Simon's Megalomaniacal Legal Resources

Retirement Homes (Ontario)
Legal Guide

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Chapter 4 - Care Plans and Care Standards

1. Overview
   
2. Care Plans
   (a) Overview
   (b) Written Copies Required
   (c) Care Plan Assessments
   (d) Development of Care Plan
   (e) Care Plan Approval
   
3. Care Standards
   (a) General
   (b) Care Standards by Care Services
   . (i) Temperature
   . (ii) Cleanliness
   . (iii) Pest Control
   . (iv) Maintenance
   . (v) Food Preparation
   . (vi) Hazardous Substances
   . (vii) Risk of Falls
   . (viii) Behaviour Management
   . (ix) Emergency Plans
   . (x) Infection prevention and Control program
   . (xi) Drugs
   . (xii) Assistance with Bathing
   . (xiii) Continence Care
   . (xiv) Assistance with Dressing
   . (xv) Assistance with Personal Hygiene
   . (xvi) Assistance with Ambulation
   . (xvii) Provision of a Meal
   . (xix) Dementia Care Program
   . (xx) Provision of Skin and Wound Care
   . (xxi) Assistance with feeding
   
4. Reduction of Care Services
   
5. Consideration of a Nursing Home
   
6. Staff and Volunteers
   (a) Staff and Staff Training
   (b) Volunteers
   (c) Police Records Checks
   
7. Resident Money
   (a) Prohibitions Regarding Resident Money
   (b) Trust Held by Licensee
   
8. Record-keeping

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1. Overview

This chapter is mostly about care plans, care standards and staff training. As mentioned in Chapter 1, the essential distinguishing feature of retirement homes from regular tenancies is the inclusion of at least two 'care services' in the contract [RHA 2(1)].

For convenience I repeat the care service list here:

RHA s.2(1)
“care service” means,

(a) a prescribed health care service provided by a member of a College as defined in the Regulated Health Professions Act, 1991,

(b) administration of a drug, as defined in the Drug and Pharmacies Regulation Act, or another substance,

(c) assistance with feeding,

(d) assistance with bathing,

(e) continence care,

(f) assistance with dressing,

(g) assistance with personal hygiene,

(h) assistance with ambulation,

(i) provision of a meal.

2. Care Plans

(a) Overview

Each resident shall have and the licensee shall comply with a 'care plan' which shall list the following [RHA 62(4,10)]:

• care services that the resident is entitled to receive from the RH, "whether or not the resident receives the services" [this means the resident may decline the services] with details, goals and "clear directions to the licensee’s staff who provide direct care to the resident";
  
  
• if the resident has consented to the inclusion of services from external care providers, and - to the extent that the licensee can reasonably obtain such information on the services - details and goals of the services;
  
  
• if given, an information release from the resident to the RH, allowing the RH to collect, use and disclose information from and with external care providers, and with others.

The licensee shall document the provision, outcomes and effectiveness of the care plan [RHA 62(11)].

(b) Written Copies Required

The care plan must be provided to the resident in writing "as soon as possible after the ... plan of care is developed" and "whenever the resident or any of the resident’s substitute decision-makers, if any, reasonably requests a copy" afterwards [Reg 8]. This wording indicates that residents may request a copy even after they have been given one earlier, in case of loss or otherwise.

(c) Care Plan Assessments

. Overview

The care plan shall be based on "an assessment of the resident and the needs and preferences of the resident" [RHA 62(1,6)], although no assessments (or re-assessment) may be done without the resident's consent [RHA 62(2)].

. Initial Assessment

The initial assessment shall take place "no later than two days after a resident commences residency in a retirement home" [Reg 43(1), RHA 62(3)], and shall consider [Reg 43(2)]:

• Continence.
  
  
• Presence of infectious diseases.
  
  
• Risk of falling.
  
  
• Known allergies.
  
  
• Dietary needs including known food restrictions.
  
  
• Cognitive ability.
  
  
• Risk of harm to self and to others.
  
  
• Risk of wandering.
  
  
• Needs related to drugs and other substances.

No initial assessment need be done if [Reg 45]:

• "the licensee, a staff member in a retirement home or a member of a College, as defined in the Regulated Health Professions Act, 1991" conducts either an initial or a full assessement "not more than 30 days before the resident commences residency";
  
  
• "the licensee or a staff member conducts a full assessment (below) of the resident not later than two days after the resident commences residency.

. Full Assessment

The full assessment shall take place "no later than 14 days after a resident commences residency", "shall ensure that a full assessment of the resident’s care needs and preferences is conducted" and shall consider [Reg 44(1-2), RHA 62(3)]:

• Physical and mental health.
  
  
• Functional capacity.
  
  
• Cognitive ability.
  
  
• Behavioural issues.
  
  
• Need for care services.
  
  
• Need for assistance with the activities of daily living.
  
  
• The factors considered in an initial assessment (above) [Reg 43(2)].
  
  
• Any other matter relevant to developing a plan of care for the resident.

No full assessment needs be done if "the licensee, a staff member in a retirement home or a member of a College, as defined in the Regulated Health Professions Act, 1991, conducts a full assessment of the resident ... not more than 30 days before the resident commences residency" [Reg 46].

Where the RH has "reason to believe" that the resident may need "dementia care, skin and wound care, or the use of a personal assistance services device" the full assessment shall be "conducted by a member of a College, as defined in the Regulated Health Professions Act, 1991", and - if the "resident’s care needs include dementia care, carried out using a clinically appropriate assessment instrument that is specifically designed for the assessment of dementia and related conditions" [Reg 44(3)].

