COMPLIANCE OVERVIEW AND CHECKLIST Phases 1 and 2 · Compliance Overview and Checklist Page 4 of 39 Introduction . This Compliance Overview (Overview) provides a list of the standards

COMPLIANCE OVERVIEW AND CHECKLIST

Phases 1 and 2

Retirement Homes Act, 2010

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Compliance Overview and Checklist Page 2 of 39

Disclaimer This overview is solely for educational purposes. It is not legal or professional advice. Readers must not rely on it to provide such advice, either generally or with respect to a particular question or issue. The overview has no legal effect. It is not an official legal interpretation of the Retirement Homes Act, 2010 (Act). You should consult this overview in conjunction with the Act and its regulations. Consult your legal counsel if you have questions about the application or interpretation of the Act.

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Contents Introduction ................................................................................................................................................ 4 Phased Implementation ............................................................................................................................. 4 Instructions and Definitions ....................................................................................................................... 5 Summary of Compliance Requirements ................................................................................................... 6 Compliance Overview: Phase 1 ................................................................................................................. 7 Posted information .............................................................................................................................. 7 Reporting certain matters to the Registrar .......................................................................................... 7 Whistle-blowing protections ................................................................................................................ 8 Compliance Overview: Phase 2 ................................................................................................................. 9 Reduction in care services .................................................................................................................... 9 Residents’ Bill of Rights ....................................................................................................................... 10 Resident agreements .......................................................................................................................... 10 Information package for residents ..................................................................................................... 12 Public information .............................................................................................................................. 15 Additional posted information ........................................................................................................... 15 Residents’ Council ............................................................................................................................... 17 Safety standards ................................................................................................................................. 19 External care providers ....................................................................................................................... 20 Information about external care providers ........................................................................................ 20 Obligations of licensees re staff and staff training ............................................................................. 21 Protection against abuse and neglect ................................................................................................ 21 Restraints and personal assistance services devices .......................................................................... 25 Procedure for complaints to licensee ................................................................................................. 32 Licensee’s duty to respond to incidents of wrongdoing ..................................................................... 35 Notice of certain events ...................................................................................................................... 35 Records (content, format and retention) ........................................................................................... 36 Conclusion ................................................................................................................................................ 38 Contact ...................................................................................................................................................... 38

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Introduction This Compliance Overview (Overview) provides a list of the standards and requirements that operators of retirement homes must meet under the new Retirement Homes Act, 2010 (Act) and its regulations as of July 1, 2012. The Retirement Homes Regulatory Authority (RHRA) is the licensing body and regulator of retirement homes in Ontario. The RHRA’s purpose for developing the Overview is to educate and assist licensees to understand the requirements under the Act that came in force on or before July 1, 2012. Licensees may also use the Overview to assess their home’s level of compliance. The Overview is not a compliance requirement. Completion of the checklist in the Overview is strictly voluntary. Although the Overview identifies relevant sections of the Act and regulations, it is not an exhaustive list of every compliance item in force as of July 1, 2012. For example, the Overview does not include a review of the requirements for complying with orders of the Registrar (sections 90 and 91 of the Act) or for providing certain requested information to the Registrar (section 108).

When completing the Overview, operators should refer to the Act and the regulations together. Unless stated otherwise, “regulation(s)” refers to Ontario Regulation 166/11. Relevant resources and where to find them, including the Act and the regulations, are set out at the end of the Overview.

Phased Implementation The Government of Ontario is phasing in the requirements of the Act over the period until January 1, 2014. The dates on which each phase of requirements comes into force are as follows:

Phase Compliance Date

1 April 15, 2012 (incorporating the mandatory reporting measures that came into force May 17, 2011)

2 July 1, 2012

3 January 1, 2013

4 July 1, 2013

5 January 1, 2014

This is the first version of the Overview. It reflects the requirements that came into force on or before July 1, 2012 (Phase 1 and Phase 2). The RHRA will release new versions of the Overview before the start of each subsequent phase.

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Instructions and Definitions While completing the checklists in the Overview, homes should review the summary at the beginning of each compliance area, together with the referenced section of the Act and/or regulation, as applicable. The checklists contain space for notes, which the licensee may use to track questions about the specific item, or if the licensee is unsure whether the home is compliant. The Overview uses the term “home” to refer to a retirement home. “Licensee” refers to the operators of homes that have been issued an RHRA licence, and homes with “deemed” status (those who applied for a licence before July 3, 2012 but who have not yet been issued a licence). “Resident” refers to a resident of a retirement home.

Definitions for other terms used in the Overview can generally be found in section 2 of the Act and section 4 of the regulation. Other definitions and/or interpretive information are located in the various sections of the Act and regulation. By way of example, the “personal assistance services devices” definition is located in section 50 of the Act. Licensees should refer to the definitions in the Act and regulations as they complete the checklist. In some instances, the definition or relevant information is included within the table for easy reference.

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Summary of Compliance Requirements

Key requirements relating to compliance in force as of April 15, 2012

1. Posted information: subsection 55 (2) para. 4, Act; subsection 3 (1), O. Reg. 165/11

2. Reporting certain matters to the Registrar: section 75, Act

3. Whistle-blowing protections: section 115, Act

Key requirements relating to compliance in force as of July 1, 2012

4. Reduction in care services: section 44, Act; O. Reg. 166/11, s. 6

5. Residents’ Bill of Rights: section 51, Act

6. Resident agreements: section 53, Act; O. Reg. 166/11, s. 8, 9

7. Information package for residents: subsections 54 (1), (2) (a – p)(s)(t), Act; O. Reg. 166/11, s. 10(d)(g)(h)

8. Public information: subsection 55 (1), Act

9. Additional posted information: subsection 55 (2), Act; O. Reg. 166/11, s. 11

10. Residents’ Council (except Residents’ Council assistant): sections 56, 58 & 59, Act; O. Reg. 166/11, s. 12

11. Safety standards: subsections 60 (3), 60 (4) para. 1 and 5, Act; O. Reg. 166/11, s. 24 – 26

12. External care providers: section 61, Act

13. Information about external care providers: subsection 63 (1), Act

14. Obligations of licensees re staff and staff training: subsection 65 (1) (a), (2) (a – d), (f) & (i), Act

15. Protection against abuse and neglect: section 67, Act; O. Reg. 166/11, s. 15

16. Restraints and personal assistance services devices (PASDs): sections 68, 69 & 71, Act; O. Reg. 166/11, s. 51, 52, 53 & 54

17. Procedure for complaints to licensee: section 73, Act; O. Reg. 166/11, s. 59

18. Licensee’s duty to respond to incidents of wrongdoing: section 74, Act

19. Notice of certain events: section 109, Act; O. Reg. 166/11, s. 63

20. Records (content, format and retention): O. Reg. 166/11, s. 55 (1) & (5) (c) & 56

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Compliance Overview: Phase 1 Phase 1: COMPLIANCE DATE – April 15, 2012

The following requirements are in force as of April 15, 2012. 1. Posted information: subsection 55 (2) para. 4, Act; subsection 3 (1), O. Reg. 165/11 The licensee must post information about reporting matters related to the care and safety of residents (i.e., mandatory reporting for abuse and neglect of residents) on a sign that the Registrar provides or approves.

