done to resolve the complaint, or that the licensee believes the complaint to be unfounded, together with the reasons for the belief, and if the licensee was required to immediately forward the complaint to the Director under clause 26 (1) (c) of the FLTCA, confirmation that the licensee did so. References: Fixing Long -Term Care Act, 2021 Ontario Regulation, 246/22 „f�rrrr%�irr, El���.�a e. e: , HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.3 DEPARTMENT: Administration SUBJECT: Requests and Concerns APPROVAL DATE: April 2004 REVISED DATE: March 2015 APPROVAL DATE: Sept. 2011 REVISED DATE: March 2011 REVISED DATE: March 2016; March 2017; Oct. 2019; Mar. 2022; April 2022 REVIEW DATE: Dec. 2020 Page 4 of 4 REQUEST AND CONCERN PROCEDURE Our goal is to provide optimum care at all times to every resident. We want to know how we are doing and appreciate your feedback. If you have a request or concern, please do not hesitate to come to us. This chart is only a guide of who you might go to first in order to have your request/concerns answered. Resident/Personal Representative and/or Visitor has a Request/Concern Inform the Registered Nurse on duty. If the concern is not resolved to your satisfaction, please continue to the next step. Manager Administrator/ Manager of Of Manager Program & Resident Of Care/Resident Care Support Therapy Coordinator Services Services Administrator Director Homes & Senior Services County Chief Administrative Office Elgin County Council Warden Ministry of Health (Toronto) Long -Term Care Division (416) 327-8952 Long -Term Care ACTION Line 1-866-434-0144 W� HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 1 of 15 PURPOSE: 1. To ensure compliance with Sections 24 and 25 of the Fixing Long -Term Care Act, 2021 and Sections 2, 7, 103-106 and 117 of Ontario Regulation 246/22. 2. Residents shall be treated with respect and dignity at all times by staff as per the Residents Bill of Rights. 3. To provide guidelines to be followed in the investigation of alleged or suspected resident abuse. 4. To ensure the effective communication and understanding of the Homes policy of Zero Tolerance toward any form of abuse. 5. To provide a consistent process for the reporting and investigation of all alleged or suspected incidents ensuring appropriate action is taken. 6. To inform all staff of his/her rights during an investigation of alleged or suspect resident abuse including disciplinary and dismissal guidelines. 7. To ensure Residents/Personal Representatives and Visitor are aware of the Homes' abuse policy including reporting requirements. 8. To ensure individuals reporting abuse are protected as outlined in the Whistle Blower Protection Act. PROCEDURE: Definition of Abuse and Neglect "Abuse" in relation to a resident, means physical, sexual, emotional, verbal or financial abuse as defined in the regulations of each case - FLTC Act, 2021 and ON Regulation 246/22 s (5). "Neglect" means the failure to provide a resident with the treatment, care, services or assistance required for health, safety or well-being, and includes inaction or a pattern of inaction that jeopardizes the health, safety, or well-being of one or more residents. FLTCA, 2021 and ON Regulation 246/22 s. (7) Examples: a) Physical abuse means (a) the use of physical force by anyone other than a resident that causes physical injury or pain, (b) administering or withholding a drug for an inappropriate purpose, or (c) the use of physical force by a resident that causes physical injury to another resident. Physical Force • Hitting, kicking, striking, slapping, shoving, pinching, beating W� HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 2 of 15 • Unauthorized or unnecessary use of physical restraints • Physical horseplay • Unnecessary roughness • The use of physical force by anyone other than a resident that causes physical injury or pain • The use of physical force by a resident that causes physical injury to another resident • Physical force does not include the use of force that is appropriate to the provision of care or assisting a resident with activities of daily living, unless the force used is excessive in the circumstances b) (Psychological)/Emotional abuse means (a) any threatening, insulting, intimidating or humiliating gestures, actions, behaviour or remarks, including social isolation, shunning, ignoring, lack of acknowledgement or infantilization that are performed by anyone other than a resident, or (b) any threatening or intimidating gestures, actions, behaviour or remarks by a resident that causes alarm or fear to another resident where the resident performing the gestures, actions, behaviour or remarks understands and appreciates their consequences. Emotional Abuse: • Threats • Teasing, making fun of resident • Refusing to provide care unless Resident conforms to caregiver requests • Verbal harassment • Unnecessary isolation of individual • Sign language • Mimicking • Performed by anyone other than a resident; or, by a resident that causes alarm or fear to another resident where the resident performing the behaviour understands and appreciates their consequences c) Neglect (Denyingmeans the failure to provide a resident with the treatment, care, services or assistance required for health, safety or well-being, and includes inaction or a pattern of inaction that jeopardizes the health, safety, or well-being of one or more residents. • Failure to give proper nourishment • Failure to allow or encourage residents to participate in Activities of Daily Living (ADL) • Failure to change incontinent residents • Failure to attend to grooming needs, combing hair, cleaning teeth, ill fitting or torn clothing W� HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 3 of 15 • Over prescribing of drugs or alcohol • Denying Residents' Rights • Failure to provide the treatment, care, services or assistance required for health, safety or well-being of one or more residents Neglect does not include situations whereby residents make a choice not to receive specific treatment, care, services or assistance despite implementation of resident centred care plan interventions d) Sexual Abuse • Touching and fondling • Sexual involvement • Rape • Any consensual or non-consensual touching, behaviour or remarks of a sexual nature or sexual exploitation that is directed towards a resident by a licensee or staff member; • Any non-consensual touching, behaviour or remarks of a sexual nature or sexual exploitation directed towards