. Subsequent Assessments

Re-assessments and reviews of the care plan shall be conducted at least every six months, or sooner if [RHA 62(12)]:

. a goal in the plan is met;

. the resident’s care needs change or the care services set out in the plan are no longer necessary; or

. the care services set out in the plan have not been effective.

(d) Development of Care Plan

. Resident's Participation

The resident, the substitute decision-maker and others they designate shall be "given an opportunity to participate in the development, implementation and reviews of the resident’s plan of care" [RHA 62(5), Reg 47].

. Initial Care Plan

The licensee "shall develop an initial plan of care for the resident based on the initial assessment of the resident’s immediate care needs" relevant to the resident’s immediate care needs, "as soon as possible and not later than two days after a resident commences residency" [Reg 47(1)]. This duty is excepted if a complete plan is done in two days after the resident commences residency [Reg 47(3)].

. Complete Care Plan

The licensee shall "(n)o later than 21 days after a resident commences residency in a retirement home", develop and approve [see "Approval of the Care Plan", below] a complete plan that takes into account all issues considered in a full assessment [(c) above] [RHA 62(9), Reg 47(2)].

The care plan shall also set out [Reg 47(4)]:

• any information that is necessary to allow the licensee’s staff to understand the resident’s needs and preferences, including cultural, spiritual and religious preferences and customary routines,
  
  
• the names and contact information of the resident’s substitute decision-makers, if any, and
  
  
• the names of the persons who participated in the development of the plan and whether the resident and his or her substitute decision-makers, if any, participated in the development of the plan.

. Interdisciplinary Care Conference Where Special Needs

Where the assessment "indicates that the resident’s care needs may include dementia care, skin and wound care or the use of a personal assistance services device, the licensee shall ensure that an interdisciplinary care conference is held as part of the development of the resident’s plan of care and that the resident’s plan of care takes into account the results of the care conference" [Reg 47(5)]. The resident or substitute decision-maker (or a designate thereof) shall be given an oppourtunity to participate in the conference [Reg 47(6)].

. Meal Plans

"If one of the care services that the licensee provides to a resident is the provision of a meal, the resident’s plan of care is only complete if it includes a description of the food restrictions, food allergies and food sensitivities of the resident that are known" [Reg 47(7)].

(e) Care Plan Approval

The following people must approve a care plan (and it's revision), and receive a copy from the licensee [RHA 62(9), Reg 48(1-2]]:

• the resident or the resident’s substitute decision-maker;
  
  
• a member of the College of Physicians and Surgeons of Ontario or the College of Nurses of Ontario, or a person acting under their supervision. If the resident's care needs "may include dementia care, skin and wound care or the use of a personal assistance services device", only a member may approve.

3. Care Standards

(a) General

There are a wide variety of care services (below), each with their own standards that, if the care service is offered in the RH, must be maintained by the licensee [RHA 60(1)]. Most require documentation.

Any care services that requires the provider to engage thereby in the practice of medicine, nursing or pharmacy as the case may be, must be performed by a qualified doctor, nurse or pharmacist, respectively [Reg 28].

As well, "(e)very licensee of a retirement home shall comply with all prescribed safety standards for the home, including standards with respect to fire, safety and public health requirements and emergency evacuation plans." [RHA 60(3)]

There are some odd provisions about when the standards apply, temporally, to the licensee. As best I can make out they apply "within the prescribed time period" [RHA 60(5)], and when reference is had to the Regulation (where such things are prescribed) they apply "by the day on which the standard or requirement, as the case may be, first applies to the licensee" [Reg 64.12]. Seems circular to me. Common sense would dictate that the care standards apply while the resident is in legal occupation.

Note:
Any of these care standards may require (in the General Regulation) that "the room in a retirement home that each resident of the home uses as living quarters contain a resident-staff communication and response system" [RHA 60(2)]. If the Reg so requires, the licensee of the home shall ensure that the home meets these requirements. However, there are no Regs to this effect.

(b) Care Standards by Care Services

(i) Temperature

There shall be procedures "in place for responding to extreme hot and cold weather conditions, including detailed practices for addressing failures of any temperature control systems in the home", and the procedures shall be documented. Timely action shall be taken to deal with extreme temperature changes [Reg 16].

(ii) Cleanliness

Common areas of the home, including the floors and any furnishings, equipment and linens in those areas, shall be clean and sanitary. Bathrooms in common areas of the home that are used by residents shall be adequately stocked with supplies including toilet paper. These "routines and methods" used to comply with these duties shall be documented [Reg 17].

(iii) Pest Control

There shall be "procedures in place to keep the home free from pests and to deal with pests in the home", which shall be documented. Timely action shall be taken to deal with pests [Reg 18].

(iv) Maintenance

There shall be "a maintenance program is in place to ensure that the building forming the retirement home, including both interior and exterior areas and its operational systems, are maintained in good repair", which slall include "policies and procedures for routine, preventative and remedial maintenance of" [Reg 19]:

• plumbing fixtures, toilets and sinks located in common areas of the home.
  
  
• heating systems and hot water boilers.
  
  
• if present, ventilation systems, air conditioning systems, hot water holding tanks and computerized systems monitoring the home’s water temperature.
  
  
• if present, equipment, devices, assistive aids, positioning aids and shower grab bars.