Item Yes No N/A Compliance Item – Posted Information Act/Reg. Has the home posted the following information in a

conspicuous and easily accessible place: Act s. 55 (2) para. 4

1.1

Information about reporting matters to the Registrar about the care and safety of residents (e.g. Section 75 abuse or neglect of a resident resulting in harm or risk of harm; improper/incompetent care or treatment of a resident resulting in harm or risk of harm; unlawful conduct resulting in harm to a resident; or misuse/misappropriation of a resident's money) on a sign the Registrar provides or that is in a form the Registrar approves?

Reg. 165/11 s. 3 (1)

NOTES

2. Reporting certain matters to the Registrar: section 75, Act The licensee (or other person such as staff of the home) must immediately report and provide information to the Registrar about suspected, alleged or witnessed abuse or neglect of a resident that resulted in harm or risk of harm to a resident, as set out in section 75.

Item Yes No N/A Compliance Item – Reporting to the Registrar Act/Reg. 2.1

The licensee and staff of the home are aware of their responsibility to report to the Registrar immediately if they have reasonable grounds to suspect that any of the section 75 events (i.e. abuse or neglect of a resident resulting in harm or risk of harm; improper/incompetent care or treatment of a resident resulting in harm or risk of harm; unlawful conduct resulting in harm to a resident; or misuse/misappropriation of a resident's money) has occurred or may occur.

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DEFINITION “Abuse” in relation to a resident, means physical abuse, sexual abuse, emotional abuse, verbal abuse or financial abuse, as may be defined in the regulations (e.g. set out in s. 1, O. Reg. 166/11) in each case [Act, s. 2(1)];

“Neglect” in relation to residents, means the failure to provide a resident with the care and assistance required for his or her health, safety or well-being and includes inaction or a pattern of inaction that jeopardizes the health or safety of one or more residents [Act, s. 2(1)].

NOTES

3. Whistle-blowing protections: section 115, Act No person shall retaliate or threaten to retaliate against another person (including dismissing, suspending or disciplining a member of the staff of the retirement home or evicting a resident from the home) who has disclosed anything to the Registrar or inspector, or has provided evidence in a proceeding or in a coroner’s inquest, as set out in subsection 115 (1).

Item Yes No N/A Compliance Item – Whistle-Blowing Act/Reg. 3.1

The licensee is aware that no person may retaliate or threaten to retaliate against another person, whether by action or omission, in circumstances where a person has disclosed information and/or provided evidence to the Registrar or to an RHRA inspector.

Act s. 115 (1)

DEFINITION “Retaliate” means: 1. Dismissing, suspending or disciplining a staff member of a retirement home. 2. Evicting a resident from a retirement home. 3. Subjecting a resident of a retirement home to discriminatory treatment. 4. Imposing a penalty on any person. 5. Intimidating, coercing or harassing any person [Act s. 115 (2)].

NOTES

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Compliance Overview: Phase 2

Phase 2: COMPLIANCE DATE - July 1, 2012

The following requirements are in force as of July 1, 2012. 4. Reduction in care services: section 44, Act; O. Reg. 166/11, s. 6 Section 44 of the Act requires the licensee to provide 90 days written notice to residents before reducing the number of care services it makes available in the home. In certain circumstances, the licensee must also take reasonable steps to provide assistance to residents in connection to the reduction of care services.

Item Yes No N/A Compliance Item – Reduction in Care Services Act/Reg.

If the licensee reduces the care services it makes available in the home, either directly or indirectly, to the residents:

4.1

a) Does the licensee deliver a written notice to each resident indicating the date the reduction will take effect at least 90 days before the reduction takes effect?

Act s. 44 (1) (a) Reg 166/11, s. 6

NOTES 4.2

b) Does the licensee give the substitute decision maker (SDM), if any, the written notice indicating the reduction at least 90 days before the reduction takes effect?

Act s. 44 (1) (b) Reg 166/11, s. 6

NOTES 4.3

c) Does the licensee take reasonable steps to facilitate the resident’s access to any external care providers, if the resident indicates he/she intends to continue to reside in the home?

Act s. 44 (1) (c)

NOTES 4.4

d) Does the licensee take reasonable steps to find appropriate alternate accommodation for the resident if the resident indicates he/she intends to cease residing in the home?

Act s. 44 (1) (d)

NOTES

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5. Residents’ Bill of Rights: section 51, Act

The licensee must fully respect and promote the Residents’ Bill of Rights, as set out in subsection 51 (2), Act.

Item Yes No N/A Compliance Item – Residents’ Bill of Rights Act/Reg. 5.1

Does the licensee ensure the Residents’ Bill of Rights, set out in subsection 51 (1) of the Act, are fully promoted and respected in the home?

Act s. 51 (2)

NOTES

6. Resident agreements: section 53, Act; O. Reg. 166/11, s. 8, 9 The licensee must enter into a written agreement with every resident of the home before the resident starts residing in the home. The agreement must contain the information set out in section 9 of the regulation. The licensee must provide a copy of each written agreement between the licensee and the resident, to the resident or his or her SDM, in accordance with section 8 of the regulation.

Written agreements

Item Yes No N/A Compliance Item – Resident Agreements Act/Reg. 6.1

Is there a written agreement between the licensee and every resident who started residing in the home after July 1, 2012?

Act s. 53 (1) Reg. 166/11 s.64.8

NOTES

6.2 Is the agreement written in plain language that is clear

and concise? Act s. 53 (3)

NOTES

Contents of agreements

Item Yes No N/A Compliance Item – Contents of Agreements Act/Reg. Does the written agreement contain the following

elements: Act s. 53 (2)

6.3 a) the heading “Retirement Homes Act, 2010 Provisions”

or equivalent if in another language? Reg. 166/11 s. 9 (a)

NOTES

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6.4

b) a notice that an RHRA inspector/investigator may inspect, copy and remove resident records containing personal/personal health information from the home for compliance purposes?

Reg. 166/11 s. 9 (b)

NOTES

6.5

c) a statement as to whether or not the licensee will indemnify the resident against loss of the resident’s possessions and if so, the details of the indemnification?

Reg. 166/11 s. 9 (c)

NOTES

6.6

d) a statement that the information package required in the Act has been given to the resident, that the package contains all required information, and that the package is accurate and complete on the date of the agreement?

Reg. 166/11 s. 9 (d)

NOTES

Copies of agreements to residents

Item Yes No N/A Compliance Item – Copies of Agreements Act/Reg. Does the home provide the resident (or the resident’s SDM,

if applicable) with a copy(s) of: Reg. 166/11 s. 8

6.7 a) the resident’s plan of care, if any? Reg. 166/11 s. 8

NOTES INFORMATION Requirements relating to plans of care are not in force and will come into force in phases,

starting on January 1, 2013 (plan of care for new residents). 6.8

b) each written agreement between the licensee and the resident?