a resident by a person other than a licensee or staff member • Sexual abuse does not include (a) touching, behaviour or remarks of a clinical nature that are appropriate to the provision of care or assisting with activities of daily living; or (b) consensual touching, behaviour or remarks of a sexual nature between a resident and a licensee or staff member that is in the course of a sexual relationship that began before the resident was admitted to the long-term care home or before the licensee or staff member became a licensee or staff member. e) Financial Abuse means any misappropriation or misuse of a resident's money or property. • Stealing of resident's money or belongings by staff, family members or others. e) Verbal Abuse means: • Threatening or intimidating form of verbal communication of a belittling or degrading nature that is made by anyone other than a resident which diminishes a resident's sense of well-being, dignity or self-worth; or • Threatening or intimidating form of verbal communication made by a resident that leads another resident to fear for his/her safety where the resident making the communication understands and appreciates its consequences Other Failure to report any above W� HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 4 of 15 • Failure to report incidents Damaging resident's belongings Repeated minor abuses leads to major abuse. 2. a) In any case of alleged or suspected abuse the employee witnessing or having knowledge of an incident shall verbally report the abuse immediately to her/his direct supervisor or delegate and provide a written statement upon reporting the alleged abuse. Upon receipt of the written statement, the Director of Homes and Seniors Services/Administrator/designate shall report the allegation to the Ministry of Long -Term Care Director. i) The Ministry of Long -Term Care shall be notified as per Mandatory Reporting Guidelines as outlined under the Fixing Long -Term Care Act, 2021. See Appendix A: Reporting Certain Matters to the MLTC (Director) and Appendix B: Decision Trees for Reporting Abuse. Failure to report may result in discipline and or termination/removal. When appropriate, reporting to the College of Nurses will occur. b) A member of management will suspend the suspected employee/s with pay, pending the outcome of the investigation. c) Immediately upon becoming aware of an alleged, suspected or witnessed incident of abuse that results in physical injury or pain, or that causes distress to the resident that could potentially be detrimental to the resident's health or well-being, the Manager of Resident Care/designate shall contact the residents' personal representative to apprise of the alleged/suspected abuse and pending investigation. All other alleged, suspected or witnessed incidents of abuse or neglect require notification within twelve (12) hours of becoming aware. The Manager of Resident Care will notify the residents' personal representative of the results of the investigation upon completion. d) The Director of Homes and Seniors Services/Administrator/or designate will investigate the allegations immediately in collaboration with the Director of Human Resources. e) A third party may be contacted to investigate the allegations as deemed necessary by Director of Homes and Senior Services and/or Director of Human Resources. W� HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 5 of 15 The Ministry of Long -Term Care shall be notified as per Mandatory Reporting Guidelines as outlined under the Fixing Long -Term Care Act, 2021. See Appendix A: Reporting Certain Matters to the MLTC (Director) and Appendix B: Decision Trees for Reporting Abuse. g) Every licensee of a long-term care home shall ensure that the appropriate police force is immediately notified of any alleged, suspected or witnessed incident of abuse or neglect of a resident. h) The medical director will be notified as soon as possible when warranted through investigation. 3. All incidents of abuse or suspected abuse will be documented fully by any person having direct knowledge of the incident (nurse, family member, resident if able, housekeeping, dietary, etc.) 4. All objective documentation shall contain the following information: a) what happened (be exact and include events leading up to the incident) b) when did it happen c) who was involved including witnesses d) where did it happen e) why did it happen (if known) 5. If following an investigation it is found that abuse has taken place, progressive discipline up to and including termination shall follow. 6. Employee's rights will consist of: a) The employer making employees aware of abuse policy. b) The employee has the right to be advised of all allegations and be given an opportunity to explain her/his actions. c) The employee has the right to be represented by her/his bargaining unit. d) The employee has the right to appeal disciplinary action through the grievance procedure. e) Management employees may only appeal dismissal through the Ontario Ombudsman and the Human Rights Commission. 7. The general accepted principle is that a police investigation is separate and independent of internal administrative procedures and decisions on discipline. W� HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 6 of 15 8. Resident(s) whom have been abused or neglected, or allegedly abused or neglected, shall be provided any required assistance and support based on the assessment of the resident and situation including, but not limited to, medical and emotional care, etc. and shall be protected under the whistle blower protection legislation. PREVENTION OF ABUSE: 1. Residents/Personal Representatives will be informed of his/her rights and what constitutes abuse during the admission process and at resident/family council meetings. Awareness of what constitutes abuse and the resident's bill of rights will promote early intervention in a situation before it results in abuse. 2. Staff education on Resident's Rights, situations that may lead to abuse and neglect and how to avoid such situations, the relationship between power imbalances between staff and residents, and the types of abuse will heighten awareness on what constitutes abuse. Education shall be completed/provided, at minimum, upon hire and annually. This combined with education on fostering a caring environment of respect and awareness of acceptable employee practices will aid in prevention. 