Committee of the Whole Meeting Date: August 23, 2016 Submitted by: Brent Kerwin, Administrator, Strathmere Lodge SUBJECT: MINISTRY OF HEALTH AND LONG TERM CARE COMPLAINT INSPECTIONS BACKGROUND: Reports of Ministry of Health and Long Term Care (MoHLTC) inspections are posted for public information at the Lodge, and shared with County Council. The Ministry also posts inspection reports on its provincial Long Term Care Homes public reporting website. ANALYSIS: During our Annual Inspection (“Resident Quality Inspection (RQI)”) in May, a Ministry of Health Compliance Inspector reviewed two (2) separate and distinct complaints that the Ministry received since our last Annual Inspection (November 2015). The Ministry of Health deals with complaints in a manner separate from its Annual Inspection process. The attached public copies of the Ministry’s complaint reports (which do not contain protected personal health information or other identifying information) were received by the Lodge from the Ministry on July 19, 2016. As a result of the complaint regarding specialized foot care services (offered by the Lodge on a not-for-profit basis), we have changed our resident/family communication (both written and verbal) to clarify when specialized foot care (versus basic foot care) is warranted. August 23, 2016 Page 1 of 16 C 14 - CW Info
Transcript
Committee of the Whole
Meeting Date August 23 2016
Submitted by Brent Kerwin Administrator Strathmere Lodge
SUBJECT MINISTRY OF HEALTH AND LONG TERM CARE COMPLAINT INSPECTIONS
BACKGROUND
Reports of Ministry of Health and Long Term Care (MoHLTC) inspections are posted for public information at the Lodge and shared with County Council
The Ministry also posts inspection reports on its provincial Long Term Care Homes public reporting website
ANALYSIS
During our Annual Inspection (ldquoResident Quality Inspection (RQI)rdquo) in May a Ministry of Health Compliance Inspector reviewed two (2) separate and distinct complaints that the Ministry received since our last Annual Inspection (November 2015)
The Ministry of Health deals with complaints in a manner separate from its Annual Inspection process
The attached public copies of the Ministryrsquos complaint reports (which do not contain protected personal health information or other identifying information) were received by the Lodge from the Ministry on July 19 2016
As a result of the complaint regarding specialized foot care services (offered by the Lodge on a not-for-profit basis) we have changed our residentfamily communication (both written and verbal) to clarify when specialized foot care (versus basic foot care) is warranted
August 23 2016 Page 1 of 16 C 14 - CW Info
The second complaint relates to a resident-to-resident incident involving two residents with dementia whereby one resident kicked another resident without injury Such incidents are to be reported to a residentrsquos substitute decision maker (SDM)alternate
Attachment
August 23 2016 Page 2 of 16 C 14 - CW Info
r)h Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4tlbull Floor London ON N6A 5R2
Ministere de la Sante et des Soins de tongue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree Faxffelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date July 18 2016
To Administrator President Residents Council President Family Council
Re Inspection 2016_260521_0017 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the LTCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
August 23 2016 Page 3 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree f~
~Ontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Long-Term Care Homes Division London Service Area Office Bureau regional de services de Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor London
LONDON ON N6A 5R2 130 avenue Dufferin 4eme etage Division des foyers de soins de Telephone (519) 873-1200 LONDON ON N6A 5R2 longue duree Facsimile (519) 873-1300 Telephone (519) 873-1200 Inspection de soins de longue duree Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0017 034619-15 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 5
August 23 2016 Page 4 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r)h Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident safety
During the course of the inspection the inspector(s) spoke with the Administrator the Acting Director of Resident Care (ADRC) a Registered Nurse a family council representative and residents
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plans of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Prevention of Abuse Neglect and Retaliation Responsive Behaviours
During the course of this inspection Non-Compliances were issued 1 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 5
August 23 2016 Page 5 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO - Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2(1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 97 Notification re incidents
Page 3 ofde 5
August 23 2016 Page 6 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
t~ gtvr Ontario Long-Term Care
Inspection Report under
Soins de longue duree
Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Specifically failed to comply with the following
s 97 (1) Every licensee of a long-term care home shall ensure that the residents substitute decision-maker if any and any other person specified by the resident (a) are notified immediately upon the licensee becoming aware of an alleged suspected or witnessed incident of abuse or neglect of the resident that has resulted in a physical injury or pain to the resident or that causes distress to the resident that could potentially be detrimental to the residents health or well-being and (b) are notified within 12 hours upon the licensee becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident 0 Reg 7910 s 97 (1 )
FindingsFaits saillants