(v) Food Preparation

These standards apply "whenever food is prepared in the home." All foods and fluids used in food preparation shall be prepared, stored, and served using methods to prevent contamination and food borne illness. Procedures, and training for staff involved in preparing food in them (with re-training annually), shall be implemented for [Reg 20]:

• the safe handling and storage of food, including how to maintain food at an appropriate temperature and how to practice good hand hygiene.
  
  
• the safe operation, cleaning and sanitizing of all dishes, utensils and equipment involved in food preparation.
  
  
• the separation of clean and dirty dishes during the service of food.
  
  
• the safe disposal of leftover food.
  
  
• appropriate cleaning schedules and sanitation practices.

Anytime food is prepared, at least one person involved in preparing the food holds a current certificate in food handling from the local board of health or an agency of the board of health, or has recently successfully completed a food handling training program equivalent to that offered by a local board of health or an agency of the board of health [Reg 20(4)].

(vi) Hazardous Substances

“Hazardous substance” means a hazardous product as defined in the Hazardous Products Act (Canada). All hazardous substances used by staff of the home or under their control are labelled properly and are kept inaccessible to residents at all times [Reg 21].

(vii) Risk of Falls

The licensee shall develop, document and implement strategies to reduce or mitigate the risk of falls in common areas of the home. If a resident of a retirement home falls in a common area of the home or while being assisted by the licensee or staff, the licensee shall ensure that [Reg 22]:

• there is a timely and appropriate response to the fall;
  
  
• corrective action is taken as necessary to prevent future harm to residents; and
  
  
• the licensee or a staff member documents the fall, the response to the fall and the corrective actions taken, if any.

Otherwise, if a resident falls and the licensee or a staff member becomes aware of the fall, the licensee shall ensure that the licensee or a staff member documents the fall, the response to the fall and the corrective actions taken, if any.

The licensee shall keep a written record of all falls for which the licensee is required to ensure documentation (as above) that occur in each year, evaluate the risk of falls in the home at least annually and keep a written record of each evaluation.

(viii) Behaviour Management

A "written behaviour management strategy" shall be developed and implemented, which shall include [Reg 23]:

• techniques to prevent and address resident behaviours that pose a risk to the resident or others in the home;
  
  
• strategies for interventions to prevent and address resident behaviours that pose a risk to the resident or others in the home;
  
  
• strategies for monitoring residents that have demonstrated behaviours that pose a risk to the resident or others in the home; and
  
  
• protocols for how staff and volunteers shall report and be informed of resident behaviours that pose a risk to the resident or others in the home.

Care service staff coming on shift shall be advised of "each resident whose behaviours require heightened monitoring because those behaviours pose a risk to the resident or others in the home."

(ix) Emergency Plans

The home shall have "(a)n emergency plan that responds to emergencies in the home or in the community in which the home is located", as follows [RHA 60(4), Regs 24-26]:

Generally [Reg 24]


• The emergency plan shall be in writing.
  
  
• In the event of any conflicts or inconsistencies between the emergency plan and the fire code [under the Fire Protection and Prevention Act, 1997], the fire code prevails.
  
  
• "(A)ll arrangements with community agencies, partner facilities and resources that will be involved in responding to an emergency" shall be kept current.
  
  
• The licensee shall, at least annually, test the emergency plan, including arrangements with community agencies, partner facilities and resources that will be involved in responding to an emergency, related to:
  
  - the loss of essential services,
  - situations involving a missing resident,
  - medical emergencies,
  - epidemics and pandemics, and
  - violent outbursts.
  
  
• The licensee shall at least once every two years, conduct a planned evacuation of the retirement home;
  
  "When conducting a planned evacuation of a retirement home ... the licensee may use a stand-in or proxy for a resident if, in the licensee’s opinion, the resident’s participation in the evacuation may cause harm or risk of harm to the resident’s health or safety" [Reg 24(6)].
  
  and
  
  
• The licensee shall keep a written record of the testing of the emergency plan and planned evacuations and of any changes made to improve the emergency plan.
  
  Retirement Homes With the Capacity to Accommodate 10 or Fewer Residents [Reg 26]
  
  
• The emergency plan shall be developed in consultation with the relevant community agencies, partner facilities and resources that will be involved in responding to an emergency.
  
  
• The emergency plan shall identify and address hazards and risks that may give rise to an emergency affecting the home.
  
  
• The emergency plan shall include steps in the evacuation of the home, including a system in the home to account for the whereabouts of all residents in the event that it is necessary to evacuate and relocate residents and evacuate staff and others in case of an emergency.
  
  
• The emergency plan shall require that resources, supplies and equipment vital for the emergency response are set aside, readily available at the home and tested regularly to ensure that they are in working order.
  
  
• The emergency plan shall identify the relevant community agencies, partner facilities and resources that will be involved in responding to an emergency.
  
  
• The emergency plan shall be updated at least annually and that the updating includes contact information for the relevant community agencies, partner facilities and resources that will be involved in responding to an emergency.
  
  Retirements Homes With the Capacity to Accommodate More than 10 Residents [Reg 25]
  
  
• The development of the emergency plan shall include:
  
  . consultation with the relevant community agencies, partner facilities and resources that will be involved in responding to an emergency;
  
  . identification of hazards and risks that may give rise to an emergency affecting the home, whether the hazards and risks arise within the home or in the surrounding vicinity or community, and strategies to address those hazards and risks.
  