3. Additional education for Staff, Residents, Personal Representatives and Volunteers will include the following policies: Whistle Blower Protection; Minimizing Restraining of Residents: Use of Restraints and Use of PASDs; Requests and Concerns. 4. Strict human resources practices will also act as a deterrent to resident abuse by staff. 5. An analysis of every incident of abuse or neglect of a resident at the home shall be undertaken promptly after the licensee becomes aware of it. 6. At least once in every calendar year, an evaluation is made to determine the effectiveness of the Home's policy to promote zero tolerance of abuse and neglect of residents, and what changes and improvements are required to prevent further occurrences. The results of the analysis undertaken are considered in the evaluation; any identified/recommended changes will be promptly implemented and a written record of the evaluation, changes, etc. will be maintained. RESOURCES AVAILABLE TO ASSIST RESIDENT/ PERSON RESPONSIBLE FOR ABUSE: • Social worker • Veterans Affairs W� HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 7 of 15 RESOURCES FOR STAFF: • Employee Assistance Program • Through Private Services for a social worker. Appendix A - Reporting Certain Matters to The MLTC (Director) Pending updated ministry documents, any references made to the LTCH Act, 2007 and ON Reg. 79/10 within Appendix A and Appendix B shall reflect the applicable sections of the legislation within the Fixing Long -Term Care Act, 2021 and ON Reg. 246/22. HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 8 of 15 Type of lincidlent in LTC home Section of Action to be taken by LTC Home to noti MOHLTC Reporting Time (Frame the LTCHA Monday. Friday All other times and 8 a.m.:- S .m < Statutory holidays Improper or incompetent LTCHA S. Immediately initiate the on- Phone the After Hours Immediately upon treatment or care of a resident 24(1)1. line Mandatory Critical Pager # becoming aware of the that resulted in harm or risk of Incident System (MCIS) form incident harm to the resilient using the mandatory report section Abuse of a resident by anyone or LTCHA S. Immediately initiate the on- Phone the After Hours Immediately upon neglect of a resident by the 24(1) 2. line MCIS foram using the Pager# becoming aware of the licensee or staff that resulted in mandatory report section incident harm or a risk of harm to the resident Unlawful conduct that resulted in LTCHA S. Immediately initiate the on- Phone the After Hours Immediately upon harm or a risk of harm to a 24(1)3. line MCIS form using the Pager # becoming aware of the resident mandatory report section incident Misuse or misappropriation of a resident's money LTCHA S. 24(1) 4. Immediately initiate the on- line MCIS form using the No after-hours reportiirg requirement Immediately upon) becoming aware of the mandatory report section incident Misuse or misappropriation of LTCHA S. Immediately initiate the on- No after-hours reporting Immediately upon funding provided to a licensee 24(1)5. line MCIS form using the requirement becoming aware of the under the LTCHA or the Local mandatory report section incident Health System Integration Act 12006. • *Please ensure that the staff person reporting abuse of a resident has reviewed the definitions of abuse set out in the LTCHA, section 2(1) and the Regulation, section 2 • Anyperson who is aware of an incident that must be reported to the Director under S. 24(1) of the LTCHA, 2007 and who does not have access to the home's critical incident reporting system should report using the toll -free Action Line # at 1• 866-434.0144, Appendix B Decision Trees for Reporting Abuse r�i �niv��rir((Gr`r<w,�k W� HOMES AND SENIORS SERVICES dyrnwr."�ru�..an,ty rfiw �rn�,�,nw� POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 LICENSEE REPORTING OF EMOTIONAL ABUSE Licensee Gu Licensee becomes aware ofallegod, Immediately suspected or Atressed ®mutionat 1 invesixgated take abuse of a resdent. action In response to brodentis 23('t9) Are i the Did Dida,,. reasonables''. mainland make gmounds toSuspect that 7"a _,� ". /l� /1 l�l l U'� - r threatening or intl indadng gentures, emotional abuse of errc�hno �., � actions ae�heviour or has occurred o. mmrark9to:another' or may aucur4 aw dontt No 7 Licensee mianages 01rougp internal process but need not report. _ 6l Page 9 of 15 Do the . � Licensee in Immediately '.. / resident performing, r!eQ0( Buspiclan& Did it ' the gestures, otters, Inlgrma'hantoDirector (vla '.. cause alarm or fear behaviour or remarks emow CIS as per mrequired - -Yes r Yes m 1u anndt7er understand and u�rYe ' to report by after boom paper .. resident? appreciate their outside boalhours) ronSequanaaS2' (s24i1h2) PA$ER 1=80RIIII 0110 '.. Licensed manages j No No through Intemat No d pecans but need not I~ pyud'- I reach, anyone Mlaar Ilan in resident risks threatening, Imsu8tfnp intimidating or. humtUahnp grsutras. arkjnms, bahawiaur. Iur`--, remarks to a resident, whichr may include imposed social bsolatBoo, shunning, ignoring, lack of acknowledgement or infantilization' I"LTCHA, 2007 rn Ci Red. 7WO *memo AugU010memo frompirmtor e w' Memo r Merr:h'1.q, let 2 mrn'io 4rrarn Director Nos._. ! d`Answ,'yss'Ilyrruhavereasonable groundstoitus=that the aivs.,c Luaus&@ manages through arc yer," (he. answer dais r0 need b be deMltivei. As soon ea reasonable grounds intenal process buy need not so,u:,glmdltum.abyta�arrwLwmm,�.r.wr.JLd.tocan�se.musttiwmrgliatelk.tenwd _ report s;u ssi,m and Intmrnra@lon Is.2A j21. w Send recent Including results; of nwestigraiion & arhons i taken ire response to iriddenf, wia els wrrPun fq ) days or earl ter if requested by 13'oreckor 100412)) a If nor all required uInI is Minable within 10 days, send preliminary repaid within 10 days and provide finny region 9within 21 days C time specified by alreclurp'e * Ir.104(3!) This demisren has is rntendad as a guide end does not constitute regal advice . Ontario Proaserefer toI.TCHA2007and 0. Rog 7WI0for the complete requirements, Mae20ta PACE ONE OF TWO rri �nlvrHir((Gr`rw,�L Wr HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 10 of 15 LICENSEE REPORTING OF PHYSICAL ABUSE Licari hecwmesaware nd Liuensseha......' immediately al suspected of seeesseei lnuasti®ate? take wmossad physical abuse of a resldall, acfocm In response be 1 11(3 23(1)) , Yw Are Ihorµ reason f � ���� � � a was - VNnB f71d of L!Caneoo to' sws ctor p W � grounds to suspaeC that �r9e'kmrmNn�e �... physical force to a the phsysical force. _.Yes» aplied Ya cause Physical _ irllr!e54teM Sher `, Inkq«nation to 0«ector {ula CG"a as per memo*; Yes required 9bPAOEreportReual,(9,24(1))paper outside phvxleela'buse has occurredjo r �J / �epsld�nl,r resident? n 6060 or May accurn r l�lUl l hocones manages III Internet process ~*Nsw No kcal nand not report No n No - Was " _ Did the the qee of Send report Including results of investigai & actions Licensee manages g Physical force cause rovi' ' 'appropriate to pmmsion ul taken m response to uloldunt vqa 015 wVYhin fq days or through It physical injury Yes r" care or assisting a comer iP requested by Director,(004(2)J need butrt uoi Aril ili OR or pain ranuleoatwith Yes ' repprocess dligh5,. r6EGENq No Yes w sg'UGHA 2007 rzo. Reg. yfilln *Memo=Aug4,2011 banYb from Gereno, Lumnseo manages Was the toime * * Memo * Mord,,2.9 202 bi from Rlvedor through internal process . No used excessive in the but need not report circumstances? * * « Answer °yt1s texaape for question marked "++'p or you have ruaso ohloproundsrosusp lthatIreaeisvtons'gss"(ie answor does out Was _,. need ire be d'aBnitlVel. ,,a drug adnrunusterchl. ++Porlhanoastlor rksd'++°,ru—,"Wilymuhe mieoueMo orlsidheldYerun aow,mw groumlle to sndllood Ih l thi,e Is'N Q. ,war doe m 11—W he inappropriate dtlln)&,_,M , 4dd'a mlane��g8 puepusef, g uri4iS+fl..RC.oaa.Y-9JiGllL..I11G'.'1G 5&'!'IUWaI1:A?IDedls'E ",!5'24.C5Av"5IlltiIG17sN1Xfll Eli 4 n s.2d 11 2 ., No Licanseemlanegss through internal t) i Ontario process but need not report, j If not all required !information is available within 10 days, send preliminary report within 10 days and provide final report wrkhin 21 days Come spepiged by Directory * * (r, I P4(3)y This decision free is intandedas a guide and does not constitute legal advice. Please refer to LTCHA 2007 and 0. Reg 79/10 for the complete requirements. May 2012 PAGE ONE Of TWO i iv ir((Gr`ro W� HOMES AND SENIORS SERVICES ha,n,��hre..�r,,, tpr tnan,,nnl POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 11 of 15 LICENSEE REPORTING OF FINANCIAL. ABUSE Ltae r ite, baroy miss nwem of Licensee to allsuspected or I Immediately wlEnessedfinancial abuse at'mm—mmmi hrvasflgata&take d resident, action jr) response to I incidenG(s.2aq)y ' Are there � -'seasonable grmunds to suspect ! % Was a residends. Money co Licensee to lmmAdlnQelV ennaiV suspicion 5endannatnan 01'adAr(wa Cis to that financial abuses tivas occurred To determine-dx �I I —.-Yperty Mrrrrrrrrrrrrrrrr'Iteerrrrrrrrrrrrrrrr�. pruimpprepranaor a a per memo not reelntred repswl byafcr�hours pagamW debunmasehours)(s24(1)8) or may nllsapptoplYatEdn jj��� Nce NO Send raked lnulutlingrasulfsoMbrvestXgalwnka�lons � �_ —i taken In response to Mncidenl via CIS wothrn 10 days or Liceii Licensee eefl rlf re;ltaesled by f7rtea1ec (a.1pm(2)p menages ihmughl manages through internalproasss '..... internal process '...,. Bfwl need rlot but nood not I report rpporl It oat all required lnior riaton isavatablls within 1) days, ...... ......... ......... ......... ......... send pnehmdnary report within fd days and provide final LE,GEOQ re paid wdun 21 days( time spooled by 0irectxr , * w uA(bp) s=LTCHA LOIY➢ r=tl, Rwg. 79)10 I * Mend = Aug 4, 20M memo s— Llimdor at * Mean* - March 2c), 21112 mama §roan invectoi * * * .Arwwalr'yes" If ymi hi mnsomba gmunds to �4$pep, a'icl Urn answar is'yas".Q,n, amsmr Jus nM snafu to he "Imalvrar. Assmnnas raasemebla Itviunuarez`atsnedad tlnarahuse axis uncwvsw7 nnnav mwvr Jhe linenseernusr lmma�dialrav rarnrn ar tivao ari aaia dnlwn ten Es 141118E �^+ y. This dealsiao tins is intended as a guide and doors not camstlfota legal advfes. May 2012 PAGE ONE Or IVY()O n 4,ari'....o Please refer to LTCHA 2007 and 0. Reg 79/10 for the complete requirements. rri �nlvw�rir((Gr`rw,�7 Wr HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 LICENSEE REPORTING GP NEGLECT bounties fracurnns aware ot! Licenses to I alleged suspeclad of immediatelakey witnessed neglect nt a ieaestiiy�3t0& t action or response to .....1 resident by Wa�nsee or $fail ' im dw,nt (03(1 .... ........ ........ Frwerrrrdrrmram Are thuro l I I� 1Jl) YlJ reasonable grounds to suspect that To neglect dekernt4rve haE occurred or may , accutP Na x .. Licensee manages through Intemai ! process but steed not report LEGEND s=12007 r=©. Hsg. 79r16 'Memo- Aug A, 2910 me.,,c iram ovectrar Memo March 29, 2012 nvemn lo. Di Answer'bes' If qom Brave remccard agroemds Is aoa c that the answer is "Ad6' [ee. emswar dnaa oat nod Cu he dstunlhw}, fjgsp�pp as reasmnahle groundla aie in earacf that neglert nos oacmmed or oiraknccur. Ihx tmenaee mus immwflalelgLeposl, swnrian maul infarnatien f2A 1)A so"1, Dud licensee ar daft Fell to ` previdc g ,widen[ with ireafmnnl care, services ©i assistance required for health safety of well-being t NOTE: Can inrJuda tear t ati or a paitem of reactlomEhatleoperd:aasthe healdh - .safely or well-being of one or more ..... residents, Na r Licensee manages through Internal proress duet need net repolrt, Page 12 of 15 Licensee to dinto Suspicion $ kierreafion to DI sell (via CIS as per mouno*P regolred In re port by after-houug pager outside business hoursp Is.24(1)'d( PAGER i•Bgit•BBBg60 ..." If ......... Send ropodtnolluding results of InweatlgatVcn S actions taken In response to'. incident via CIS vnthdn 1 g days or eadior if requester} by Director. P AP)4621h x 11 not all required lnlormaldil 15 auallahle wigtin 10 days serf prolic"roatp raped wifiintGdays good provide final report within 21 days (trine speckiied by area iur)* ry (r.ig4(4)) This decision tree Is intended as a guide and does not consthute legal advieo. May 20�12 PAGE ONE OF TWO Please refer to 1. TCHA 2007 and O, Reg 79t10 for the complete requiremanta, r!� �niv7!/�rilfGr`rat W� HOMES AND SENIORS SERVICES dLro�."�nu�..an,iy ern �rta�,�,nd� POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 LIOen ite frF.GAmeS nWana of b'censee to u88eged, suspected or essessionsessessessI smodialely ImgskGguta& nuke witnessed sexual abuse of a. ,achon rm response 10 tes9:. mfi urrndr;nt{s.2,)1)1 rwWasmrav�sa�weasa Are them reasonable grounds to suspect Ihat To a r e sexlaal abuse determine has srmatrutl or� lIII I>I j� occur? ' No w Licensee manages through irre mol proms but reed not report LICENSEE REPORTING OF SEXUAL ABUSE Was leaching. . behavlourar roaoarhs of a soruao nature or sexual axxpladai n directed Is a resident? No Licensee manages through internal oneness but need not report. 