LQIP

Long-Term Care Homes Quality

Inspection Program (LQIP)

~ Overview & Up-date ~

Family Councils Program

March 23, 2012

Karen Slater & Mary Nestor

Performance Improvement & Compliance Branch

Ministry of Health and Long-Term Care

1

Agenda

1.

Compliance Transformation to Compliance Transformed – overview

2.

LQIP Implementation Status

3.

Inspection Data

4.

Family Councils ~ Provisions under LTCHA

Appendices

A.

Additional Questions

B.

Overview ~ RQI (Resident Quality Inspection)

C.

Inspection Protocols (IPs) – significance & use

Performance Improvement and Compliance Branch

Health System Accountability and Performance Division

2

Ontario LTC Home Quality Agenda

2010

•

LTCHA in force July 1

•

Introduction of the new inspection process

630+ Long-Term

Care Homes

(77,228 beds)

2009

•

First LTC Public Report Card

•

Residents First Program

2008

•

Key Risk Indicator Development

•

Beginning of Compliance

Transformation

2007 Development of the LTCHA



2005 Beginning of RAI-MDS 2.0

Implementation

3

Performance Improvement & Compliance Branch (PICB)

LQIP function

• Branch established in 2007

• LQIP introduced in July 2010

• 81 inspectors: Nursing, Dietary,

Environmental Health

• 5 Service Area Offices: Toronto,

Hamilton, Ottawa, London, Sudbury

• 2 Senior Managers

• Types of inspections: comprehensive (RQI), complaint, critical incident, follow-up and others



4

The New Inspection System ~ LQIP

The Long-Term Care Homes Act, 2007 (the Act) is the foundation of the government’s commitment to reforming the accountability of the long-term care home system. The Act and its regulations came into force on July 1, 2010.

The new comprehensive inspection program, Long-Term Care Homes Quality

Inspection Program (LQIP), focuses on the residents’ quality of care and quality of life.

The cornerstone of LQIP is the comprehensive inspection – Resident Quality

Inspection (RQI)

Resident-centred process:

 Residents are surveyed, documentation is reviewed

 Residents and families feel heard and valued

 The outcomes of these activities determine where the inspectors need to conduct an in-depth inspection in RQI Stage 2 to determine compliance with the Act and regulations

5

The New Inspection System ~ LQIP (cont’d)





Extensive research by clinical experts to identify the quality of life,

quality of care and screening indicators required in the inspection process to identify potential presence of non-compliance

Resident responses and care outcomes guide the inspection process.

Evidence-based approach means results are much less subject to interpretation





Improved objectivity and consistency of quality of care/quality of life problem identification through a structured information gathering process

Greater automation facilitates better organization of inspection findings and enhanced documentation

 Also targets inspection resources on homes with the largest number of quality concerns for improved risk management and resource deployment



6

LQIP

Implementation Status



7

Implemented

 Resident Quality Inspections (RQI)

 commenced February 2011

 represents a comprehensive inspection of a LTCH

 foundation of LQIP

 strategy & “roll-out” plan being developed to address completion of RQIs on a go-forward

 Complaint Inspections

 Critical Incident Inspections

 Follow-up Inspections

 all Orders require a follow-up inspection



8

Implemented (cont’d)

 SAO-Initiated Inspections

 r/t transitional requirement for inspections in all LTCHs by

Dec.31/2011

 aligned with RQI framework

 short inspection (usually one day)

 risk-based approach

 features: tour of LTCH, interview with Residents’ Council, dining observation, (IPs: Residents’ Council Interview, Quality

Improvement, Dining Observation)



9










Inspector training in RQI

 completed April / May 2011

 all inspectors trained and “adhered” (certified) in RQI

Satisfaction Surveys

 post-RQI

 residents, families, LTCHs

Inspection Protocols – 2 nd version released in April 2011

 posted on ltchomes.net

 French translation completed

Inspectors’ Handbook

 policies and procedures, reference and support manual for inspectors

 ensure inspection process integrity and standardization



10










Inspection data reporting

 quantity & quality of available reports is increasing

Continuing education and support for inspectors

Extensive I.T. systems development & implementation

 supports inspection process

 critical to RQIs (abaqis and IQS)

 instrumental in data collection and reporting

Publishing of Inspection Reports [LTCHA s. 173]

 Via MOHLTC public website

 narrative/ explanatory portion up-dated & written in “plain language”

 all Reports up to June 30 th posted in February with completion anticipated by

May 31st  remainder on a schedule after that

 anticipated that there will be in excess of 3,000 reports and Orders a year published through this website (approximately 250 per month)

 goal is to publish the Report within 2 of serving the Report on the Licensee



11

Coming Soon

 Centralized Intake, Assessment and Triage (CIAT)

 design and development underway

 will provide consistency and standardization in this critical function

CQI Activities:

 CQI Framework – built on 3 pillars:

1.