Reg. 166/11 s. 8

NOTES

6.9

Does the licensee provide the resident (or the resident’s SDM, if applicable) with the required copy(s) as soon as possible after the agreement(s) is made or plan of care developed?

Reg. 166/11 s. 8 (a)

NOTES 6.10

Does the licensee provide the resident (or the resident’s SDM, if applicable) with copies of the plan of care or agreement whenever reasonably requested?

Reg. 166/11 s. 8 (b)

NOTES:

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7. Information package for residents: subsections 54 (1), (2) (a – p)(s)(t)Act; O. Reg. 166/11, s. 10

(d)(g)(h) The licensee must give each resident a package of information before the resident starts living in the home. Section 54 (2) of the Act and section 10 of the regulations list the content that must be in the package. The package must be accurate and homes must revise it as necessary and provide any revisions to residents.

Information package

Item Yes No N/A Compliance Item – Information Package Act/Reg. 7.1

Does the home provide an information package to every resident (or his or her SDM, if any) before the resident commences residency in the home?

Act s. 54 (1) (a)

NOTES

7.2

Does the home make an information package available to family members or persons of importance to the resident if the resident or his or her SDM, if any, so consents?

Act s. 54 (1) (b)

NOTES 7.3

Is the package of information accurate and revised as necessary?

Act s. 54 (1) (c)

NOTES 7.4

Does the home provide material revisions to the package to current residents of the home and to other persons who received the original package?

Act s. 54 (1) (d)

NOTES

Contents of the information package

Item Yes No N/A Compliance Item – Contents of Information Package Act/Reg. Does the information package include the following

information/statements: Act s. 54 (2)

7.5 a) the Residents’ Bill of Rights? Act s. 54 (2) (a)

NOTES 7.6

b) if the retirement home also falls within the meaning of a “care home” as defined in the Residential Tenancies Act, 2006 (RTA), a statement that nothing in the Retirement Homes Act overrides or affects the provisions of the RTA?

Act s. 54 (2) (b)

NOTES

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7.7

c) the licensee’s policy to promote zero tolerance of abuse and neglect of residents [as required by s. 67 (4) of the Act]?

Act s. 54 (2) (c)

NOTES

7.8 d) the complaints procedure for the home [as required by

s. 73 (1) of the Act]? Act s. 54 (2) (d)

NOTES

7.9

e) the licensee’s policy for the use of PASDs (personal assistance services devices) in the home [as required by s. 68 (3) of the Act]?

Act s. 54 (2) (e)

NOTES

7.10 f) the name, telephone number and e-mail address of the

licensee? Act s. 54 (2) (f)

NOTES

7.11 g) information about the role of the RHRA and its contact

information? Act s. 54 (2) (g)

NOTES

7.12

h) information about the Residents’ Council, including information provided by the Residents’ Council for inclusion in the package?

Act s. 54 (2) (h)

NOTES

7.13 i) an explanation of the protection afforded for whistle-

blowing described in section 53 of the Act? Act s. 54 (2) (i)

NOTES

7.14

j) information relating to the contents of the written agreement between residents and the home (required under section 53 of the Act)?

Act s. 54 (2) (j)

NOTES

7.15

k) an itemized list of the different types of accommodation and care services provided in the retirement home and their prices?

Act s. 54 (2) (k)

NOTES 7.16

l) a statement that a resident may purchase or apply for

care services, other services, programs or goods from external care providers?

Act s. 54 (2) (l)

NOTES

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7.17

m) information about the home’s process for assisting residents to purchase or apply for care services and other services, programs or goods from external providers?

Act s. 54 (2) (m)

NOTES 7.18

n) information regarding the rights of residents if the home

chooses to reduce or discontinue the care services that the home provides to residents?

Act s. 54 (2) (n)

NOTES 7.19

o) disclosure of any non-arm’s length relationships that exist between the home and external care providers?

Act s. 54 (2) (o)

NOTES 7.20

p) the contact information for the Community Care Access

Centre for the area in which the retirement home is located?

Act s. 54 (2) (p)

NOTES 7.21

q) information about whether the home has automatic sprinklers in each resident’s room?

Act s. 54(2)(s)

NOTES 7.22

r) information relating to staffing, including night time staffing levels and qualifications of staff of the home?

Act s. 54(2)(t)

NOTES

Does the information package include the following additional information/statements: Reg. 166/11 s. 10

NOTES 7.23

a) a statement regarding whether the home offers programs, activities or services to address the social, recreational and spiritual needs of residents and information about them?

Reg. 166/11 s. 10 (d)

NOTES 7.24

b) a statement as to whether services in the home are

provided in French or in any other languages and a list of those languages?

Reg. 166/11 s. 10 (g)

NOTES 7.25

c) a statement regarding the prohibition of restraints except under the common law duty (s. 71 of the Act) when immediate action is necessary to prevent serious bodily harm to a resident or to others?

Reg. 166/11 s. 10 (h)

NOTES

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7.26

d) a statement that sections 77 and 80 of the Act authorize an inspector or an investigator respectively to inspect, copy and remove records containing a resident’s personal information, including personal health information from the home for the purpose of determining whether the licensee is in compliance with the requirements of the Act?

Reg. 166/11 s. 10 (k)

NOTES

8. Public information: subsection 55 (1), Act The licensee must ensure that certain information is available in the home in an easily accessible location in the home.

Item Yes No N/A Compliance Item – Public Information Act/Reg. Does the operator make the following information available

and easily accessible in the home: Act s. 55 (1)

8.1 a) The retirement home’s information package? Act s. 55 (1) para. 1 NOTES 8.2

b) Copies of final reports done by RHRA inspectors under section 77 in the previous two years?

Act s. 55 (1) para. 2

NOTES 8.3

c) Orders made by the Registrar regarding the home that

are in effect or that have been made in the previous two years?

Act s. 55 (1) para. 3

NOTES 8.4

d) Decisions of the Licence Appeal Tribunal or the

Divisional Court with respect to the home within the previous two years?

Act s. 55 (1) para. 4

NOTES 8.5

e) Minutes of the most recent Residents’ Council meeting, if disclosure is permitted by the Resident’s Council?

Act s. 55 (1) para. 5

NOTES

9. Additional posted information: subsection 55 (2), Act; O. Reg. 166/11, s. 11 The licensee must ensure that certain information is posted in a conspicuous and easily accessible place in the home.

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Item Yes No N/A Compliance Item – Posted Information Act/Reg. Has the home posted the following information in a

conspicuous and easily accessible place: Act s. 55 (2)

9.1 a) The Residents’ Bill of Rights? Act s. 55 (2) para. 1 NOTES 9.2

b) The retirement home’s licence? Act s. 55 (2)

para. 2

NOTES 9.3

c) An explanation of the measures to be taken in case of fire?

Act s. 55 (2) para. 3

Has the home posted the following additional information in a conspicuous and easily accessible place:

Act s. 55 (2) para. 4

9.4 i. Contact information for the RHRA? Reg. 166/11 s. 11, para. 1

NOTES 9.5

ii. A statement as to whether services in the home are

provided in French or in any other and a list of those languages?