6>LtcWA2007 r�=rJ. Neg.79110 * Memo a Aug.n, 20t0 memo lose Dgectnr *+Moira - Marsh 24 of rnorno hour pur„ofu * tr s Air—' yes (evicers for guestlnns marked 'irk') it you have ranern9ble yromisds to suspect In a Ifin ans'm is yes (1 d. enswW doo nor nice Itl so dBPIPi11uH). ++For thw questions margwR "ri amswrr'No" iP you have roars, dosale grounds ro %tspe,M that the answer is 'No' or; answer dues nut have [a be duliniWel. As soon as ressamood, nmu6ds are susoxod drat show has uanrmmad or may 9F2YL..G1.G ilcansee n7uStlJOD7.Ed�SeIYLEAD1ISa5➢1g^PCLdR 'd.11lpAf.LG,191.11EL alas it by a licensee Was it .. r prsoft No -a-. uonsenYsuel7 Yves mermbert, 4+ Licensee manages f through Informal .e_Yes prosees butrred rut Yes report, v Was No 'tile teumring -`'Was if behatufaur or remarks in at a str ioal notate the course of a sexual relationship appropriate to the hebuaenthe resident and Ilitseepaor provision DI care or assisting Nor staff member that began before llhe a resident with resident Nas adnutledorfwtatethe . pp 7++ licensee or staff mamber No became licensee or staff? Yes ++; Licensee Yes manages r through internal - Was the pieces$ but reaching need notropnd, behaulnuf feirlarkS cansonsualT di Licensee manages..... through internal process'JOS bus need and report. Page 13 of 15 ireasee to I. Lt g id siespiclvri & ralorme0on to Director (via CLS as pen merncr' required to report by after-hours payer utuislde buslneas'hours)Qs24(112) WER 1,800,268.6060 v Send nalrad including results. of invitiogelmn & actions taken III respoaser to incident via CIS witbun 10 daps ar earlier if requested by Nicobar (r 9tii w If riot all required Irrlerrrialian rs available wilyin 10 days, send preliminary tefuud Wdhlr 10 days and provide final report wlthyr 21 days dime specified tryCtcectord* (rl0q(0)) ��Ontario This decision dreg is intended as a guide and does not constitute legal advice. Please refer toLTCHA2007and fJ, Reg 791fgfor thecomplete requitamanls May2012 PAGE ONE OFTWO HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14,1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 N Oleg.310,08 Every licensee of a long term care home shall ensure that the appropriate police force is immediately notified of any alleged, suspected or witnessed incident of abose or nulm of a resident that the liaosee inspects ma) Constitute a criminal of CrifliiiialCt)de0bncesthat May Appl,v Theft (Sec.322C.C.) Assault (Sec,265(k) Sexual Assault (W71 Intimidantion(Sec.423 Ifitimul3tion(SecA3 I I C.c) I C,c) I cq Theft by holding Power Assault with a Weapon ofAttorney (Sec33I I or causing bodily harm I Sexual Assault with 4 C'C') (sec'267(X) weapoo,threatstoa third party or cansing Stopping Mail with Aggravated Assault htidily harm (Sec'272 Intent (Su345 C,(,) (Set.261 C,C) C.(,) Extortim (SuA Forcible Confinement Aggravated Sexual C'C') ('SK279('Q Assaoh(SmM Ck) Forgery (,Set. 365 C.(,) Fraud (Sa, 381) C,C.) Murder ('Sec'229 C.C) Manslaughter (So.234 (,C,) Uttering Threats Uttering Threats (Sec.264'1 C.C.) I (klfl C'C') Criminal negligence causing bodily harm or death (See,220-21 cq Breach of Duq to Harassing Telephone 1121'assiogTelcphone provide nCCCssities Calls (See,372.3 CC,) Calls(Sec,3713 U.) (Scc,215C.C,) Nor nk4 used will permission 01 Reglor4 Munkipalily of Durham aid Durham Regional Poke Service, The wharf is intended as a guide and does not constitute legal advice. Please rein IQ dTCHA 2007, 0 Reg 791, and Criminal Code for the complete iepiremon15 14 of 15 r�i ynrv��rir((Gr`rw,�� Wr HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.11 DEPARTMENT: Administration SUBJECT: Resident Abuse APPROVAL DATE: May 14, 1986 APPROVAL DATE: Sept. 2011 REVISION DATE: March 2011; April 2022 REVIEW DATE: March 2015 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Licensee incomes aware of Licensee to immediately... "Infied, suspecad or giiA take 8,a ur in III uviverbal abuse aP mafrone a noes( resident.. e to IncitVest Is 23(1)) Area Ihere '..... Peas to ua' �1� W;Mll gmuinas to susnoct Ghat TO verbal abuse determinehas Occurred 111 ar may Occur? No r Licensee manages through 1, ermal process but need not report...... E�GENtl, s= LTC H'p 2007 1=0LReg 791i0 *M,sr = Aug,a, 2010 memo from Lln'ocwr * * Meno=10-h 2l 2012 memo Tom ©kedur *** Me —"yes if you havereasonablegroueds tcsurkp,Wthaltlheanswer Is .Nee (n a arrywar vJaax mnr r tnd tle dsf nlhv,i .bd,59LgAs,2 k"r4ASlan!b.:V.rQ,ld dti.dLk nClSAdnd s I1Sp&WS7srehaldeirt ea og irrfurrmahan 0.24 fI I2). * Page 15 of 15 LICENSEE REPORTING OF VERBAL ABUSE Licensee to mindatell ,.. repgrlsuspiuoon & Did My Yes Interns l [a Director tvla G�da resident Clans Per meet➢*, re"I'led msUdant make tllld id ', wine made the to mPorl by afCar•ho�urs Pager any too of Verbal lead .another verbal sommunwahan outside business hours. — communication of a 1Ves a.," reidentlafeerfor ,_Yew/ mrdergarrdillabonedafe (s.24(1)2) theamtening hrgfher thecpmsegaengas PAGERI-NO-268-6060 ,.arintnmitlaing ' safety?, of then ..... nature? codnmunle, shone No Licensee manages Ne * ...... 1 0 through Internal N4 Sand spent Including needle Dd process bedbneed not t of investigation B actions someone acher than "'. report _...... taken In response to incidem - a imulnnimake any form od Verbal via CPS v ifbBn 110 days communication, Chat was of a ... Ye " earrieP'if requested 211isctar. hneatendrrg of rnimidaling.- by m9t4ry? No If hot a19 required 6rllormatlnn Is eversble ©id ... wiihim 10 days, sand someone other than ._ preliminary report whKri l a fee !dent make any term ofverbal .. 1pdays and provide final Communication that was of a rUpuh wodhin'21 days j Leta(ng or degrading nature Whirl) dfmm shed Yes (ill specified by the resident's sense or (`1ira0t4r. F' nQ. d d9J 1 w`dil-bring drgnlhf of .. .-, sell-worib;r this decision tree is Intended as a guide and does not constitute ii advice. NT e Please refer to I.TCHA 207 and 0, Reg Mm for Me comprete requirements, Licensee manages thmogh mtemal process but mead nal Irepor. — - May 2012 PAGE ONE OF NVG a HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.12 DEPARTMENT: Administration SUBJECT: Staff Reporting & Whistle Blower Protection APPROVAL DATE: Sept. 2011 REVISION DATE: April 2022 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 1 of 7 PURPOSE: This policy is part of the Home's ongoing efforts to identify and respond to any conduct that may pose a risk of harm to residents or staff, or to the operation of the Home. This policy reflects the strong whistle -blowing protections in the Fixing Long -Term Care Homes Act, 2021 (the "FLTCA") , and reporting under this policy will assist the Home in meeting the requirements of the FLTCA in this and other areas. 