2.

Program performance (internal)

LTCHs inspection results / performance (external)





3.

Resident experience

QCLI Threshold Review – initial review

RQI Reviews – designing “embedded” review process to ensure ongoing integrity of inspection methodology



12

Inspection Data



13

Provincial Inspections from

July 1, 2010 – March 10, 2012

Inspection Type

Complaint Inspection

Critical Incident Inspections

Follow-up

Other*

RQI

TOTAL

#

1885

1383

405

267

51

3991

% of Total Inspections

47%

35%

10%

6%

1%

* Other inspections include: SAO-Initiated inspections, Post-occupancy

Special Inspection, etc



14

Provincial Findings from

July 1, 2010 – October 15, 2011

Non-compliance

Written Notification (with no other action)

Voluntary Plan of Correction

(VPC)

2515

1880

#

Compliance Orders (CO) 477

Referral to the Director (DR) 3

Total * ~ 4875

% of non-compliances

52%

39%

10%

<1%

*Total does not include Written Notifications associated with a VPC, CO or

DR.



15

LTC Action Line Intake

January - October 2010 January - October 2011

LTC Intake Call

Reports sent to

Service Area Offices

2086

•

From 2010 – 2011:

15% increase in the # of reports sent to SAO’s

2399



16

6 Most Frequent Areas of Non-Compliance

July 1, 2010 – October 15, 2011

1.

Plan of Care

2.

Policies to be followed

3.

Duty to Protect

[NEW]

4.

Residents’ Bill of Rights

5.

Transferring and positioning techniques

6.

Accommodation services – cleanliness and repair



17

Top 10 Most Frequently Cited Non-Compliance

July 1, 2010 – October 15, 2011

Non-compliance

LTCHA s.6 (7)

LTCHA s.6 (1)(c)

LTCHA s. 6 (1)

O. Reg. 79/10 8 (1)(b)

Description # of Homes

Cited

264 Plan of Care ~ The licensee shall ensure that the care set out in the plan of care is provided to the resident as specified in the plan

Plan of Care ~ clear directions to staff and others who provide care

Plan of Care ~ sets the planned care, goals and provides clear direction

Policies ~ comply with own policies

217

132

128

LTCHA s. 19 (1) Duty to protect ~ every licensee of a long-term care home shall protect residents from abuse by anyone and shall ensure that residents are not neglected by the licensee or staff

97

LTCHA s. 6 (10)(b)

O. Reg. 79/10 s. 8 (1)(a)

Plan of Care ~ reassessment & revision when resident’s care needs change

Policies ~ in compliance with the LTCHA

LTCHA s. 3 (1)

O. Reg. 79/10 s. 36

Residents’ Bill of Rights

Transferring and positioning techniques

LTCHA s. 15 (2) (c) Accommodation services ~ furnishings & equipment maintained in safe condition & good state of repair



97

90

85

74

54

18

Family Councils

Provisions under LTCHA s. 59 to 61 ~ Family Council s. 62 to 68 ~ General



19

LTCHA, Part IV (Councils)

Sections 59 to 61 re Family Council

Section 59 – Family Council

s. 59(1) – Family Council Every LTCH may have a Family Council

s. 59(2) – Request for FC

s. 59(3) – Licensee to assist

If no FC, a family member of a resident or a person of importance to a resident may request the establishment

Licensee shall assist in establishing a FC within 30 days of receiving request

s. 59(4) – Notification of

Director

When FC established, licensee to notify Director within

30 days of establishment

s. 59(5) – Right to be a member Family member of a resident or a person of importance to a resident may be a member

s. 59(6) – Who may not be a member

List of persons who may not be members: ex. licensee or management of LTCH, officer/director of licensee, LTCH

Administrator or staff

s. 59(7) – Licensee obligations if no FC



If no FC, licensee shall: (a) advise of right to establish; and

(b) convene semi-annual mtgs to advise of right to establish

20


Sections 59 to 61 re Family Council (cont’d)

s. 60(1) – Powers of

Family Council

Any or all of the following:

Section 60 – Powers of Family Council

1. Provide assistance, information & advise to residents, family members of residents & persons of importance to residents incl. newly admitted residents

2. Advise re rights & obligations under the LTCHA

3. Advise re rights & obligations of the licensee under the LTCHA or agreement

4. Attempt to resolve disputes between licensee & residents

5. Sponsor and plan activities for residents

6. Collaborate w/ community groups & volunteers re activities for residents



21



s. 60(2) – Duty to respond

Section 60 – Powers of Family Council (cont’d)

(Cont’d)

s. 60(1) – Powers of

Family Council

Any or all of the following:

7. Review: i.

inspection reports & summaries received under s. 149 [re required inspections]; ii.

detailed allocation, by the licensee, of funding under LTCHA & amounts paid by residents iii.