Reg. 166/11 s. 11, para. 2

NOTES 9.6

iii. Information about reporting to the Registrar matters relating to the care and safety of the residents of the home that is on a sign that the Registrar provides or approves?

Reg. 166/11 s. 11, para. 4

NOTES

9.7

iv. A statement that sections 77 and 80 of the Act authorize an RHRA inspector or an investigator to inspect, copy and remove records containing a resident’s personal and personal health information, from the home for the purpose of determining whether the home is in compliance with the requirements of the Act?

Reg. 166/11 s. 11, para. 5

NOTES

9.8 v. A copy of the most recent final inspection report

prepared by an RHRA inspector? Reg. 166/11 s. 11, para. 6

NOTES

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10. Residents’ Council (except Residents’ Council assistant): sections 56, 58 & 59, Act; O. Reg.

166/11, s. 12 The licensee must allow the residents to establish a Residents’ Council (Council). The licensee must respond to Council care and safety recommendations or concerns about the operation of the home within 10 days, as set out in section 56. The licensee must consult regularly and cooperate with the Council, as set out in section 58, and it must provide information and assistance in accordance with section 12 of the regulation. Residents’ Council in the home

Item Yes No N/A Compliance Item – Resident’s Council Act/Reg. 10.1

Does the home allow the residents of the home to establish a Residents’ Council?

Act s. 56 (1)

NOTES INSTRUCTIONS It is not mandatory that a Residents’ Council be formed. If the residents have not established a

Council within the home, skip to Section 9 of the Overview.

INFORMATION The powers of the Residents’ Council are set out in s. 56 (3) of the Act.

Only residents/duty to respond Item Yes No N/A Compliance Item – Residents and Duty to Respond Act/Reg. 10.2

Is membership in the Residents’ Council restricted to residents?

Act s. 56 (2)

NOTES

10.3

Does the licensee respond, in writing, to concerns or recommendations raised by the Council about the operation of the home within 10 days of receiving the advice?

Act s. 56 (4)

NOTES

10.4

Does the licensee respond, in writing, to advice or recommendations provided by the Council to improve care or quality of life in the home within 10 days of receiving the advice?

Act s. 56 (4)

NOTES

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Duties of licensee/meetings with Council Item Yes No N/A Compliance Item – Duties & Meetings Act/Reg. 10.5

Does the licensee not attend a Residents’ Council meeting unless invited and ensure that staff of the home do not attend meetings unless invited to do so?

Act s. 58(3)

NOTES

10.6

Does the licensee cooperate with the Residents’ Council and provide information and/or assistance (e.g. regarding building maintenance, safety and care, food and activities) within 10 days, if the licensee is reasonably able to do so?

Act s. 58 (1) (a) Reg. 166/11 s. 12 (1) (a)

NOTES 10.7

If the requested information and/or assistance is not provided within 10 days, does the licensee, within 10 days, advise the Council of the reason for the delay, the date the information and/or assistance might be provided, and provide it as soon as is reasonably practicable?

Reg. 166/11 s. 12 (2) (a) & (b)

NOTES 10.8

If the requested information and/or assistance cannot be provided, does the licensee advise the Council, within 10 days of receiving the request, of the reasons why the licensee will not be providing the information or assistance?

Reg. 166/11 s. 12 (3)

NOTES 10.9

Does the licensee provide an area within the home that is easily accessible to residents and where the Council can hold private meetings?

Reg. 166/11 s. 12 (1) (b)

NOTES 10.10

Does the licensee make available an area for the Council to post notices/information, etc. that is easily accessible to residents within the home?

Reg. 166/11 s. 12 (1) (c)

NOTES 10.11

Does the licensee consult regularly with the Residents’ Council and at a minimum at least every three months?

Act s. 58 (1) (b)

NOTES 10.12

If invited by the Council, does the licensee or its representative attend the Residents’ Council meetings?

Act s. 58 (2) (a) & (b)

NOTES

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No interference Item Yes No N/A Compliance Item – No Interference Act/Reg. Does the licensee ensure that there is no interference with

the Resident’s Council in relation to: Act s. 58 (4)

10.13 a) Resident’s Council meetings or operations? Act s. 58 (4) (a)

NOTES

10.14

b) charging fees for any purpose relating to the Council’s creation, administration or activities?

Act s. 58 (4) (b)

NOTES

10.15

c) preventing a member of the Residents’ Council from performing any duties as a member of the Council and/or hinder, obstruct or interfere with such a member carrying out those duties?

Act s. 58 (4) (c)

NOTES

10.16 d) ensuring staff members don’t do anything that the licensee is forbidden from doing under clauses 58 (4) (a)(b) and (c)?

Act s. 58 (4) (e)

NOTES

11. Safety standards: subsections 60 (3), 60 (4) para. 1 and 5, Act; O. Reg. 166/11, s. 24 – 26 Section 60 of the Act requires licensees to have an emergency plan that meets the requirements of section 2 and 25 or 26 (as applicable) of the regulations. If the home consults as soon as possible after July 1, 2012 with partner facilities and other entities set out in the regulation about the development of the plan, the licensee has until January 1, 2013 to develop the plan. If the licensee does not consult, it must have an emergency plan as of July 1, 2012.

Safety standards and plans

Item Yes No N/A Compliance Item – Emergency Plan Act/Reg. 11.1

Does the home have an emergency plan that responds to emergencies in the home or in the community in which the home is located and that meets the requirements in the regulations? (The plan is not mandatory until January 1, 2013 if the home meets the consultation requirement under item 11.2 below.)

60 (4), para. 1 Reg 166/11 s. 24-26

NOTES

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11.2

Has the licensee consulted about the development of the emergency plan, or will the licensee consult, as soon as possible, with the relevant community agencies, partner facilities and resources that will be involved in responding to an emergency and have or will the consultations be documented?

Act s. 60 (4), para. 1; Reg 166/11 s. 64.12 (3)

NOTES

11.3 Does the licensee conduct a planned evacuation at least

once every two years? Reg. 166/11 s. 24 (5) (b)

NOTES

12. External care providers: Section 61, Act The licensee must not prevent a resident from accessing care services from an external care provider or interfere with the provision of the care services. The definition of “external care provider” is in section 2 of the Act.

Item Yes No N/A Compliance Item – Access to External Care Providers Act/Reg. 12.1

Does the home allow a resident to access care services from an external care provider of the resident’s choosing?

Act s. 61 (1)

NOTES 12.2

Does the licensee ensure it does not interfere with the provision of care services to a resident by an external care provider (unless interference is required in order to protect the resident from abuse or neglect, or restraining)?

Act s. 61 (2)

NOTES

13. Information about external care providers: subsection 63 (1), Act If a resident requests, the licensee must promptly provide readily available information about external care providers.

Item Yes No N/A Compliance Item – Information Act/Reg.

13.1 Does the licensee promptly provide readily available information to residents about care services offered by external care providers, if requested by the resident?