  
• The emergency plan provides for:
  
  . Dealing with fires, community disasters, violent outbursts, bomb threats, medical emergencies, epidemics and pandemics, chemical spills, situations involving a missing resident, and loss of one or more essential services.
  
  . Evacuation of the retirement home, including a system in the home to account for the whereabouts of all residents in the event that it is necessary to evacuate and relocate residents and evacuate staff and others in case of an emergency.
  
  . Resources, supplies and equipment vital for the emergency response being set aside and readily available at the retirement home and regular testing of all such resources, supplies and equipment to ensure that they are in working order.
  
  
• Identification of the community agencies, partner facilities and resources that will be involved in responding to an emergency.
  
  
• The emergency plan shall address the following components:
  
  . Plan activation.
  
  . Lines of authority.
  
  . Communications plan.
  
  . Specific staff roles and responsibilities.
  
  
• The licensee shall ensure that the emergency plan for the retirement home is evaluated and updated at least annually and that the updating includes contact information for the relevant community agencies, partner facilities and resources that will be involved in responding to an emergency.

(x) Infection Prevention and Control Program

The home shall have an "infection prevention and control program", as follows [RHA 60(4), Regs 27]:

• The licensee shall consult on an ongoing basis and not less than once a year with the local medical officer of health or designate about identifying and addressing health care issues in the retirement home in order to reduce the incidence of infectious disease outbreaks in the home. A written record of the consultation shall be kept, including a record of when the consultation took place, what was discussed and any recommendations that the local medical officer of health or designate made.
  
  
• The licensee of a retirement home shall ensure that a written surveillance protocol is established in consultation with the local medical officer of health or designate in order to identify, document and monitor residents who report symptoms of respiratory or gastrointestinal illness.
  
  
• The licensee of a retirement home shall ensure that:
  
  . any guidance, advice or recommendations given to retirement homes by the Chief Medical Officer of Health are followed in the retirement home;
  
  . all reasonable steps are taken in the retirement home to follow,
  
  - any directive respecting coronavirus (COVID-19) issued to long-term care homes by the Chief Medical Officer of Health under section 77.7 of the Health Protection and Promotion Act, and
  
  - any guidance, advice or recommendations respecting coronavirus (COVID-19) that are given to long-term care homes by the Chief Medical Officer of Health and made available on the Government of Ontario’s website respecting coronavirus (COVID-19);
  
  . if an infectious disease outbreak occurs in the home, the outbreak is reported to the local medical officer of health or designate (and to the Retirement Homes Regulatory Authority on the same day) and the licensee defers to the officer or designate, as the case may be, for assistance and consultation as appropriate. Processes for meeting this duty shall be established and recorded in writing.
  
  . if there is an increase in the number of symptomatic residents in the home, the increase is reported immediately to the local medical officer of health or designate and that the officer or designate, as the case may be, is consulted. Processes for meeting this duty shall be established and recorded in writing.
  
  
• The licensee of a retirement home shall ensure that each resident and the resident’s substitute decision-makers, if any, are given information about how to reduce the incidence of infectious disease, including the need for and method of maintaining proper hand hygiene and the need for and process of reporting infectious illness.
  
  
• The licensee of a retirement home shall ensure that waterless, alcohol-based hand sanitizer or another form of hand sanitation that provides equivalent protection against infectious disease transmission is available for use by residents and staff in communal resident areas and in staff work areas.
  
  
• The licensee of a retirement home shall ensure that:
  
  . each resident, each member of the staff of the home and each volunteer receive information about the advantages of an annual influenza vaccination and where the vaccination is available;
  
  . each resident is screened for tuberculosis within 14 days of commencing residency in the home, unless the resident has been screened not more than 90 days before commencing residency and the documented results of the screening are available to the licensee;
  
  . each member of the staff has been screened for tuberculosis and all other infectious diseases that are appropriate in accordance with evidence-based practices or, if there are no such practices, in accordance with prevailing practices. The screening for each of the infectious diseases shall have been done using procedures that accord with evidence-based practices or, if there are no such practices, with prevailing practices.
  
  
• The licensee shall ensure that each staff member who works in the retirement home receives training on how to reduce the incidence of infectious disease transmission, including:
  
  . the need for and method of maintaining proper hand hygiene and method of preventing cross contamination, including proper handling of soiled linens, the protection of uniforms, and the separation of clean and dirty items; and
  
  . the need for and process of reporting, providing surveillance of and documenting incidents of infectious illness.

(xi) Drugs

Care services involving the dispensation of drugs or other substances by staff or the licensee are subject to the following regulations. "Drugs" means a drug as defined in the Drug and Pharmacies Regulation Act [Reg 4(1)]:

• Administration of drugs or other substances [Reg 29]
  
  . only prescription drugs may be given,
  
  . the drugs may only be given in accordance with the directions for use specified by the person who prescribed the drugs for the resident,
  
  . the one administering the drugs is trained in procedures applicable to the administration of the drug,
  
  . a member of a appropriate College [doctors, nurses, pharmacists] supervises the administration of the drug or other substance,
  
  . staff involved in the administration of the drug or other substance at the home, must be trained in:
  
  - ways of reducing the incidence of infectious disease, including maintaining proper hand hygiene,
  - the safe disposal of syringes and other sharps, and
  - recognizing an adverse drug reaction and taking appropriate action.
  
  An “adverse drug reaction” means a harmful and unintended response by a resident to a drug or combination of drugs that occurs at doses normally used or tested for the diagnosis, treatment or prevention of a disease or the modification of an organic function [Reg 4(1)].
  