Financial statements re the home filed w/ the Director under the regulations; and iv.

the operation of the home

8. Advise the licensee of any concerns/recommendations from

FC re operations of the home

9. Report to the Director any concerns/recommendations that, in opinion of FC should be brought to the Director’s attention

10. Exercise any other powers provided for in regulations

If FC has advised the licensee of concerns/recommendations, the licensee shall respond to FC in writing, within 10 days of receiving the advice



22



s. 61(2) – Duties

Section 61 – Family Council assistant

s. 61(1) – Family Council assistant

If FC requests, the licensee shall appoint a Family Council assistant who is acceptable to FC and who will assist the

FC

FC assistant will take instructions from FC, ensure confidentiality where requested and report to the FC



23


Sections 62 to 68 re General provisions re Councils

Section 62 to 68 – General

s. 62 – Licensee to co-operate with & assist Councils

Licensee to co-operate w/ RC & FC and their assistants, and provide such financial & other information & assistance required by regulation

s. 63 – Licensee duty to meet w/ Council

If invited by RC/FC, licensee shall meet, or if licensee is a corporation, representatives of the licensee shall meet

s. 64 – Attendance @ meetings Licensee shall attend meetings only if invited and ensure that staff, including Administrator, and other persons involved in the management/operation of the home, only attend a meeting if invited



24


Sections 62 to 68 re General provisions re Councils (cont’d)

Section 62 to 68 – General (cont’d)

s. 65 – No interference by licensee

A licensee of a LTCH:

(a) shall not interfere w/ meetings or operation of RC/FC

(b) shall not prevent a member if the RC/FC from

entering the home to attend a meeting of the Council or to perform any function as a member of the Council and shall not otherwise hinder, obstruct or interfere with such a member carrying out those functions

(c) shall not prevent a RC/FC assistant from entering the home to carry out duties or otherwise hinder, obstruct or interfere with the assistant carrying out duties

(d) shall ensure that no staff member, including

Administrator, and other persons involved in the management/operation of the home does anything the licensee is forbidden to do



25


Sections 62 to 68 re General provisions re Councils (cont’d)

Section 62 to 68 – General (cont’d)

s. 66 – Immunity – Council members, assistants

s. 67 – Duty of Licensee to consult Councils

No action or proceeding shall be commenced against a member of RC/FC or their assistants for anything done or omitted to be done in good faith in their capacity as a member or assistant

Licensee has duty to consult regularly w/ RC/FC (if any), and in any case, shall consult w/ them every 3 months

s. 68 – Regulations Regulation-making provisions – Power of Lieutenant

Governor in Council to make regulations



26

APPENDIX A

Additional Questions



27

Additional Questions

1. If a Family Council makes a request from a home and does not get an answer – what recourse does the Family

Council have?

2. Is the MOHLTC aware of the frustration of family members when there hasn’t been an inspection?



28

APPENDIX B

Overview

Resident Quality Inspection (RQI)



29

RQI: How it works

Two-stage inspection process

Stage 1:

A preliminary inspection is conducted using interviews, records and observations of 40 residents (randomly selected) to target Stage 2 in-depth inspections. No non-compliances are determined at this stage.

Stage 2:

In-depth inspection in care areas targeted based on Stage 1 to determine compliance with the Long-Term Care Homes Act,

2007 and Regulations.

30

Made-in-Ontario Solution – Resident Quality Inspection (RQI)

(Based on USA QIS Methodology)

Stage 1:













Resident, family and staff interviews

Residents’ Council and Family Council interviews

Team inspections

Standard sample of residents randomly selected from RAI-MDS data feed

Mandatory audits of core requirements

Data is categorized and compared against pre-set thresholds





Aligned to LTCHA with adaptations and Ontario thresholds validated through field tests

If thresholds are exceeded, compliance with minimum standards in resident care areas and practices may be at risk, triggering a further inspection protocol for Stage 2

 System includes extensive training and reliability checks for inspectors



31

Quality of Care and Life Indicators (QCLIs)

Where does information come from?

MDS - includes Risk

Indicators

40%

Resident Interview

13%

Resident

Observation

21%

Staff Interview

6% Record Review

10%

Family/Designate

Interview

12%

Resident Interview (17)

Family/Designate Interview (16)

Staff Interview (8)

Resident Observation (28)

Record Review (13)

MDS - includes Risk Indicators (54)



32

Made-in-Ontario Solution – Resident Quality Inspection (RQI)

(Based on USA QIS Methodology)

Stage 2:

Care areas and Inspection Protocols (IPs) map to LTCHA regulations (IPs have made available to LTCH operators via ltchomes.net)

 Inspector is able to determine if there is non-compliance







Uses internally developed Inspectors’ Quality Solution (IQS) to complete detailed inspection protocols and summarize evidence data

Generates inspection reports

Enables inspector to identify sanctions, including Orders

Note:

Applicable to All Inspections (i.e. comprehensive, complaint, critical incident and follow-up)



33

APPENDIX C

Inspection Protocols



34

Inspection Protocols – Definition

What are Inspection Protocols (IPs)?