Act s. 63 (1)

NOTES

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14. Obligations of licensees re staff and staff training: subsection 65 (1) (a), (2) (a – d), (f) & (i), Act Staff members who work in the home must have the proper qualifications and skills to work in the home. Licensees must ensure that staff members receive training in a number of areas before they start work in the home. Staff qualifications and training

Item Yes No N/A Compliance Item – Staff Qualifications & Training Act/Reg. 14.1

Does the licensee ensure that staff who work in the home have the proper skills and qualifications to perform their duties?

Act s. 65 (1) (a)

NOTES

Does the licensee ensure that all staff are trained in the following areas before they start working in the home:

Act s. 65 (2)

14.2 a) Residents’ Bill of Rights? Act s. 65 (2) (a)

NOTES

14.3 b) the home’s policy to promote zero tolerance of abuse

and neglect of residents? Act s. 65 (2) (b)

NOTES

14.4 c) the whistle-blowing protection measures? Act s. 65 (2) (c)

NOTES

14.5 d) the home’s policy on the use of PASDs? Act s. 65 (2) (d)

NOTES

14.6 e) fire prevention and safety? Act s. 65 (2) (f)

NOTES

14.7

f) all Acts, regulations, policies of the RHRA and similar documents, including policies of the licensee, relevant to the person’s duties?

Act s. 65 (2) (i)

NOTES

15. Protection against abuse and neglect: section 67, Act; O. Reg. 166/11, s. 15 Section 2 of the Act identifies five types of abuse: physical, sexual, emotional, verbal and financial abuse. Section 1 of the regulations defines each type of abuse. A licensee must protect residents from abuse by anyone and from neglect by staff of the home. The licensee must also have a written policy to promote zero tolerance of abuse and neglect of residents.

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Protection from abuse and neglect and policy to promote zero tolerance of abuse and neglect

Item Yes No N/A Compliance Item – Zero Tolerance of Abuse Policy Act/Reg. 15.1

Does the licensee protect residents of the home from abuse by anyone?

Act s. 67 (1)

NOTES

15.2 Does the licensee ensure that the licensee and the staff of

the home do not neglect residents? Act s. 67 (2)

NOTES

15.3

Does the licensee protect residents who are absent from the home, but who continue to receive care services from the home, from abuse and neglect?

Act s. 67 (3)

NOTES

15.4

Does the licensee have a written policy that promotes zero tolerance of abuse and neglect of residents and does the licensee comply with the policy?

Act s. 67 (4)

NOTES

Contents of policy

Item Yes No N/A Compliance Item – Abuse Policy Content Act/Reg. Does the written policy to promote zero tolerance of abuse

and neglect of residents, at a minimum: Act s. 67 (5)

15.5 a) set out what constitutes abuse and neglect?

Act s. 67 (5) (a)

NOTES 15.6

b) provide that abuse and neglect are not to be tolerated? Act s. 67 (5) (b)

NOTES 15.7

c) provide for a program, that complies with the regulations, for preventing abuse and neglect?

Act s. 67 (5) (c)

NOTES 15.8

d) contain an explanation of the duty under section 75 of the Act to make mandatory reports?

Act s. 67 (5) (d)

NOTES 15.9

e) contain procedures for investigating and responding to

alleged, suspected or witnessed abuse and neglect of residents?

Act s. 67 (5) (e)

NOTES

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15.10 f) set out the consequences for those who abuse or

neglect residents? Act s. 67 (5) (f)

NOTES

Staff training and retraining requirements

Item Yes No N/A Compliance Item – Staff Training Act/Reg. Does the licensee’s written policy to promote zero tolerance

of abuse and neglect entail training and retraining of all staff, including:

Reg. 166/11 s. 15 (1)

15.11 a) on power imbalances (i.e. between staff and residents

and the potential for abuse and neglect)? Reg. 166/11 s. 15 (1) (a)

NOTES

15.12 b) on situations that may lead to abuse and neglect and

how to avoid such situations? Reg. 166/11 s. 15 (1) (b)

NOTES Procedures and interventions

Item Yes No N/A Compliance Item – Procedures and Interventions Act/Reg. 15.13

Does the licensee’s written policy to promote zero tolerance of abuse and neglect identify how allegations will be investigated (i.e. who does the investigation and who will be informed about it)?

Reg. 166/11 s. 15 (2)

NOTES

Does the licensee’s written policy to promote zero tolerance of abuse and neglect contain procedures and interventions to:

15.14 a) assist and support residents who have been abused or

neglected or allegedly abused or neglected? Reg. 166/ 11 s. 15 (3) (a)

NOTES

15.15 b) deal with persons who have abused or neglected or

allegedly abused or neglected residents, as appropriate? Reg. 166/11 s. 15 (3) (b)

NOTES

15.16 c) identify measures and strategies to prevent abuse and

neglect? Reg. 166/11 s. 15 (3) (c)

NOTES

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Notify the resident’s SDM and other persons of importance

to the resident of abuse or neglect: Reg. 166/11 s. 15 (3) (d)

15.17

d)(i) immediately upon becoming aware of an alleged, suspected or witnessed incident that resulted in physical injury or pain to the resident?

Reg. 166/11 s. 15 (3) (d) (i)

NOTES

15.18

d)(ii) within 12 hours of the home becoming aware of any other alleged, suspected or witnessed incident of abuse or neglect of a resident?

Reg. 166/11 s. 15 (3) (d) (ii)

NOTES

15.19

e) provide for notification of the resident or SDM of the results of the investigation immediately upon completion?

Reg. 166/11 s. 15 (3) (e)

NOTES

15.20

f) provide for immediate notification of the police of any alleged, suspected or witnessed incident of abuse or neglect of a resident that the licensee suspects may constitute a criminal offence?

Reg. 166/11 s. 15 (3) (f)

NOTES

Analysis and evaluation

Item Yes No N/A Compliance Item – Analysis and Evaluation Act/Reg. 15.21

Does the licensee analyse every incident of abuse or neglect of a resident promptly after the licensee becomes aware of it?

Reg. 166/11 s. 15 (3) (g) (i)

NOTES

15.22

Does the licensee conduct an evaluation at least once every calendar year of the effectiveness of the policy and changes to prevent further abuse and neglect of residents?

Reg. 166/11 s. 15 (3) (g) (ii)

NOTES

15.23 Are the results of the analysis undertaken in Item 49.1

considered in the evaluation in Item 49.2? Reg. 166/11 s. 15 (3) (g) (iii)

NOTES

15.24 Are the changes and improvements identified in Item 49.2

promptly implemented? Reg. 166/11 s. 15 (3) (g) (iv)

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NOTES

15.25

Is there a written record prepared of the analysis and evaluation (Items 49.1 – 49.4) including the date of the evaluation, names of the persons who participated and the date changes and improvements were implemented?