1. This policy is intended to encourage Elgin County Homes Staff, Volunteers and others to report suspected or actual occurrence (s) of illegal, unethical or inappropriate events (behaviours or practices) without retribution; 2. To ensure that there is no retaliation against those who make reports in good faith under this policy; 3. To ensure compliance with reporting and whistle -blowing provisions of the FLTCA. 4. The County of Elgin Human Resources Policy 2.90 "Code of Conduct" provides employees with a guide to acceptable professional conduct of which may allies. PROCEDURE: 1. Section 30 of the FLTCA, 2021 forbids retaliation or threats of retaliation against a person for disclosing anything to an inspector or the Ministry of Long -Term Care Director/other MLTC personnel/any other person/entity provided for in the FLTCA/regulations, or for giving evidence in a proceeding under the FLTCA or during a coroner's inquest. Under section 30, staff members, licensees, officers, and directors cannot discourage these disclosures. 2. Staff Reporting Any staff member who is aware of or suspects any of the following must report it as soon as possible in accordance with the reporting procedures in this policy: a. Improper or incompetent treatment or care of a resident; or unlawful conduct that affects or may affect a resident b. Abuse of a resident by anyone, or neglect of a resident by a staff member or board member of the Home. This includes misuse or misappropriation of resident property c. Verbal complaints concerning resident care or operation of the Home a HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.12 DEPARTMENT: Administration SUBJECT: Staff Reporting & Whistle Blower Protection APPROVAL DATE: Sept. 2011 REVISION DATE: April 2022 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 2 of 7 d. Breach of the Home's policies, standards, procedures or by-laws, or breaches of legislation or government policy that applies to the Home, including the FLTCA and its regulations e. Any retaliation against a person for making a report under this policy, or for disclosing anything to an inspector or the MLTC Director/MLTC personnel, or for giving evidence in a proceeding under the FLTCA or in a coroner's inquest. Staff Reporting and Mandatory/Immediate Reporting under the FLTCA Staff should be aware that section 28(1) of the F LTCA requires certain persons to make immediate reports to the MLTC Director where there is a reasonable suspicion that certain conduct or events occurred or may occur. See Administration policy 1.3 Mandatory and Critical Incident Reporting (formerly Unusual Occurrence Reporting) for reporting requirements. Staff should immediately report through this policy any conduct or events that may lead to a mandatory/immediate report under section 28(1). Staff should also understand that it is an offence under the FLTCA to discourage or suppress a section 28 report. No Retaliation or Discouragement of Reports The Home will protect staff members and board members from harassment, coercion, penalty or discipline in the context of the following: a. Reports in good faith under this policy, and b. Disclosure of anything to an inspector or the MLTC Director/other MLTC personnel, or giving evidence in a proceeding under the FLTCA or during a coroner's inquest. The Home will protect a resident (and their family members, personal representative, and persons of importance) against any threats or discrimination in connection with the resident's disclosure of anything to an inspector or the MLTC Director/inspector/other personnel, or his or her giving evidence in a proceeding under the FLTCA or during a coroner's inquest. Staff members, management of the Home, licensee and board members must not do anything to discourage any of the following: a HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.12 DEPARTMENT: Administration SUBJECT: Staff Reporting & Whistle Blower Protection APPROVAL DATE: Sept. 2011 REVISION DATE: April 2022 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 3 of 7 a. Reports under this policy, b. Mandatory/immediate reports under the FLTCA, and c. Disclosures to an inspector or the MLTC Director/other personnel, or the giving of evidence in a proceeding under the FLTCA or during a coroner's inquest. d. A staff member or board member who retaliates, threatens a resident, or discourages a report in breach of this policy may be subject to disciplinary action, which may include termination or removal. Reporting in Good Faith In making a report under this policy, a person must not act maliciously or in bad faith. A person who makes a report maliciously or in bad faith may be subject to disciplinary action, which may include termination or removal. A. Reporting The Home will process and respond to reports of resident abuse and neglect through its Policy to Promote Zero Tolerance of Abuse and Neglect. Any and all situations of alleged and/or suspected Abuse and Neglect must be reported according the Home's Abuse Policy Admin 2.11. A Whistle -blower who is a staff member or volunteer who makes a report that is not done in good faith is subject to discipline, including termination of employment or volunteer status and/or other legal means to protect the residents and the reputation of the County of Elgin. Should this pertain to a visitor to the home, the Director/Administrator has the authority to supervise and/or restrict entrance to the home. No action or other proceeding shall be commenced against any person for reporting unless the person acted maliciously or in bad faith. 1. All complaints must be submitted in writing as soon as possible after the complaint is brought forward. 2. Crimes against person or property, such as assault, rape, burglary, etc., should immediately be reported to local law enforcement personnel. 3. Supervisors, managers and/or Administrator who receive the reports must promptly act to investigate and/or resolve the issue. If a staff member complains that an employer or person a HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.12 DEPARTMENT: Administration SUBJECT: Staff Reporting & Whistle Blower Protection APPROVAL DATE: Sept. 2011 REVISION DATE: April 2022 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 4 of 7 acting on behalf of the employer violates this policy, then that issue can be filed with the County of Elgin Homes Committee and/or under the regulations of The Labour Relations Act, 1995. 