 Serve as inspection tools, utilized during all inspection types (RQI, Complaints,

Critical Incident inspections, Follow-ups)

 Contain inspection instructions, guidance, probes and questions for inspectors to determine status of a LTC home’s compliance with legislative requirements

 Responses to questions lead directly to a determination of compliance or noncompliance

 All questions within the IPs are:

 directly linked to provisions in either the Long-Term Care Homes Act, 2007 or

Regulation 79, or both

 the cross-walk between QCLIs (Quality of Care and Quality of Life Indicators) and the Act and Regulations

 31 distinct documents organized into 3 over-arching categories [Mandatory,

Home-related Triggered, Resident-related Triggered]



35

Inspection Protocol Summary (31)

Home-Related Mandatory

1. Admission Process

2. Dining Observation

3. Family Council Interview

4. Infection Prevention and

Control

5. Medication

6. Quality Improvement

7. Resident Charges

8. Residents’ Council Interview

Home-Related Triggered

1. Accommodation Services:

Housekeeping


Laundry


Maintenance

4. Critical Incident Response

5. Food Quality

6. Hospitalization and Death

7. Prevention of Abuse, Neglect, and Retaliation

8. Reporting and Complaints **

9. Safe and Secure Home

10. Snack Observation

11. Sufficient Staffing

12. Training and Orientation **

13. Trust Accounts

** Inspector-Initiated IPs



Resident-Related Triggered

1.

Continence Care and Bowel

Management

2.

Dignity, Choice and Privacy

3.

Falls Prevention

4.

Minimizing of Restraining

5.

Nutrition and Hydration

6.

Pain

7.

Personal Support Services

8.

Recreation and Social

Activities

9.

Responsive Behaviours

10. Skin and Wound Care

36

Uses of Inspection Protocols

By inspectors

 During the RQI (Resident Quality Inspection, i.e. the comprehensive inspection):

 IPs usage clearly prescribed as part of basic RQI methodology

 A set number of IPs must be reviewed during the RQI, i.e. “mandatory” IPs

 Two IPs are “inspector-initiated”, i.e. inspectors use their judgement and discretion to determine utilization based upon evidence uncovered during inspection

 Remainder of IPs are “triggered” by evidence from the inspection and when set thresholds are breached for individual QCLIs

 During CCF (Complaints, Critical Incident and Follow-up) inspections:

 IPs are used in accordance with the focus of the particular inspection type – e.g. Skin and Wound Care, Recreation and Social Activities, Dignity, Choice &

Privacy, Prevention of Abuse, Neglect and Retaliation.



37

Uses of Inspection Protocols (cont’d)

By long-term care homes

 To enhance understanding of:

 the inspection process and methodology

 legislative requirements

 Contribute to LTCHs’ quality management activities:

 carry out “mock” or practice inspections based upon IP content and other educational and inspection-related materials available on ltchomes.net

 test own level of compliance

 Assist staff and residents to become comfortable and familiar with inspection process and topics being addressed by inspectors



38

QCLI: Prevention of Abuse, Neglect and Retaliation

Stage 1 Screening

125253

(Resident Interview)

Abuse

1. Have you ever been treated roughly by staff?

2. Has staff yelled or been rude to you?

3. Do you ever feel afraid because of the way you or some other resident is treated?

225205

(Resident Observation)

Abuse

Are staff treating the resident in a manner that may indicate abuse

(yelling at resident, striking resident, treating resident in a rough manner, etc.)?

325236

(Family Interview)

Abuse

1. Have you ever noticed any staff member being rough with, talking in a demeaning way or yelling at [resident's name] or any other resident?

2. Did you report it?

3. Did home staff act promptly to investigate and correct the situation?

Threshold

0.0%

Threshold

0.0%

Threshold

0.0%

Stage 2

Prevention of Abuse, Neglect & Retaliation IP



39

QCLI: Falls Prevention

Stage 1 Screening

410512

(Staff

Interview)

Fall in Last 30

Days

Threshold

1.0%

610711

(MDS)

Fall in Last 30

Days

Threshold

15.5%

Stage 2

Falls Prevention IP



40



Thank you.

41

LQIP - Family Councils` Program

Long-Term Care Homes Quality

Inspection Program (LQIP)

Agenda

Implementation Status

Inspection Data

Family Councils

Additional Questions

Two-stage inspection process

Stage 1:

Stage 2:

Inspection Protocols

Thank you.

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