Reg. 166/11 s. 15 (3) (g) (v)

NOTES

16. Restraints and personal assistance services devices (PASDs): sections 68, 69 & 71, Act; O. Reg.

166/11, s. 51, 52, 53 & 54 The licensee must not confine or restrain residents in any way, including by a physical device or by a drug, except as permitted by section 71 (common law duty). The licensee must ensure that PASDs are used only for the purpose of assisting a resident with routine activities of daily living and their use is restricted, as set out in section 69. The licensee must ensure that prohibited devices such as vest or restraint jackets, as set out in section 51 of the regulation, are not used in the home. The licensee must have a written policy for the use of PASDs and the policy must meet the requirements set out in section 52 of the regulation. The licensee must meet the requirements of sections 53 and 54 of the regulation if a resident is restrained by a device or drug pursuant to common law duties. 16a. PASDS Use of PASD policy

Item Yes No N/A Compliance Item – PASD Policy Act/Reg. DEFINITION “personal assistance services device” means a device that is intended to assist a resident with a

routine activity of living if the device has the effect of limiting or inhibiting the resident’s freedom of movement and the resident is not able, either physically or cognitively to release oneself from the device. [Act s. 50 (1)]

16.1 Does licensee have a written policy for the use of personal

assistance services devices for residents? Act s. 68 (3)

NOTES

Does the licensee’s written policy for the use of PASDs for residents deal with the following:

16.2

a) the duties and responsibilities of staff (i.e. who has authority to apply/release PASD and staff aware of its use at all times)?

Reg. 166/11 s. 52 (1) (a) (i – ii)

NOTES

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16.3

b) the prohibition on restraining a resident in any way unless under the common law duty to prevent serious bodily harm to the person or others?

Reg. 166/11 s. 52 (1) (b)

NOTES

16.4 c) the types of PASDs permitted to be used? Reg. 166/11 s. 52 (1) (c)

NOTES

16.5 d) how consent for use is to be obtained and documented? Reg. 166/11 s. 52 (1) (d)

NOTES

16.6

e) alternatives to the use PASDs (i.e. how the alternatives are planned, developed and implemented, using an interdisciplinary approach)?

Reg. 166/11 s. 52 (1) (e)

NOTES

16.7 f) how the use of PASDs are evaluated? Reg. 166/11 s. 52 (1) (f)

NOTES

Restrictions on use of PASDs Item Yes No N/A Compliance Item – Restrictions on PASD Use Act/Reg. 16.8

Are PASDs only used to assist residents with routine activities of daily living?

Act s. 69 (1)

NOTES

Does the licensee or an external care provider only permit the use of PASDs for a resident if:

16.9 a) alternatives to the PASD have been considered or tried,

but have not been effective to assist the resident? Act s. 69 (2) (a)

NOTES

16.10 b) it has been determined that the PASD is reasonable, is

the least restrictive, and is effective for the resident? Act s. 69 (2) (b)

NOTES

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16.11

c) the PASDs has been approved for use by a legally qualified medical practitioner, a member of the College of Nurses of Ontario, College of Occupational Therapists of Ontario or College of Physiotherapists of Ontario?

Act s. 69 (2) (c) (i – iv)

NOTES

16.12 d) the resident/SDM has consented to the use of the

PASD? Act s. 69 (2) (d)

NOTES

16.13

e) the use if the device is included in the resident’s plan of care (if a plan of care is in place before January 1, 2013)?

Act s. 69 (2) (e)

NOTES

Criteria for use of PASDs Item Yes No N/A Compliance Item – Criteria for PASD Use Act/Reg. Are the PASDS that are used in the home: Reg. 166/11

s. 52 (2) 16.14

a) well maintained? Reg. 166/11 s. 52 (2) (a) NOTES

16.15 b) applied by staff of the home in accordance with the

manufacturer’s instructions, if any? Reg. 166/11 s. 52 (2) (b)

NOTES

16.16

c) used in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices?

Reg. 166/11 s. 52 (2) (c)

NOTES

16.17 d) not altered except for routine adjustments in

accordance with the manufacturer’s instructions, if any? Reg. 166/11 s. 52 (2) (d)

NOTES

16.18

e) removed as soon as it is no longer required to assist a resident with a routine activity of living, unless the resident requests that it be retained?

Reg. 166/11 s. 52 (2) (e)

NOTES

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16.19

f) removed as soon as a resident has altered skin integrity or is at risk of altered skin integrity related to the use of the device?

Reg. 166/11 s. 52 (2) (f)

NOTES

Prohibited devices

Item Yes No N/A Compliance Item – Prohibited Devices Act/Reg. Are the following devices prohibited from use in the home: Reg. 166/11

s. 51 16.20

a) a roller bar on wheelchairs, commodes or toilets? Reg. 166/11 s. 51 (1) NOTES

16.21 b) any device used to restrain a person to a commode or

toilet? Reg. 166/11 s. 51 (2)

NOTES

16.22 c) vest or jacket restraints? Reg. 166/11 s. 51 (3)

NOTES

16.23 d) any device with locks that can only be released by a

separate device, such as a key or magnet? Reg. 166/11 s. 51 (4)

NOTES

16.24 e) four point extremity restraints? Reg. 166/11 s. 51 (5)

NOTES

16.25 f) any device that cannot be immediately released by

staff? Reg. 166/11 s. 51 (6)

NOTES

16.26 g) sheets, wraps, tensors or other types of strips or

bandages used other than for a therapeutic purpose? Reg. 166/11 s. 51 (7)

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16b. Common Law Duties re Restraint and Confinement

Common law duty and records

Item Yes No N/A Compliance Item – Common Law Duties Act/Reg. 16.27

Are residents of the home restrained only when immediate action is needed to prevent serious bodily harm to the resident or to others?

Act s. 71 (1)

NOTES

16.28

Does the home keep the required records [set out in Items 16.38 – 16.43 (physical device) and 16.46 - 16.51 (drugs), below] in relation to the common law use of restraint or confinement of a resident in the home?

Act s. 71 (4)

NOTES

INFORMATION The following does not constitute “restraint” in the interpretation of the Act: 1. The use of a physical device from which a resident is both physically and cognitively able to

release oneself. 2. The use of a personal assistance services device permitted by section 69. 3. The administration of a drug to a resident as part of the resident’s treatment as provided for in

the resident’s plan of care if the restraining effect of the drug is not the primary purpose for its administration.

4. Confinement to a secure unit as permitted by section 68 or 70 [Act, s. 50 (2) paras. 1 -4] Restraint by a physical device

Item Yes No N/A Compliance Item – Common Law Duty (Restraint by Physical Device)

Act/Reg.

16.29

If the licensee restrains a resident by a physical device pursuant to common law duty, does the licensee ensure the device is used as follows:

Act s. 71 (2)

NOTES 16.30

a) The device is ordered by a member of College of

Physician and Surgeons of Ontario or the College of Nurses of Ontario?

Reg. 166/11 s. 53 (1), para. 1

NOTES 16.31

b) Staff apply the device in accordance with manufacturer’s instructions?

Reg. 166/11 s. 53 (1), para. 2

NOTES 16.32

c) The device is well maintained? Reg. 166/11 s. 53 (1), para. 3 NOTES

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16.33

d) The device is not altered except for routine adjustments in accordance with manufacturer’s instructions?

Reg. 166/11 s. 53 (1), para. 4

NOTES Supervision and assessment, post-restraining care


Act/Reg.

If a resident is restrained by a physical device pursuant to the common law duty, is the resident:

16.34

a) monitored or supervised on an on-going basis and released from the device and repositioned as necessary based on the resident’s condition or circumstances?