  . no drug is administered by a volunteer.
  
  
• Storage of drugs or other substances [Reg 30]
  
  . the drugs or other substances are stored in an area or a medication cart that:
  
  - is used exclusively for drugs or other substances and for supplies related to drugs or other substances,
  - is locked and secure,
  - protects the drugs or other substances from heat, light, humidity or other environmental conditions that may affect their efficacy, and
  - complies with the manufacturer’s instructions for the storage of the drugs or other substances.
  
  . controlled substances as defined in the Controlled Drugs and Substances Act (Canada) are stored in a separate, double-locked stationary cupboard in the locked area or stored in a separate locked area within the locked medication cart, and an audit of the controlled substances is performed monthly.
  
  
• Medication management system [Reg 31]
  
  . a medication management system shall be established, which includes written policies and procedures, to ensure that all drugs and other substances to be administered to residents of the home are acquired, received in the home, stored, dispensed, administered, destroyed and disposed of correctly as required by law and in accordance with prevailing practices.
  
  . as part of the medication management system, the licensee shall make a current reference text about pharmaceuticals available to all staff who are involved in the administration of a drug or other substance to a resident.
  
  
• Drug Records [Reg 32]
  
  . the person who administered the drug or other substance shall prepare a written record noting the name and amount of the drug or other substance, the route of its administration and the time and date on which it was administered;
  
  . if a drug is administered, there is written evidence that the drug was prescribed by a person who is authorized to prescribe the drug; and
  
  . the administration of drugs and other substances in the home is evaluated at least annually and a written record of each evaluation is kept.
  
  
• Medication error [Reg 33]
  
  “Medication error”, means an act of commission or omission by the licensee or a member of the staff in connection with the prescribing, ordering, storing, labelling, dispensing, administering or distributing of a drug or other substance or the transcribing of a prescription if the act results in harm to a resident of the home.
  
  . if a medication error occurs or if a resident of the home has an adverse reaction to a drug or other substance administered to them by staff, the licensee shall ensure that:
  
  - a written record is prepared documenting the error or reaction and the immediate actions taken to assess and maintain the resident’s health;
  - the error or reaction is reported to the resident, the resident’s substitute decision-makers, if any, and, to the extent that the following persons are known to the licensee: the person who prescribed the drug, the resident’s attending physician or registered nurse in the extended class and any person who provides pharmacy services to the resident;
  - a written record is prepared indicating to whom the error or reaction was reported; and
  - in the case of a medication error, corrective action is taken as necessary to prevent future harm to residents.
  
  . the risk of medication errors and adverse drug reactions in the home shall be evaluated at least annually and a written record kept of each evaluation.
  
  An “adverse drug reaction” means a harmful and unintended response by a resident to a drug or combination of drugs that occurs at doses normally used or tested for the diagnosis, treatment or prevention of a disease or the modification of an organic function [Reg 4(1)].

(xii) Assistance with Bathing [Reg 35]

The staff person bathing the resident shall be "trained to bathe a person of the resident’s characteristics and condition". Bathing shall "respect() the resident’s privacy and preferences, except to the extent that these are contraindicated by a medical condition". Bathing shall be done as frequently as is consistent with the resident’s plan of care.

(xiii) Continence Care [Reg 36]

If continence care is provided as a care service, it shall include a program that:

• measures to promote continence;
  
  
• measures to prevent constipation, including nutrition and hydration protocols;
  
  
• toileting programs; and
  
  
• strategies to maximize the resident’s independence, comfort and dignity, including the use of equipment, supplies, devices and assistive aids.

If the licensee provides continence care products as part of the program, it shall:

• provide products that are based on the resident’s individually assessed needs,
  
  
• provide products that properly fit the resident,
  
  
• provide products that promote the resident’s comfort, ease of use, dignity and good skin integrity,
  
  "Altered skin integrity” means potential or actual disruption of epidermal or dermal tissue, including skin breakdown, pressure ulcers and skin tears or wounds [Reg 4(1)].
  
  
• provide products that promote continued independence wherever possible,
  
  
• provide products that are appropriate for the time of day, and for the individual resident’s type of incontinence, and
  
  
• evaluate the resident’s satisfaction with the products at least annually in consultation with the resident, the resident’s substitute decision-makers, if any, and the staff who provide care services to the resident, and consider the evaluation when purchasing products.

(xiv) Assistance with Dressing [Reg 37]

If dressing is one of the care services provided, the resident shall be assisted with getting dressed as required, is dressed appropriately (suitably to the time of day and the weather), in keeping with his or her preferences, in his or her own clean clothing and in appropriate clean footwear.

(xv) Assistance with Personal Hygiene

If assistance with personal hygiene is provided as a care service, the licensee shall ensure:

• that resident receives individualized personal care, including hygiene care and grooming, on a daily basis;
  
  
• the resident receives oral care to maintain the integrity of oral tissue that includes, to the extent required,
  
  - mouth care in the morning and evening, including the cleaning of dentures, and
  - cuing the resident to brush his or her own teeth or physically assisting the resident to do so if the resident cannot do so, for any reason;
  
  
• the resident receives assistance, if required, to insert and remove dentures;
  
  
• the resident receives preventive and basic foot care services, as required, including the cutting of toenails, to ensure comfort and prevent infection; and
  
  
• the resident receives fingernail care, as required, including the cutting of fingernails.