4. If the complaint is of a nature other than concerns or Abuse and Neglect, the Requests/Concern Policy and/or written complaint process will be followed. 5. All reports under this policy should be to a staff member's immediate supervisor or manager. Where an immediate supervisor is implicated, or where a staff member is uncomfortable reporting to their supervisor, the report should go to the next level of leadership or a member of senior management/CAO. 6. The CAO should report to the Warden, where appropriate. 7. Reports concerning management staff members should be to the Director/CAO; or if the report implicates the Administrator/Director or CAO, to the Warden. 8. Reports concerning conduct of professional staff or service providers (physicians and medical students, dentists, nurses in the extended class, Manager of Resident Care, supervisors) should be to the Administrator/Director or CAO. 9. A staff member or board member who experiences any form of retaliation before or after submitting a report should immediately inform their supervisor or a member of the management team/CAO; or the Warden. B. Investigation 1. The person receiving the report will review, and if warranted, investigate and resolve the subject matter of the report. Where necessary, that person will advise or involve members of senior management, i.e., Director of Human Resources, CAO. 2. Responsibility for investigation and resolution may be referred to senior management team or CAO. The County of Elgin expects staff members to cooperate during any investigation. 3. If feasible and appropriate, the Director of Homes and Seniors Services will inform the individual who made the report about the results of an investigation and the steps taken to a HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.12 DEPARTMENT: Administration SUBJECT: Staff Reporting & Whistle Blower Protection APPROVAL DATE: Sept. 2011 REVISION DATE: April 2022 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 5 of 7 address the conduct in question. The Whistleblower shall receive a report within ten business days of the initial report, regarding the investigation, disposition or resolution of the issue. 4. If the investigation of a report, that was done in good faith and investigated by internal personnel, is not to the Whistleblower's satisfaction, then he/she has the right to report the event to the appropriate legal or investigative agency. 5. The identity of the Whistleblower shall remain confidential to those persons directly involved in applying this policy, unless the issue requires investigation by law enforcement, in which case members of the organization are subject to subpoena. C. Confidentiality The Home will accept reports under this policy on a confidential basis. The Home's normal procedure will be to keep all reports confidential to the extent possible, subject to the need to conduct an effective investigation or to take action to comply with the FLTCA or other law. The home will not tolerate any attempt by a person or group to identify a person who submits a report in good faith on a confidential basis. 2. The identity of the reporting individual shall remain confidential to those persons directly involved in applying this policy, unless the issue requires investigation by law enforcement, in which case members of the organization are subject to subpoena. D. Staff Orientation and Training 1. Staff members will receive orientation and annual re-training on the reporting obligations under the FLTCA, the home's internal procedures for reporting, and the whistle -blowing protections in the FLTCA. 2. The reporting individual should promptly report the suspected or actual event to the supervisor. At no time will anyone do anything that discourages a person from forwarding suspected or actual occurrences of concern. And furthermore, no person shall encourage a person to fail to report any such concern. a HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.12 DEPARTMENT: Administration SUBJECT: Staff Reporting & Whistle Blower Protection APPROVAL DATE: Sept. 2011 REVISION DATE: April 2022 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 6 of 7 3. If the reporting individual would be uncomfortable or otherwise reluctant to report to the Supervisor, then the reporting individual could report the event to the next highest or another level of management, including the Administrator. 4. The reporting individual shall report the event verbally and in writing with his/her identity. 5. The reporting individual shall receive no retaliation or retribution for a report that was provided in good faith - that was not done primarily with malice to damage another or the organization. If a complaint is made in good faith and without malice to a Ministry Inspector, Administrator or supervisor in the Home, regardless of the outcome of the investigation, they will not be subject to any form of discipline, intimidation, coercion, or harassment. 6. In addition, a resident shall not be discharged from a long-term care home, threatened with discharge, or in any way subjected to discriminatory treatment because of any reported concern, even if the resident or another person linked to a resident acted maliciously or in bad faith, and no family member of a resident, substitute decision maker of a resident or person of importance to resident shall be threatened with the possibility of any of those actions being done to the resident. E. Reprisal This policy prohibits reprisals against employees who have made good faith complaints or provided information regarding a complaint or incident workplace harassment. Employees who engage in reprisals or threats of reprisals may be disciplined up to and including dismissal from employment. Reprisal includes: o Any act of retaliation that occurs because a person has complained of or provided information about an incident. o Intentionally pressuring a person to ignore or not report an incident o Intentionally pressuring a person to lie to provide less than full cooperation with an investigation of a complaint or incident. o Intimidating, coercing or harassing any person. o Imposing a penalty upon any person. a HOMES AND SENIORS SERVICES POLICY & PROCEDURE NUMBER: 2.12 DEPARTMENT: Administration SUBJECT: Staff Reporting & Whistle Blower Protection APPROVAL DATE: Sept. 2011 REVISION DATE: April 2022 REVIEW DATE: March 2016; March 2017; Oct. 2019; Dec. 