Reg. 166/11 s. 53 (2) (a)

NOTES 16.35

b) reassessed only by a member of the College of Physicians and Surgeons of Ontario or the College of Nurses of Ontario at least every 15 minutes and at any other time when reassessment is necessary based on the resident’s condition or circumstances?

Reg. 166/11 s. 53 (2) (b)

NOTES 16.36

Does the licensee explain to the resident or SDM the reason for the physical restraint after its use?

Reg. 166/11 s. 53 (3)

NOTES 16.37

Is appropriate post-restraining care provided (i.e. to ensure the resident’s comfort and safety)?

Reg. 166/11 s. 53 (4)

NOTES

Documentation for restraint by a physical device


Act/Reg.

Does the licensee document the following after every use of the physical device pursuant to the common law duty:

16.38 a) The circumstances precipitating the application of the

device? Reg. 166/11 s. 53 (5), para. 1

NOTES 16.39

b) The person who made the order, what device was ordered and any instructions relating to the order?

Reg. 166/11 s. 53 (5), para. 2

NOTES

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16.40 c) The person who applied the device and the time of

application? Reg. 166/11 s. 53 (5), para. 3

NOTES 16.41

d) All assessments, reassessments and monitoring of the resident, including the resident’s response?

Reg. 166/11 s. 53 (5), para. 4

NOTES 16.42

e) Every release of the device and all repositioning? Reg. 166/11 s. 53 (5), para. 5 NOTES

16.43

f) The removal or discontinuance of the device, including the time of removal or discontinuance of the device and the post-restraining care of the resident?

Reg. 166/11 s. 53 (5), para. 6

NOTES

Restraint by a drug: authorized prescriber

Item Yes No N/A Compliance Item – Common Law Duty (Restraint by a Drug)

Act/Reg.

If a resident is being restrained by a drug pursuant to common law duty, does the licensee ensure the drug administration was ordered by:

Act s. 71 (3)

16.44 a) a legally qualified medical practitioner? OR Act s. 71 (3)

NOTES

16.45

b) a nurse practitioner?

Reg. 166/11 s. 54 (1)

NOTES

Documentation and ceasing use of drug as a restraint


Act/Reg.

Does the licensee document the following for every administration of a drug to restrain a resident pursuant to the common law duty:

Reg. 166/11 s. 54 (2)

16.46 a) The circumstances precipitating the administration of

the drug? Reg. 166/11 s. 54 (2), para. 1

NOTES

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16.47 b) The prescriber, the drug administered, dosage, route,

time and by whom? Reg. 166/11 s. 54 (2), para. 2

NOTES

16.48 c) The resident’s response to the drug? Reg. 166/11 s. 54 (2), para. 3

NOTES

16.49 d) All assessments, reassessments and monitoring of the

resident? Reg. 166/11 s. 54 (2), para. 4

NOTES

16.50 e) Explanation with resident/SDM reasons for the use of

the drug? Reg. 166/11 s. 54 (2), para. 5

NOTES

16.51

Does the licensee ensure that restraint by the drug ceases immediately once the threat of serious bodily harm to residents or others has passed?

Reg. 166/11 s. 54 (3)

NOTES

Policy and training


Act/Reg.

16.52 Does the licensee have policies to ensure the requirements

of Items 16.47 – 16.52 (above) are met? Reg. 166/11 s. 54 (4)

NOTES

16.53 Does the licensee train staff annually in the policies relating

to the use of restraints by a drug? Reg. 166/11 s. 54 (4)

NOTES

17. Procedure for complaints to licensee: section 73, Act; O. Reg. 166/11, s. 59 The licensee must have a written procedure to deal with complaints made by any person about the operation of the home. The licensee must ensure that every written or verbal complaint that is made to the licensee or staff of the home concerning the care of residents is dealt with in accordance with section 59 of the regulation.

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Procedure and requirements

Item Yes No N/A Compliance Item – Complaints to Licensee Act/Reg. 17.1

Does the licensee have a written complaints procedure (i.e. regarding how persons can complain to the licensee and how the licensee will deal with complaints)?

Act s. 73 (1)

NOTES

Does the licensee’s written procedure for dealing with every written or verbal complaint provide as follows:

Act s. 73 (2) O. Reg. 166/11, s. 59

17.2

a) that the complaint be investigated immediately where harm or risk of harm to one or more residents has been alleged?

Reg. 166/11 s. 59 (1), para. 1

NOTES

17.3

b) that the complaint be resolved, if possible, and a response provided to person who made the complaint within 10 business days of its receipt?

Reg. 166/11 s. 59 (1), para. 2

NOTES

17.4

c) if the complaint cannot be investigated and resolved within 10 business days, does the licensee acknowledges its receipt within 10 business days and provide a follow up response as soon as possible?

Reg. 166/11 s. 59 (1), para. 3

NOTES

17.5

d) does each response to the complainant indicate: (i) what the licensee has done to resolve the complaint, or (ii) that the licensee believes the complaint to be

unfounded and the reasons for the belief?

Reg. 166/11 s. 59(1), para. 4 (i )( ii)

NOTES

Written complaint record

Item Yes No N/A Compliance Item – Complaints to Licensee Act/Reg. Does the licensee have a written complaint record that

includes: Reg. 166/11 s. 59 (2)

17.6 a) the nature of each verbal or written complaint? Reg. 166/11 s. 59 (2) (a)

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INFORMATION Item 17.6 (above) is not applicable to verbal complaints that the home resolves within 24 hours of the complaint being received [Reg. 166/11 s. 59 (4)]

NOTES

17.7 b) the date that the complaint was received? Reg. 166/11 s. 59 (2) (b)

NOTES

17.8

c) the type of action taken to resolve the complaint, including the date of the action, time frames for actions to be taken and any follow-up action required?

Reg. 166/11 s. 59 (2) (c)

NOTES

17.9 d) the final resolution, if any, of the complaint? Reg. 166/11 s. 59 (2) (d)

NOTES

17.10 e) every date on which any response was provided to the

complainant and a description of the response? Reg. 166/11 s. 59 (2) (e)

NOTES

17.11 f) any response made in turn by the complainant? Reg. 166/11 s. 59 (2) (f)

NOTES

Evaluation and analysis of complaints

Item Yes No N/A Compliance Item – Complaints to Licensee Act/Reg. 17.12

Are the written complaint records reviewed and analyzed for trends at least quarterly?

Reg. 166/11 s. 59 (3) (a)

NOTES

17.13

Are the results of the review and analysis taken into account in determining what improvements are required in the home?

Reg. 166/11 s. 59 (3) (b)

NOTES 17.14

Is a written record kept of each review and of the improvements made in response?