(xvi) Assistance with Ambulation [Reg 39]

If assistance with ambulation is provided as a care service, the licensee shall ensure that staff use safe transferring and positioning devices or techniques when assisting the resident - and provide the resident help in accessing his or her mobility devices, including wheelchairs, walkers and canes.

(xvii) Provision of a Meal [Reg 40]

If provision of a meal service is provided as a care service, the licensee shall ensure that:

• if the licensee is the sole provider of the resident’s meals, the resident is offered at least three meals per day at reasonable and regular meal hours, a beverage between the morning and midday meals, a snack and a beverage between the midday and evening meals and a snack and a beverage after the evening meal;
  
  
• menus provide adequate nutrients, fibre and energy for the resident, include fresh seasonal foods and are consistent with Canada’s Food Guide;
  
  
• the menu is varied and changes daily;
  
  
• the menu cycle changes at least every 21 days;
  
  
• the menu includes alternative entrée choices at each meal;
  
  
• an individualized menu is developed for the resident if the resident’s needs cannot be met through the home’s menu cycle;
  
  
• the resident is informed of his or her daily and weekly menu options;
  
  
• the resident is given sufficient time to eat at his or her own pace;
  
  
• food service workers and staff assisting the resident are aware of the resident’s diet, special needs and preferences;
  
  
• staff monitor the resident during meals as required;
  
  
• staff and volunteers hold and transport perishable hot and cold food safely; and
  
  
• all dishes, utensils and equipment involved in the provision of a meal and provided by the licensee are clean and sanitary before each use and are cleaned and sanitized after each use.

(xix) Dementia Care Program [Reg 41]

If dementia care is a care service provided, the licensee shall ensure that:

• the program shall include,
  
  . therapies, techniques and activities, including mental stimulation, to maximize the functioning and independence of the resident in the areas of physical, cognitive, sensory and social abilities;
  
  . monitoring the resident for safety and wellbeing;
  
  . therapies, techniques and activities to promote quality of life and wellbeing;
  
  . strategies for communicating with the resident if they have compromised communication and verbalization skills, a cognitive impairment or cannot communicate in the languages used in the retirement home; and
  
  . strategies for identifying and addressing triggers for responsive behaviours if the resident exhibits responsive behaviours.
  
  Responsive behaviours” means behaviours that often indicate [Reg 4(1)]:
  
  
  • an unmet need in a person, whether cognitive, physical, emotional, social, environmental or other, or
    
    
  • a response to circumstances within the social or physical environment that may be frustrating, frightening or confusing to a person.
  
  
• the program shall be developed and implemented in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices;
  
  
• the program shall be supervised by a member of a College, as defined in the Regulated Health Professions Act, 1991, with specific training in dementia care and care of older adults;
  
  
• the program shall be evaluated at least annually and the licensee shall keep a written record of each evaluation.

(xx) Provision of Skin and Wound Care [Reg 42]

If provision of skin and wound care is a care service program provided, the licensee shall ensure:

• the care provided under the program shall include,
  
  - effective skin and wound care interventions;
  - routine skin care to maintain the resident’s skin integrity and prevent wounds;
  - strategies to promote the resident’s comfort and mobility;
  - strategies to promote the prevention of infection, including the monitoring of the resident;
  - strategies to transfer and position the resident to reduce and prevent skin breakdown and to reduce and relieve pressure, including the use of equipment, supplies, devices and positioning aids; and
  - preventive measures, including physiotherapy, nutrition care and proper positioning, if necessary.
  
  
• the program shall be developed and implemented in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices;
  
  
• if a resident who receives care under the program is at risk of altered skin integrity, the licensee shall ensure that the resident promptly receives a skin assessment by a member of a College, as defined in the Regulated Health Professions Act, 1991, who has adequate training in skin and wound care. If such a skin assessment determines that the resident is not exhibiting altered skin integrity, the licensee shall ensure that all necessary modifications are made to the resident’s plan of care that will reduce the risk to the resident of altered skin integrity.
  
  "Altered skin integrity” means potential or actual disruption of epidermal or dermal tissue, including skin breakdown, pressure ulcers and skin tears or wounds [Reg 4(1)].
  
  
• if a resident who receives care under the program is exhibiting altered skin integrity, staff shall ensure that the resident immediately receives the required treatments and interventions under the supervision of a member of the College of Physicians and Surgeons of Ontario or the College of Nurses of Ontario.
  
  
• if a resident who does not receive care under the program is exhibiting altered skin integrity and the licensee or staff of the home are aware or ought to be aware of the resident’s altered skin integrity, the licensee shall ensure that the resident and the resident’s substitute decision-makers, if any, are immediately informed about the risk of harm to the resident and options for obtaining the required treatments and interventions under the supervision of a member of the College of Physicians and Surgeons of Ontario or the College of Nurses of Ontario.

(xxi) Assistance with Feeding [Reg 34]

If one of the care services provided is assistance with feeding, the licensee shall ensure that:

• if there is a dining area in the home, the area contains furnishings and equipment that,
  
  - are suitable for the age of the population being served,
  - allow adequate space for residents and any staff and volunteers assisting them to use the area safely, - are available in sufficient quantities for the number of residents who use the dining area and for the staff and volunteers who assist them;
  
  
• the resident receives assistance, if required, to eat and drink as safely, comfortably and independently as possible, including assistance with any eating aids or assistive devices and any necessary encouragement;
  
  
• the resident receives assistance, if required, to insert his or her dentures before a meal;
  
  
• staff monitor the resident during a meal; and
  
  
• if the resident is unable to independently access snacks and drinks between meals, the resident is given access to those items.

