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Ministry of Health and Long Term Care Performance Improvement and Compliance Branch Compliance Management Program

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Ministry of Health and Long Term Care Performance Improvement and Compliance Branch Compliance Management Program. Presentation to the North East Family Councils Network May 1, 2009 Presentation by: Monique Berger. Compliance Inspection and Enforcement Overview.

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Ministry of Health and Long Term Care Performance Improvement and Compliance BranchCompliance Management Program

Presentation to the North East Family Councils Network

May 1, 2009

Presentation by: Monique Berger

compliance inspection and enforcement overview
Compliance Inspection and Enforcement Overview
  • It is designed to safeguard residents’ rights, safety, security, quality of care and quality of life.
  • It provides a framework for evaluating LTC homes’ compliance with Ministry’s requirements as defined through applicable legislation, service agreements, and LTC Homes Program Manual, which sets out standards for care, services and operations.
  • It is the monitoring arm of Ministry’s accountability framework in administering the Service Agreements entered into with LTC homes.
compliance inspection and enforcement framework
Compliance Inspection and Enforcement Framework


  • Nursing Homes Act
  • Charitable Institutions Act
  • Homes for the Aged and Rest Homes Act
  • Regulations under these Acts

LTC Home Program Manual

  • Sets out requirements for care, services and operations
ltc home program manual standards criteria
LTC Home Program Manual - Standards & Criteria
  • The LTC Home Program Manual is the source of operational policies and standards and criteria for resident care and services.
  • MOHLTC retains responsibility for the LTC Home Program Manual.
  • LTC Home Program Manual may change in purpose when new legislation is proclaimed. The focus of the LTCH Program Manual may change to incorporate interpretive guidelines as the homes will be inspected based on a consistent piece of legislation and accompanying regulations.
ltc home program manual standards criteria1
LTC Home Program Manual - Standards & Criteria
  • Resident safeguards: Resident Rights, Restraints, Advocacy and Resident’s Council
  • Resident Care and Services: Assessment, Care Planning, Care according to assessed needs, evaluation of care and services.
  • Nursing Services: Nursing Care, Medication Administration, Role and Responsibility of Director of Care
  • Volunteer Services: Orientation &Training
  • Staff Education: Orientation and ongoing Training for all Staff
ltc home program manual standards criteria2
LTC Home Program Manual - Standards & Criteria
  • Recreation and Leisure Services: Resident needs and Programs
  • Facility Organization & Administration: CQI, Risk Management, Infection Control, Health and Safety, Disaster Planning and Record Management
  • Medical Services: Medical Director and Attending Physician Services
  • Environmental Services: Housekeeping, Laundry, Maintenance, Safety and Building Services
  • Nutritional and Dietary Services: Meal Production, Meal service and Nutritional care
  • Pharmacy Services: Responsibilities of Pharmacist, Quality Management


  • Compliance Advisors (Registered nurses)
  • Dietary Advisors (Registered dietitians)
  • Environmental Health Advisors (Certified public health inspectors)
authority of inspectors
Authority of Inspectors
  • For the purposes of the Acts and the Regulations, the Minister appoints inspectors.
  • To determine compliance with the Acts, Regulations, license and service agreements.
  • The Acts, Regulations, LTC Home Program Manual and other Ministry policies provide the basis for all inspections conducted by inspectors.
    • LTC Home Program Manual has been the basis for the standard inspection tools used by inspectors.
compliance staff role lapadd
Compliance Staff Role  LAPADD

Look– observe, listen to what is happening in a home, review charts, talk to operators, management, staff, families, tour, record relevant information

Assess – compare observations in relation to Ministry expectations

Point– to “gaps” with respect to Ministry expectations, notify of instances were requirements are not being met, bring forward “best practices” and ideas to consider to support meeting of compliance, point to to other initiatives within broader LTC home sector

Apply– decision-making framework

Decide– on appropriate course of action/sanction as necessary

Direct – homes to develop and implement a plan of corrective actions as necessary to rectify all instances of non-compliance

decision making framework for non compliance
Decision-Making Framework for Non-Compliance
  • Severity – degree of harm (conditions have been observed that pose actual or potential risks to a resident’s health, safety, welfare or rights);
  • Prevalence – frequency of risk or harm (conditions that have been observed that are prevalent or recurring; conditions may or may not be serious);
  • Recurrence – pattern of non-compliance (conditions have been identified during previous reviews, but have not been corrected within the negotiated time frame for corrective action);
  • Negligence or Lack of due diligence – appropriate actions not taken to prevent or mitigate risk/ harm; or the home has not taken prompt measures to initiate corrective action.
compliance inspection activities
Compliance Inspection Activities
  • Annual Reviews
  • Investigations of complaints submitted by residents/families and the general public by compliance staff
  • Inspections on reports of Critical Incidents where required
  • Follow-up inspections on compliance plan submissions by LTC homes and follow-up visits by compliance staff to ensure compliance
  • Referral visits by Dietary and Environmental Health Advisors
compliance inspection activities1
Compliance Inspection Activities
  • Special inspection visits by any compliance staff
  • Pre-occupancy visits for new homes
  • Pre-occupancy, pre-sale and post-sale comprehensive reviews by compliance, dietary and environmental health advisors
  • Utilize standardized audit tools to conduct reviews
recent and upcoming changes
Recent and Upcoming Changes
  • 3 Acts/regulations + LTC Facility manual One act & regulations (Bill 140)
  • Moving to a risk management framework which will trigger inspections
  • Appeal process to be implemented (Bill 140)
  • Regional Office reporting to manager/regional director Service Area office with local manager, reporting to corporate manager/director
  • 7 Regional offices 5 Service Area Offices
  • Regions LHIN Areas
  • Info Line: 1-866-434-0144 – public complaint reporting
  • Public Website: : provides information:
    • On individual homes and their record of care.
    • Home profiles, outcome of selected compliance inspections and verified concerns of compliant investigations for a 12-month period.
    • Updated approximately every three months.