Reg. 166/11 s. 59 (3) (c)

NOTES

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INFORMATION • Items 17.12 – 17.14 (above) are not applicable to verbal complaints that the home resolves within 24 hours of the complaint being received [Reg. 166/11 s. 59 (4)]

• If a complaint is made before July 1, 2012, but not finally dealt with by that day, the complaint shall be dealt with as provided in section 59 of the regulations, to the extent possible. [Reg 166/11 s. 59(5)]

18. Licensee’s Duty to Respond to Incidents of Wrongdoing: section 74, Act The licensee must ensure that every reported or known incident of alleged, suspected or witnessed abuse or neglect of a resident is immediately investigated and appropriate action is taken to deal with the incident. Reporting/duty to respond

Item Yes No N/A Compliance Item – Duty to Respond Act/Reg. 18.1

Does the licensee immediately investigate every alleged, suspected or witnessed incident of abuse of a resident by anyone or neglect of a resident by the licensee or by staff?

Act s. 74 (a) (i)( ii)

NOTES

18.2 Does the home take appropriate action in response to every

incident described in Item 18.1, above? Act s. 74 (b)

NOTES

19. Notice of certain events: section 109, Act; O. Reg. 166/11, s. 63 The licensee must give the Registrar notice at least two months before, or as soon as practicable, of the events set out in Section 109. These events include where a person ceases to have a controlling interest in the licensee, or where a person acquires a controlling interest. Under section 63 of the regulations, the licensee must also report changes to information contained in the RHRA Public Register and material changes to information that the licensee provided to the RHRA in support of its application for a licence.

Item Yes No N/A Compliance Item – Notice of Certain Events Act/Reg.

Does the licensee give the Registrar a written notice setting out the details at least two months before any of the following events occurs, or as soon as practicable:

Act s. 109 (1)

19.1 1. If a person ceases to have a controlling interest in the

licensee? Act s. 109 (1), para. 1

NOTES

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19.2 2. If a person acquires a controlling interest in the licensee? Act s. 109 (1), para. 2

NOTES 19.3

3. If any other event that would result in the termination of the licence occurs?

Act s. 109 (1), para. 3

NOTES 19.4

As soon as possible after any of the following events occurs, does the licensee give the Registrar a written notice setting out the details of the event:

Act s. 109 (2)

19.5 1. If there is a change in the directors or officers of the

licensee? Act s. 109 (2), para. 1

NOTES

19.6 2. If there is a change in the directors or officers of a person

who has a controlling interest in the licensee? Act s. 109 (2), para. 2

NOTES

19.7

3. If the licensee employs or retains a person to manage the operations or most of the operations of the retirement home?

Act s. 109 (2), para. 3

NOTES

19.8

4. A material change in any of the information required to be contained in a register under subsection 106 (1) of the Act in respect of the licence of a licensee.

Reg 166/11 s. 63, para. 1

NOTES

19.9

5. A material change in any of the information that a licensee provided to the Registrar in support of the licensee’s application for a licence.

Reg 166/11 s. 63, para. 2

NOTES

20. Records (content, format and retention): O. Reg. 166/11, s. 55 (1) & (5) (c) & 56 The licensee must keep records for each resident of the home. The licensee must keep a record of staff training and qualifications to prove compliance with the Act as set out in subsection 55(5) (c) of the regulation. The licensee must keep records in accordance with section 56 of the regulation including that records must be kept in a readable and useable format and kept for a reasonable length of time based on the nature of the record, and resident records must be kept for at least seven years.

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Resident records

Item Yes No N/A Compliance Item – Records Act/Reg. 20.1

Does the licensee keep records for residents that include a copy of the written agreement between the resident and the licensee.

Reg. 166/11 s. 55 (2)(e)

NOTES

Staff/volunteer and general records

Item Yes No N/A Compliance Item – Staff Records Act/Reg. 20.2

Does the licensee keep records proving compliance with the Act and this regulation in relation to the skills, qualifications and training of the staff who work in the home?

Reg. 166/11 s. 55 (5)(c)

NOTES

Format and retention of records Item Yes No N/A Compliance Item – Format and retention of records Act/Reg. 20.3

Does the licensee keep records in a readable and useable format that can be easily copied?

Reg. 166/11 s. 56 (3)

INFORMATION ”Record” means any document or record of information, including personal health information, in any form. This section applies to all records that the licensee of a retirement home is required to keep under the Act or this regulation, including records relating to a resident, and documentation that the licensee is required to keep when providing a care service to a resident. [Reg. 166/11 s. 56 (1) & (2)]

NOTES

20.4 Does the licensee retain records for a reasonable length of

time based on the nature of the record? Reg. 166/11 s. 56 (4)

NOTES

20.5

Does the licensee retain resident records for no less than seven years from the last day on which the person is a resident of the home and keep a copy of the record in the home during that period?

Reg. 166/11 s. 56 (5)

NOTES

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20.6 Does the licensee keep records (i.e. relating to residents

and to staff) secure and confidential? Reg. 166/11 s. 56 (6)

NOTES

20.7

Does the licensee have a written policy detailing how the home will comply with the format and retention of records requirements in the regulation?

Reg. 166/11 s. 56 (7)

NOTES

Conclusion

The purpose of this first edition of the Overview is to educate and assist operators in understanding the requirements under the Act and regulations that came into force on or before July 1, 2012.

The next set of requirements will come into force on January 1, 2013. The RHRA will release a second version of the Overview in fall 2012 that reflects the new requirements. If you have questions about the Overview the Act generally, you may contact the RHRA by email at [email protected] or by calling 1-855-ASK-RHRA (275-7472). You can also visit the RHRA’s website at www.rhra.ca. There are additional resources on the website to help you understand the Act. Examples of resources on the website include:

1. The Retirement Homes Act, 2010 and regulations 2. Plain Language Guide: An overview of the new Retirement Homes Act, 2010. This guide

explains some of the standards set out in the Act 3. Fact Sheet: Phasing in the Act and Operator Compliance Checklist provides an overview

of the phasing in of the standards.

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Contact You can contact the RHRA at the address and phone number below. Retirement Homes Regulatory Authority 160 Eglinton Avenue East, 5th Floor Toronto, ON M4P 3B5 Phone: 1-855-ASK-RHRA (275-7472) Email: [email protected] Web: www.rhra.ca

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DisclaimerContentsIntroductionPhased ImplementationInstructions and DefinitionsCompliance Overview: Phase 1Compliance Overview: Phase 2Only residents/duty to respondDuties of licensee/meetings with CouncilNo interferenceStaff qualifications and trainingStaff training and retraining requirementsProcedures and interventionsAnalysis and evaluationRestrictions on use of PASDsCriteria for use of PASDs16b. Common Law Duties re Restraint and ConfinementDocumentation for restraint by a physical deviceDocumentation and ceasing use of drug as a restraintPolicy and trainingWritten complaint recordEvaluation and analysis of complaintsFormat and retention of recordsConclusionThe purpose of this first edition of the Overview is to educate and assist operators in understanding the requirements under the Act and regulations that came into force on or before July 1, 2012.The next set of requirements will come into force on January 1, 2013. The RHRA will release a second version of the Overview in fall 2012 that reflects the new requirements.Contact

COMPLIANCE OVERVIEW AND CHECKLIST Phases 1 and 2 · Compliance Overview and Checklist Page 4 of 39 Introduction . This Compliance Overview (Overview) provides a list of the standards

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