4. Reduction in Care Services

The RH may not reduce care services available in the home to the residents, directly or indirectly, unless it [RHA 44(1)]:

• has delivered directly to each resident or substitute decision-maker a written notice indicating the date the reduction will take effect, at least 90 days before the reduction takes effect [Reg 6];
  
  
• if a resident indicates that he or she is going to continue to reside in the home, has taken reasonable steps to facilitate the resident’s access to any external care providers that the resident needs; and
  
  
• if a resident indicates that he or she is going to cease to reside in the home, has taken reasonable steps to find appropriate alternate accommodation for the resident.

Note:
Section 44(2) of the RHA provides that, if the Regs specify different classes of licensee relating to the provision of care services, that "a retirement home shall not make available to the residents of the home more, fewer or different care services than the types of care services authorized for that class of licence." In other words, no variation in care services without changing the class of license. However, there are no Regs made under this provision, and as such RHs are free to reduce care services on notice as described here.

A corresponding charge reduction on a reduction in care services is not dealt with under the RHA. If a separate charge is made for the care service and it is itemized on the monthly invoice, then deduction should follow accordingly. If not then you may have a restitution case to recover the amount.


5. Consideration of a Nursing Home

There are provisions (couched in euphemistic terms) dealing with duties to provide information to the resident and substitute decision-makers about "alternatives to living in the retirement home", but it is obvious that this is about when an assessment indicates that the resident should be transferred to a nursing home [governed by the Fixing Long-Term Care Act, 2021] [RHA 63(3), Reg 49].

These are triggered when the resident meets the requirements for admission to a long-term care home, or "the resident’s care needs cannot be met at the home" [Reg 49]. Then the licensee shall [RHA 63(3)]:

• provide relevant information to the resident or their substitute decision-maker "about other alternatives to living in the retirement home and information about admission to a long-term care home",
  
  
• if requested by the resident or substitute decision-maker, contact the placement co-ordinator for their area so they can provide more information "about alternatives to living in a retirement home", and
  
  
• the licensee shall document such actions and provide such documentation to the Registrar annually [Reg 49(2)].

6. Staff and Volunteers

(a) Staff and Staff Training

(i) Generally

'Staff', in relation to a retirement home, means every person who works or provides services at the home [RHA 2(1)]:

• as an employee of the licensee,
  
  
• pursuant to a contract or agreement with the licensee, or
  
  
• pursuant to a contract or agreement between the licensee and an employment agency or other third party.

(ii) All Staff

All staff working in the RH shall "have the proper skills and qualifications to perform their duties" and "possess the prescribed qualifications" [RHA 65(1)]. More specifically, the licensee shall ensure that all staff "have received training in" the following [RHA 65(2)]:

• the Residents’ Bill of Rights;
  
  
• the RH's policy to promote zero tolerance of abuse and neglect of residents [see Ch.3 "Procedural Rights", s.7 "Licensee Duty Regarding Abuse and Neglect" re this] [Act 67(4)];
  
  
• the protection afforded for whistle-blowing [see Ch.6: "Enforcement", s.7: "Whistle-Blowing"];
  
  
• the policy regarding the use of personal assistance services devices for residents; [see Ch.5: "Confinement and Restraint", s.3 "'Normal' Restraint and Confinements"];
  
  
• injury prevention;
  
  
• fire prevention and safety;
  
  
• the emergency evacuation plan for the home [see this chapter, s.2: "Care Standards by Care Services", (ix): "Emergency Plans"] [RHA 60(3)];
  
  
• the emergency plan and the infection prevention and control program of the licensee for the home [see this chapter, s.3(b): "Care Standards by Care Services", (ix): "Emergency Plans" and (x) Infection"] [Act 60(4)];
  
  
• "all Acts, regulations, policies of the Authority and similar documents, including policies of the licensee, that are relevant to the person’s duties".
  
  Included in this training is the procedures for persons to make complaints to the licensee [see Ch.6: "Enforcement", s.3 "Complaints to the Licensee"] [Reg 14, RHA 73(1)].

Staff shall receive on-going training in the above matters [under RHA 65(2)] annually [RHA 65(4), Reg 14(2)].

Non-employees (contractors and temporary agency workers) working at the home are exempt from the above-listed training [under RHA 65(2,4)], if "(t)he person is only to provide occasional maintenance or repair services to the home or entertainment or religious or recreational services in the home" and they are "not to provide direct care to residents" [Reg 14(2.1]. Prior to such an exempt worker performing work at the home however, the licensee shall provide them with information regarding "the home’s policy to promote zero tolerance for abuse and neglect of residents, emergency plan and infection prevention and control program" [Reg 14(2.2)].

In the event of staff brought in "emergencies or exceptional and unforeseen circumstances" these requirements [listed above]) may be fulfilled in their first week [RHA 65(3)].

(iii) Additional Training for Staff Who Provide Care Services

Also, staff who additionally provide care services to residents shall, "as a condition of continuing to have contact with residents", receive this additional training [RHA 65(5), Reg 14(3)]:

• abuse recognition and prevention.
  
  
• mental health issues, including caring for persons with dementia.
  
  
• behaviour management.
  
  
• "ways to minimize the need of residents for personal assistance services devices and if a resident needs such a device, the ways of using it in accordance with its manufacturer’s operating instructions, this Act and the regulations."
  