1 The licensee has failed to ensure that the residents Substitute Decision Maker (SOM) and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident
A record review revealed a progress note identified an incident occurred
An interview with the Registered Nurse (RN) revealed the RN thought the SOM was notified of several incidents later the following week
An interview with the management confirmed the residents SOM was not notified of the witnessed documented incident and it was the homes expectation that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident [s 97 (1) (b)]
Page 4 ofde 5
August 23 2016 Page 7 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 5 ofde 5
August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
The second complaint relates to a resident-to-resident incident involving two residents with dementia whereby one resident kicked another resident without injury Such incidents are to be reported to a residentrsquos substitute decision maker (SDM)alternate
Attachment
August 23 2016 Page 2 of 16 C 14 - CW Info
r)h Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4tlbull Floor London ON N6A 5R2
Ministere de la Sante et des Soins de tongue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree Faxffelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date July 18 2016
To Administrator President Residents Council President Family Council
Re Inspection 2016_260521_0017 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the LTCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
August 23 2016 Page 3 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree f~
~Ontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Long-Term Care Homes Division London Service Area Office Bureau regional de services de Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor London
LONDON ON N6A 5R2 130 avenue Dufferin 4eme etage Division des foyers de soins de Telephone (519) 873-1200 LONDON ON N6A 5R2 longue duree Facsimile (519) 873-1300 Telephone (519) 873-1200 Inspection de soins de longue duree Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0017 034619-15 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 5
August 23 2016 Page 4 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r)h Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident safety
During the course of the inspection the inspector(s) spoke with the Administrator the Acting Director of Resident Care (ADRC) a Registered Nurse a family council representative and residents
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plans of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Prevention of Abuse Neglect and Retaliation Responsive Behaviours
During the course of this inspection Non-Compliances were issued 1 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 5
August 23 2016 Page 5 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO - Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2(1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 97 Notification re incidents
Page 3 ofde 5
August 23 2016 Page 6 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
t~ gtvr Ontario Long-Term Care
Inspection Report under
Soins de longue duree
Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Specifically failed to comply with the following
s 97 (1) Every licensee of a long-term care home shall ensure that the residents substitute decision-maker if any and any other person specified by the resident (a) are notified immediately upon the licensee becoming aware of an alleged suspected or witnessed incident of abuse or neglect of the resident that has resulted in a physical injury or pain to the resident or that causes distress to the resident that could potentially be detrimental to the residents health or well-being and (b) are notified within 12 hours upon the licensee becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident 0 Reg 7910 s 97 (1 )
FindingsFaits saillants
1 The licensee has failed to ensure that the residents Substitute Decision Maker (SOM) and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident
A record review revealed a progress note identified an incident occurred
An interview with the Registered Nurse (RN) revealed the RN thought the SOM was notified of several incidents later the following week
An interview with the management confirmed the residents SOM was not notified of the witnessed documented incident and it was the homes expectation that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident [s 97 (1) (b)]
Page 4 ofde 5
August 23 2016 Page 7 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 5 ofde 5
August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
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August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
r)h Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4tlbull Floor London ON N6A 5R2
Ministere de la Sante et des Soins de tongue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree Faxffelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date July 18 2016
To Administrator President Residents Council President Family Council
Re Inspection 2016_260521_0017 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the LTCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
August 23 2016 Page 3 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree f~
~Ontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Long-Term Care Homes Division London Service Area Office Bureau regional de services de Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor London
LONDON ON N6A 5R2 130 avenue Dufferin 4eme etage Division des foyers de soins de Telephone (519) 873-1200 LONDON ON N6A 5R2 longue duree Facsimile (519) 873-1300 Telephone (519) 873-1200 Inspection de soins de longue duree Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0017 034619-15 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 5
August 23 2016 Page 4 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r)h Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident safety
