Compliance Transformation in Ontario’s Long Term Care Homes

On July 1, 2010 the Long Term Care Homes Act, 2007 and its associated Regulation 79 came into effect. Both the Act and its regulations were developed to improve the care and quality of life for residents in Long Term Care (LTC) homes across Ontario 1.

This new method of inspecting homes is based on an individualized focus on quality of life and quality of care for our residents and Registered Dietitians are an essential component in meeting this daily need.

The process began in 2007 when legislation and accompanying regulations were consolidated and updated under Bill 140 in one overarching statute. As a result the Performance Improvement and Compliance Branch was formed in June 2007 and one of its most important initiatives was the “transformation” of the compliance inspection process to support the LTC Homes Act, 2007. During the period of 2007-2009 the foundation for transformation was set. 3

Beginning July 1, 2010 the Compliance Management Program used to inspect long-term care homes was replaced by the LTC Quality Inspection Program (LQIP), a new compliance and enforcement program required under the LTC Homes Act, 2007. 2

“Compliance Transformation” reflects a new system focused on the enforcement of requirements for longterm care homes such as the quality of resident care, quality of life and the prevention of potential risk instead of focusing on the longterm care homes processes, policies and procedures.3

This new inspection process also aligns with five operational domains: resident care, resident rights, leadership and governance, operations and services, and environmental health which are outlined in the LTC Act. 3

In order to find new inspection methodologies a jurisdictional review was conducted in Canada, Australia, the United Kingdom, and the United States.3 The American Quality Indicator Survey (QIS) System was adopted and renamed Resident Quality Inspection since it best reflected the goals for compliance and enforcement under the new LTCHA. 2

As the program rolled out, LTC homes were given the opportunity to volunteer as test sites to assist Ministry Inspectors and other LTC homes in trialing, implementing and training in the new processes.

The LTC Quality Inspection Program aligns with the other Inspection and Enforcement Ministries and directs Ministry Inspectors to use set inspection protocols to focus on areas of risk in the home, quality of care, and quality of life for the residents. This new method is a very resident focused way of inspecting homes and is meant to assure residents, families and the public, that residents are the first priority. According to Ministry of Health reports, four homes interviewed in the U.S. indicated greater fairness, standardization, clarity and focus in the process and an increased number of “non-compliance” results using the system.

The inspection process is designed to improve standardization by using Inspection Protocols to guide the inspector through resident, staff and family interviews.

Computer tablets were issued to inspectors to assist with data accumulation gleaned from observations and interviews, the tablets also help provide immediate outcome reports of either positive results or negative non-compliance in the home.

The Resident Quality Inspection (RQI) has two stages. In stage one, 40 residents are randomly selected from the individual homes’ previously submitted RAI MDS information. The inspectors review specific protocols for stage one. They then interview and observe residents, interview families, and staff members, as they relate to residents identified in the RAI MDS information or observations they have made in the homes related to risk. Each inspection protocol is linked directly to the appropriate section of the LTCHA or regulation.

A sample of stage one questions for a resident may include the following:

“Are you able to participate in making decisions regarding food choices/preferences”

“Do you participate in choosing your bed time?”

“Do you feel the staff treats you with respect and dignity? Does the staff take time to listen to you?” 2

Stage one has several protocols that are mandatory for review: dining, infection prevention and control, quality improvement program, resident charges, interviews with resident council and family council representatives, medication administration, safe and secure home. 3

In order to evaluate the home, the system directs inspectors to evaluate 139 resident care outcomes and process indicators in 30 different care areas. The data collected is then entered into the computer tablets which records and analyzes the data against specific care thresholds. The report generated helps the inspector to identify if further inspection is needed under a stage two in-depth inspection.

If the home has no issues identified under the first stage then at that point the review ends; otherwise further actions are required under stage two. If a care area is triggered then a minimum of three residents must be reviewed for each triggered care area. The computer tablet selects the stage two sample to be conducted. The results of the protocols reviewed in this stage will identify areas of non-compliance and the inspector’s tablet will display the possible sanctions.

A confidential report is then generated using a judgment matrix tool from the tablet. A report is then given to the licensee and a public report is given to the Resident Council and the Family Council. The report is reviewed thoroughly by the Ministry before it is sent to the home.

All Ministry information is shared with the homes, so homes may fully understand how they can improve through further staff education, engage the staff in the home’s quality programs, or review and update the home’s policies and procedures. Homes that are non-compliant are expected to see compliance achieved on the next unannounced inspection. The public inspection report must also be posted in the home.

Actions or sanctions taken by the Inspector are based on severity, scope and compliance history, and these actions may include the following: written notification, voluntary plan of correction, issuance of a compliance or work order and activity order, or referral to the Ministry Director when the severity of the non-compliance is beyond the scope of inspector, and an issuance of non-compliance is made to the licensee of the home 3.

The industry is continuing to lobby for further funding from the Ministry of Health to work with the new Act and regulations. The dedication and commitment of healthcare workers in longterm care across the province are the key factor in providing the best quality of care to our residents.

Christina Bisanz, CEO of the OLTCA interviewed on CBC December 22, 2010 has stated that “the OLTCA agrees that a strong regulatory and compliance framework is an integral part of delivering care to Ontario’s oldest, frailest and most vulnerable citizens. It is important that new regulations be implemented and enforced in a consistent way that ensures transparency and follow up.”

Bisanz further stated that, “considerable positive change has occurred in the past two years, and especially since the introduction of the Long Term Care Homes Act on July 1 of 2010, which holds, as a fundamental principle, that long term care homes are primarily the home of its residents.”

The nutritional component of resident care has been recognized by the Ministry of Health by ensuring that in the new regulations Registered Dietitian time in all homes increased from a minimum of 15 minutes/resident/month to a minimum of 30 minutes/resident/month.

The importance of nutrition, hydration and dining in improving care and quality of life is very evident in this process as dining observation is one of the first mandatory audits to occur during the home’s inspection.

Additional audits which may be triggered at stage two include nutrition and hydration, food quality and snack observation. These continue to reflect the many opportunities throughout the day not only to improve each resident’s nutrition and hydration but also to enhance the quality of life through their enjoyment of meals and snacks.

As Registered Dietitians working with residents in LTC homes, we anticipate that this standardized framework will provide information to continue to develop evidence-based practice to guide effective nutrition and hydration care while maximizing residents’ enjoyment of meals and snacks in their home.

Dietitians of Canada supports the changes and increased standardization in the inspection process throughout Ontario and the recognition that increased dietitian time in each of the homes is essential to improve quality care for the long term care residents in Ontario.