  
• "ways to encourage mental stimulation in residents, ways to provide mental stimulation to residents and the positive effects of encouraging and providing such mental stimulation"; and also training in
  
  
• "each care service offered in the home so that the staff member is able to understand the general nature of each of those services, the standards applicable under the Act to each of those services and the aspects of each of those services that may be relevant to the staff member’s own duties in the home".

In the event of staff brought on in the event of "emergencies or exceptional and unforeseen circumstances" these additional requirements [listed above for staff who directly provide care services] shall be fulfilled as soon as possible, and in any event "no later than six months from the day the person becomes a staff member at the home" [RHA 65(5)(5), Reg 14(4)].

Staff shall receive on-going training in the above matters [under RHA 65(5)] annually [RHA 65(5)(5), Reg 14(5)].

(b) Volunteers

“Volunteer”, in relation to a retirement home, means a person who works in or supplies services to the home, but who is not part of the staff of the home and who does not receive a wage or salary for the services or work that the person provides in the home [RHA 2(1)].

Every retirement home "who allows volunteers to participate in the lives and activities of residents of the home" shall ensure that they are trained in [RHA 66(1)]:

• the emergency plan and the infection prevention and control program of the licensee for the home [see this chapter, s.3(b): "Care Standards by Care Services", (ix): "Emergency Plans" and (x) Infection"] [Act 60(4), 66(1)], and
  
  
• the RH's policy to promote zero tolerance of abuse and neglect of residents [see Ch.3 "Procedural Rights", s.7 "Licensee Duty Regarding Abuse and Neglect" re this] [Act 66(1), 67(4)].

These volunteer requirements do not apply if [RHA 66(2)]:

• "they are occasional volunteers who do not provide direct care to residents of the home";
  
  
• "their work in the home is monitored and supervised in accordance with written policies" of the retirement home; and
  
  
• "they have received information about the matters covered" by the volunteer training described above.

(c) Police Records Checks

Screening measures (police record checks) (except for those under 18), are required for staff and volunteers in retirement homes [RHA 64(1,2)].

The police record check shall be carried out "within six months before the licensee of the home hires the staff member or accepts the volunteer to work in the home" [Reg 13(1)], and it shall be a "vulnerable sector check" under the Police Record Checks Reform Act, 2015 "to determine the person’s suitability to be a staff member or volunteer (SS: the "applicant") in a retirement home and to protect residents from abuse and neglect" [Reg 13(2)].

The applicant shall provide the licensee with a "signed declaration" from an authorized police record check provider, that discloses [Reg 13(3)]:

• every offence with which the person has been charged under the Criminal Code, the Controlled Drugs and Substances Act, the Food and Drugs Act or the Cannabis Act, and the outcome of the charge;
  
  
• every order of a judge or justice of the peace made against the person in respect of an offence under the Criminal Code, the Controlled Drugs and Substances Act, the Food and Drugs Act or the Cannabis Act, including a peace bond, probation order, prohibition order or warrant to arrest,
  
  
• every offence of which the person has been convicted under the Criminal Code, the Controlled Drugs and Substances Act, the Food and Drugs Act or the Cannabis Act.

The applicant (then staff employee) is under an ongoing duty to provide the declaration again each time that [Reg 13(4)]:

• they have been made aware that a charge has been laid or an order has been made against them; or
  
  
• they have been convicted or the charge is otherwise disposed of, in the case of a charge.

These police check duties do not apply to staff members who [Reg 13(5)]:

• are non-employment contractors, or persons engaged by the retirement home through "an employment agency or other third party";
  
  
• is only to provide occasional maintenance or repair services to the home;
  
  
• is not to provide direct care to residents, and
  
  
• is to be monitored and supervised by the licensee in accordance with written policies that the licensee has prepared to monitor and supervise persons who provide occasional maintenance or repair services.

Also, these police check duties do not apply to qualified doctors, nurses and pharmacists [Reg 13(6)].


7. Resident Money

(a) Prohibitions Regarding Resident Money

"A licensee, staff member, external care provider or volunteer of a retirement home shall not" [Reg 57.1(1)]:

. borrow money or other property from a resident; or

. "receive or hold a resident’s money or other property", except as per (b) below ['Trust Held by Licensee'] or "for the payment of rent, care services or other legitimate charges connected to the retirement home".

There is a exemption to these prohibitions where a "licensee, staff member, volunteer or external care provider is related to the resident" [Reg 57.1(2)], although that exception itself does not apply if such activities are prohibited by:

. a written policy of the retirement home, or

. a "contract or agreement between the licensee and a staff member or an employment agency or other third party in respect of the staff member, a volunteer or an external care provider" [Reg 57.1(3)].

'(R)elated to the resident' includes "a person related through adoption, marriage or conjugal relationship outside marriage" [Reg 57.1(4)].

(b) Trust Held by Licensee

At the licensee's discretion, resident's funds may be entrusted to the licensee and the licensee shall establish a trust account under the rules set out under Reg 57. "Reasonable fees" may be charged "as consideration for holding money in trust on behalf of the resident", but no transaction fees. Petty cash systems are allowed [RHA 72, Reg 57].


8. Record-keeping

The licensee shall keep records on the residents. Such records shall include documentation such as information consents, care assessments, care plans, agreements with the licensee, next-of-kin, doctors, health numbers, medical history and more [Reg 55(1-4), 56]. As well, they shall keep staff member files regarding police checks, skills and qualifications, and more [Reg 55(5), 56].