During the course of the inspection the inspector(s) spoke with the Administrator the Acting Director of Resident Care (ADRC) a Registered Nurse a family council representative and residents
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plans of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Prevention of Abuse Neglect and Retaliation Responsive Behaviours
During the course of this inspection Non-Compliances were issued 1 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 5
August 23 2016 Page 5 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO - Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2(1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 97 Notification re incidents
Page 3 ofde 5
August 23 2016 Page 6 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
t~ gtvr Ontario Long-Term Care
Inspection Report under
Soins de longue duree
Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Specifically failed to comply with the following
s 97 (1) Every licensee of a long-term care home shall ensure that the residents substitute decision-maker if any and any other person specified by the resident (a) are notified immediately upon the licensee becoming aware of an alleged suspected or witnessed incident of abuse or neglect of the resident that has resulted in a physical injury or pain to the resident or that causes distress to the resident that could potentially be detrimental to the residents health or well-being and (b) are notified within 12 hours upon the licensee becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident 0 Reg 7910 s 97 (1 )
FindingsFaits saillants
1 The licensee has failed to ensure that the residents Substitute Decision Maker (SOM) and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident
A record review revealed a progress note identified an incident occurred
An interview with the Registered Nurse (RN) revealed the RN thought the SOM was notified of several incidents later the following week
An interview with the management confirmed the residents SOM was not notified of the witnessed documented incident and it was the homes expectation that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident [s 97 (1) (b)]
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Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 5 ofde 5
August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
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August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree f~
~Ontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Long-Term Care Homes Division London Service Area Office Bureau regional de services de Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor London
LONDON ON N6A 5R2 130 avenue Dufferin 4eme etage Division des foyers de soins de Telephone (519) 873-1200 LONDON ON N6A 5R2 longue duree Facsimile (519) 873-1300 Telephone (519) 873-1200 Inspection de soins de longue duree Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0017 034619-15 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
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August 23 2016 Page 4 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r)h Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident safety
During the course of the inspection the inspector(s) spoke with the Administrator the Acting Director of Resident Care (ADRC) a Registered Nurse a family council representative and residents
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plans of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Prevention of Abuse Neglect and Retaliation Responsive Behaviours
During the course of this inspection Non-Compliances were issued 1 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
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August 23 2016 Page 5 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO - Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2(1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 97 Notification re incidents
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Ministry of Health and Ministere de la Sante et des
t~ gtvr Ontario Long-Term Care
Inspection Report under
Soins de longue duree
Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Specifically failed to comply with the following
s 97 (1) Every licensee of a long-term care home shall ensure that the residents substitute decision-maker if any and any other person specified by the resident (a) are notified immediately upon the licensee becoming aware of an alleged suspected or witnessed incident of abuse or neglect of the resident that has resulted in a physical injury or pain to the resident or that causes distress to the resident that could potentially be detrimental to the residents health or well-being and (b) are notified within 12 hours upon the licensee becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident 0 Reg 7910 s 97 (1 )
FindingsFaits saillants
1 The licensee has failed to ensure that the residents Substitute Decision Maker (SOM) and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident
A record review revealed a progress note identified an incident occurred
An interview with the Registered Nurse (RN) revealed the RN thought the SOM was notified of several incidents later the following week
An interview with the management confirmed the residents SOM was not notified of the witnessed documented incident and it was the homes expectation that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident [s 97 (1) (b)]
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Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
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August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
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August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
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Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