2020; March 2022 Page 7 of 7 References Fixing Long -Term Care Act, 2021 Ontario Regulation 246/22 REPORT TO COUNTY COUNCIL FROM: Brian Lima, General Manager - Engineering, Planning, and Enterprise (EPE) - �uluouum, Deputy CAO E191T1 rogd,r ssiv . by Na,Wre DATE: May 4, 2022 SUBJECT: Contract Award - County Administration Building - Council Chambers & Reception Upgrades Project RECOMMENDATIONS: THAT report "Contract Award - County Administration Building - Council Chambers & Reception Upgrades" from the General Manager - Engineering, Planning, and Enterprise (EPE) - Deputy CAO be received for information; and THAT K&L Construction (Ontario Ltd). be awarded the County Administration Building - Council Chambers & Reception Upgrades Project, Tender No. 2022-T09 at a total price of $1,113,600.00 (exclusive of HST); and THAT the Warden and Chief Administrative Officer be authorized to sign the respective contract. INTRODUCTION: As part of the approved 2021 Capital Budget, a tender for the Accessible Elevator and Basement Washroom Renovation Project, which also originally included renovations to Council Chambers and the creation of a new entrance lobby reception kiosk was previously tendered on June 16, 2021. At the direction of Council, staff was directed to proceed with retendering the project in two parts. In addition to this, Council approved funds in the 2022 Capital budget for the establishment of new Economic Development, Tourism and Paramedicine office suites, utilizing the former POA court room suites. Accordingly, a second tender titled County Administration Building - Council Chambers & Reception Upgrades Project was advertised and issued as per the County's Procurement Policy, that includes remodelling of Council Chambers, the establishment of a new entrance lobby kiosk, and new remodelled Economic Development, Tourism, and Paramedicine office suites. 2 DISCUSSION: Ten (10) contractors downloaded the tender documents from the County's bid portal. A total of two (2) contractors submitted electronic bids for this tender which closed on May 2, 2022. Bids results were received as follows: Company Bid Price (exclusive of HST) K&L Construction (Ontario Ltd). $1,113,600.00 Elgin Contracting and Restoration Ltd. $1,119,000.00 K&L Construction (Ontario Ltd) submitted the lowest compliant bid for the project at a price of $1,113,600.00, exclusive of HST, and inclusive of a $302,500 project contingency. FINANCIAL IMPLICATIONS: The following summary of projected estimated costs is provided for review and will be confirmed throughout the project: Architectural / Engineering' $ 90,000.00 Construction $ 1,113,600.00 Net HST (1.76%) $ 21,183.36 Total Projected Costs $ 1,224,783.36 2021 & 2022 Combined Capital Budget $ 714,774.00 Forecast Budget Surplus/(Deficit) ($ 510,009.36) 'Administration Building - Council Chambers Modernization and Entrance Lobby Reception Renovation Project Update architectural design and contract administration engineering service fees in the amount of $49,000.00 (excluding HST) were previously awarded to L360 Architecture by County Council at its January 19, 2021 meeting 2Includes a $302,500 of cash allowance & contingency. Despite higher than expected tender results, staff recommends that K&L Construction (Ontario Ltd). be awarded the project, and that the funding deficit be budgeted for in the 2023 Capital Budget. 3 ALIGNMENT WITH STRATEGIC PRIORITIES: Serving Elgin Growing Elgin ® Ensuring alignment of ❑ Planning for and current programs and facilitating commercial, services with community industrial, residential, need. and agricultural growth ® Exploring different ways of addressing community need. ® Engaging with our community and other stakeholders. ® Fostering a healthy environment. ® Enhancing quality of place. LOCAL MUNICIPAL PARTNER IMPACT: Investing in Elgin ® Ensuring we have the necessary tools, resources, and infrastructure to deliver programs and services now and in the future. ® Delivering mandated programs and services efficiently and effectively. A modernization of Council Chamber and establishment of a new front Lobby Reception kiosk will address challenges associated with the original administration building design and will provide an enhanced barrier -free customer service level experience. In addition, the establishment of new Economic Development, Tourism, and Paramedicine office suites will also facilitate respective customer focused enhanced levels of services at the County's Administration Building. COMMUNICATION REQUIREMENTS: All Council, Staff and Administrative Building tenants will be advised of the Project and be provided construction progress updates throughout the duration of construction, including advance notice of any facility access or temporary service disruptions. CONCLUSION: This project once completed, will address many significant legacy design challenges associate with the original Administration Building design. Despite higher than expected tender bid results, staff recommends that K&L Construction (Ontario Ltd) be awarded the County Administration Building — Council Chambers & Reception Upgrades Project as set out in this report. Work on this project is expected to commence immediately following Council tender award, with substantial completion anticipated to be achieved in the first quarter of 2023. All of which is Respectfully Submitted Brian Lima General Manager Engineering, Planning, and Enterprise (EPE) / Deputy CAO Mike Hoogstra Purchasing Coordinator Eugenio DiMeo Manager of Corporate Facilities Approved for Submission Julie Gonyou Chief Administrative Officer 2 CLOSED MEETING AGENDA May 10, 2022 Staff Reports: 1) General Manager of EPE/Deputy CAO - Municipal Act Section 239 (2) (a) the security of the property of the municipality or local board; (h) information explicitly supplied in confidence to the municipality or local board by Canada, a province or a Crown agency of any of them; (k) a position, plan, procedure, criteria or instruction to be applied to any negotiations carried on or to be carried on by or on behalf of the municipality or local board- Property Matter (VERBAL) 2) Chief Administrative Officer - Municipal Act Section 239 (2) (a) the security of the property of the municipality or local board- Security of Property (VERBAL) 3) Chief Administrative Officer - Municipal Act Section 239 (2) (b) personal matters about an identifiable individual, including municipal or local board employees - Organizational Update (VERBAL)