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Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
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Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
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August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
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August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des
r)h Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident safety
During the course of the inspection the inspector(s) spoke with the Administrator the Acting Director of Resident Care (ADRC) a Registered Nurse a family council representative and residents
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plans of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Prevention of Abuse Neglect and Retaliation Responsive Behaviours
During the course of this inspection Non-Compliances were issued 1 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 5
August 23 2016 Page 5 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO - Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2(1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 97 Notification re incidents
Page 3 ofde 5
August 23 2016 Page 6 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
t~ gtvr Ontario Long-Term Care
Inspection Report under
Soins de longue duree
Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Specifically failed to comply with the following
s 97 (1) Every licensee of a long-term care home shall ensure that the residents substitute decision-maker if any and any other person specified by the resident (a) are notified immediately upon the licensee becoming aware of an alleged suspected or witnessed incident of abuse or neglect of the resident that has resulted in a physical injury or pain to the resident or that causes distress to the resident that could potentially be detrimental to the residents health or well-being and (b) are notified within 12 hours upon the licensee becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident 0 Reg 7910 s 97 (1 )
FindingsFaits saillants
1 The licensee has failed to ensure that the residents Substitute Decision Maker (SOM) and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident
A record review revealed a progress note identified an incident occurred
An interview with the Registered Nurse (RN) revealed the RN thought the SOM was notified of several incidents later the following week
An interview with the management confirmed the residents SOM was not notified of the witnessed documented incident and it was the homes expectation that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident [s 97 (1) (b)]
Page 4 ofde 5
August 23 2016 Page 7 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 5 ofde 5
August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO - Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2(1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 97 Notification re incidents
Page 3 ofde 5
August 23 2016 Page 6 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
t~ gtvr Ontario Long-Term Care
Inspection Report under
Soins de longue duree
Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Specifically failed to comply with the following
s 97 (1) Every licensee of a long-term care home shall ensure that the residents substitute decision-maker if any and any other person specified by the resident (a) are notified immediately upon the licensee becoming aware of an alleged suspected or witnessed incident of abuse or neglect of the resident that has resulted in a physical injury or pain to the resident or that causes distress to the resident that could potentially be detrimental to the residents health or well-being and (b) are notified within 12 hours upon the licensee becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident 0 Reg 7910 s 97 (1 )
FindingsFaits saillants
1 The licensee has failed to ensure that the residents Substitute Decision Maker (SOM) and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident
A record review revealed a progress note identified an incident occurred
An interview with the Registered Nurse (RN) revealed the RN thought the SOM was notified of several incidents later the following week
An interview with the management confirmed the residents SOM was not notified of the witnessed documented incident and it was the homes expectation that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident [s 97 (1) (b)]
Page 4 ofde 5
August 23 2016 Page 7 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 5 ofde 5
August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des
t~ gtvr Ontario Long-Term Care
Inspection Report under
Soins de longue duree
Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Specifically failed to comply with the following
s 97 (1) Every licensee of a long-term care home shall ensure that the residents substitute decision-maker if any and any other person specified by the resident (a) are notified immediately upon the licensee becoming aware of an alleged suspected or witnessed incident of abuse or neglect of the resident that has resulted in a physical injury or pain to the resident or that causes distress to the resident that could potentially be detrimental to the residents health or well-being and (b) are notified within 12 hours upon the licensee becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident 0 Reg 7910 s 97 (1 )
FindingsFaits saillants
1 The licensee has failed to ensure that the residents Substitute Decision Maker (SOM) and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident
A record review revealed a progress note identified an incident occurred
An interview with the Registered Nurse (RN) revealed the RN thought the SOM was notified of several incidents later the following week
An interview with the management confirmed the residents SOM was not notified of the witnessed documented incident and it was the homes expectation that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident [s 97 (1) (b)]
Page 4 ofde 5
August 23 2016 Page 7 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 5 ofde 5
August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dun~eI)bull
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the residents SOM and any other person specified by the resident were notified within 12 hours upon becoming aware of any other alleged suspected or witnessed incident of abuse or neglect of the resident to be implemented voluntarily
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 5 ofde 5
August 23 2016 Page 8 of 16 C 14 - CW Info
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
r-~ Ministry of Health and Long-Term Care
London Service Area Office Long-Term Care Inspections Branch Long-Term Care Homes Division 130 Dufferin Avenue 4Lh Floor London ON N6A 5R2
Ministere de la Sante et des Soins de longue duree tontario Bureau regional de services de London TelephoneTelephone 519-873-1200 Inspection de soins de longue duree 1-866-663-3775 Division des foyers de soins de longue duree FaxTelecopieur 519-873-1300 130 avenue Dufferin 4iem etage London ON N6A 5R2
Date
To
Re
July 18 2016
Administrator President Residents Council President Family Council
Inspection 2016_260521_0016 Report Date June 13 2016 Type of Inspection Complaint
Enclosed is an Inspection Report- Public Copy for an inspection conducted under the Long-Term Care Homes Act 2007 (LTCHA) for the purpose of ensuring compliance with requirements under the L TCHA
Individual envelopes addressed to the President Residents Council and President Family Council must be distributed unopened to the addressee
This Inspection Report - Public Copy must be posted in the home in a conspicuous and easily accessible location in accordance with the LTCHA 2007 SO 2007 c8 s79 (1) and (2) A copy of the Inspection Report-Public Copy must be made available without charge upon request
The report will also be on file with the Service Area Office Long-Term Care Inspections Branch and posted on the Long-Term Care Homesnet website
http publi eportingltchomes eten-cadefaultaspx
August 23 2016 Page 9 of 16 C 14 - CW Info
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Long-Term Care
r-~gtr Ontario Inspection Report under
the Long-Term Care Homes Act 2007
Long-Term Care Homes Division London Service Area Office Long-Term Care Inspections Branch 130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2 Division des foyers de soins de Telephone (519) 873-1200 longue dun~e Facsimile (519) 873-1300 Inspection de soins de longue dun~e
Ministere de la Sante et des Soins de longue duree
Rapport dinspection sous la Loi de 2007 sur les foyers de soins de longue duree
Bureau regional de services de London 130 avenue Dufferin 4eme etage LONDON ON N6A 5R2 Telephone (519) 873-1200 Telecopieur (519) 873-1300
Public CopyCopie du public
Report Date(s) I Inspection No I Log I Type of Inspection I Date(s) du apport No de inspection Registre no Genre dinspection
Jun 13 2016 2016 260521 0016 012381-16 Complaint
LicenseeTitulaire de permis THE CORPORATION OF THE COUNTY OF MIDDLESEX co Strathmere Lodge 599 Albert Street PO Box 5000 STRATHROY ON N7G 3J3
Long-Term Care HomeFoyer de soins de longue duree STRATHMERE LODGE 599 Albert Street Box 5000 STRATHROY ON N7G 3J3
Name of lnspector(s)Nom de linspecteur ou des inspecteurs REBECCA DEWITTE (521)
Inspection SummaryResume de inspection
Page 1 ofde 7
August 23 2016 Page 10 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
The purpose of this inspection was to conduct a Complaint inspection
This inspection was conducted on the following date(s) May 17 18 19 and 20 2016
This complaint inspection pertained to resident charges
During the course of the inspection the inspector(s) spoke with the Administrator Acting Director of Resident Care (ADRC) the Rai-Coordinator the Registered Practical Nurse for foot care services a family council representative residents and families
The inspector(s) also conducted a tour of all resident areas and common areas observed residents and care provided to them medication passes medication storage areas reviewed health care records and plan of care for identified residents policies and procedures
The following Inspection Protocols were used during this inspection Admission and Discharge Personal Support Services Resident Charges
During the course of this inspection Non-Compliances were issued 2 WN(s) 1 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s)
Page 2 ofde 7
August 23 2016 Page 11 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des
r-~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
NON-COMPLIANCE I NON - RESPECT DES EXIGENCES Legend
WN - Written Notification VPC - Voluntary Plan of Correction DR - Director Referral CO - Compliance Order WAO -Work and Activity Order
Non-compliance with requirements under the Long-Term Care Homes Act 2007 (L TCHA) was found (a requirement under the L TCHA includes the requirements contained in the items listed in the definition of requirement under this Act in subsection 2(1) of the L TCHA)
Legende
WN - Avis ecrit VPC - Plan de redressement volontaire DR - Aiguillage au directeur CO - Ordre de conformite WAO - Ordres travaux et activites
Le non-respect des exigences de la Loi de 2007 sur les foyers de soins de longue duree (LFSLD) a ete constate (une exigence de la loi comprend les exigences qui font partie des elements enumeres dans la definition de laquo exigence prevue par la presente loi raquo au paragraphe 2( 1) de la LFSLD
The following constitutes written notification Ce qui suit constitue un avis ecrit de non-of non-compliance under paragraph 1 of respect aux termes du paragraphe 1 de section 152 of the L TCHA article 152 de la LFSLD
WN 1 The Licensee has failed to comply with OReg 7910 s 224 Information for residents etc
Specifically failed to comply with the following
s 224 (1) For the purposes of clause 78 (2) (r) of the Act every licensee of a longshyterm care home shall ensure that the package of information provided for in section 78 of the Act includes information about the following 5 A list of the charges that a licensee is prohibited from charging a resident under subsection 91 (1) of the Act 0 Reg 7910 s 224 (1 )
FindingsFaits saillants
Page 3 ofde 7
August 23 2016 Page 12 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue Cturee
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that the admission package included what the licensee should not be charging a resident for A complaint received revealed the licensee was charging some residents $25 per foot care services
A review of the admission package resident information booklet revealed Foot care is provided on a fee for service basis
A review of the admission agreement - goods and services included with accommodation appendix failed to mention preventative and basic foot care services would be included in with the resident accommodation services
A review of the purchased service agreement appendix 1 point 13 revealed residents may purchase specialized foot care services at a cost of $25 per half hour visit
An interview with management confirmed the admission package did not include what the licensee should not be charging a resident for [s 224 (1) 5]
Additional Required Actions
VPC - pursuant to the Long-Term Care Homes Act 2007 SO 2007 c8 s152(2) the licensee is hereby requested to prepare a written plan of correction for achieving compliance to ensure that the admission packages include what the licensee should not be charging a resident for to be implemented voluntarily
Page 4 ofde 7
August 23 2016 Page 13 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue dureef)
tr-gtOntario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
WN 2 The Licensee has failed to comply with 0Reg 7910 s 245 Non-allowable resident charges The following charges are prohibited for the purposes of paragraph 4 of subsection 91 (1) of the Act 1 Charges for goods and services that a licensee is required to provide to a resident using funding that the licensee receives from
i a local health integration network under section 19 of the Local Health System Integration Act 2006 including goods and services funded by a local health integration network under a service accountability agreement and
ii the Minister under section 90 of the Act 0 Reg 7910 s 245 2 Charges for goods and services paid for by the Government of Canada the Government of Ontario including a local health integration network or a municipal government in Ontario 0 Reg 7910 s 245 3 Charges for goods and services that the licensee is required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a local health integration network 0 Reg 7910 s 245 4 Charges for goods and services provided without the residents consent 0 Reg 7910 s 245 5 Charges other than the accommodation charge that every resident is required to pay under subsections 91 (1) and (3) of the Act to hold a bed for a resident during an absence contemplated under section 138 or during the period permitted for a resident to move into a long-term care home once the placement co-ordinator has authorized admission to the home 0 Reg 7910 s 245 6 Charges for accommodation under paragraph 1 or 2 of subsection 91 (1) of the Act for residents in the short-stay convalescent care program 0 Reg 7910 s 245 7 Transaction fees for deposits to and withdrawals from a trust account required by section 241 or for anything else related to a trust account 0 Reg 7910 s 245 8 Charges for anything the licensee shall ensure is provided to a resident under this Regulation unless a charge is expressly permitted 0 Reg 7910 s 245
FindingsFaits saillants
Page 5 ofde 7
August 23 2016 Page 14 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des Long-Term Care Soins de longue duree _~
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
1 The licensee has failed to ensure that residents were not charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network
A complaint was received claiming the licensee would charge a resident a fee for foot care services
A record review of the foot care binder revealed there were a significant number of residents receiving or had received a fee for foot care services Files were reviewed from the binder which revealed basic foot care was delivered to some residents for a fee per visit
Interviews with some Power of Attorneys (POAs) revealed it was their understanding from the time of admission that there was a fee for service for foot care provided to all residents
An interview with management revealed the fee for service foot care provided to a resident was not considered to be specialized as there was nothing wrong with the residents feet
The management and the nurse both confirmed it was the homes expectation that basic foot care services should have been provided to all residents which included the cutting of toenails to ensure comfort and prevent infection
The management confirmed residents should not be charged for goods and services that the licensee was required to provide to residents under any agreement between the licensee and the Ministry or between the licensee and a Local Health Integration Network [s 245 3]
Page 6 ofde 7
August 23 2016 Page 15 of 16 C 14 - CW Info
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
Original report signed by the inspector
Page 7 ofde 7
August 23 2016 Page 16 of 16 C 14 - CW Info
BACKGROUND
ANALYSIS
Ministry of Health and Ministere de la Sante et des
~ Long-Term Care Soins de longue duree
tontario Inspection Report under Rapport dinspection sous la the Long-Term Care Loi de 2007 sur les foyers de Homes Act 2007 soins de longue duree
Issued on this 21st day of June 2016
Signature of lnspector(s)Signature de linspecteur ou des inspecteurs
