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OPSEU/SEFPO’s Submission to Ontario’s Long-Term Care COVID-19 Commission on behalf of Long-Term Care Home Inspectors

We the North
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Our long-term care system is in crisis and the COVID-19 pandemic has made things worse.  People are dying.   Front-line long-term care home inspectors represented by OPSEU/SEFPO have raised alarms for years and know what needs to be done, but unfortunately their voices have not been heard.  The findings in this submission have been gathered from our members.  Their recommendations are expert opinions on how to better protect residents during COVID-19, and beyond. OPSEU/SEFPO and its members are committed to being part of the solution to the crisis in long term care.

The long-term care inspection system desperately needs fixing. None of what the Canadian Military found in its damming report on the long-term care homes in May 2020 came as a surprise to inspectors, although the conditions were made even worse by short-staffing due to COVID-19. OPSEU/SEFPO repeatedly pointed out a long list of problems to government well before the military issued its report. It has long been a source of frustration for inspectors that senior managers in the Ministry of Long-Term Care review, second-guess, and direct inspectors to downgrade the severity of the findings in their reports. Managers overrule inspectors’ orders, and too often advocate for long-term care homes rather than the vulnerable residents who live in them, and the staff who work in them.

The current “risk-based approach” to inspections is not working, especially during a pandemic. Few proactive inspections are taking place in long-term care homes. Instead, the vast majority of inspections are done in response to a complaint or critical incident report, and only the issue raised in the complaint or critical incident is investigated.

The Ministry of Long-Term Care needs to adopt a proactive model, where every home has a full, comprehensive inspection called a Resident Quality Inspection (RQI) once a year in addition to the reactive inspections of critical incidents and complaints. Currently, in the midst of a pandemic, it is more important than ever to ensure that every long-term care home receives Infection Prevention and Control Inspections (IPAC), including every time an inspector visits the home.

In order to do this, the ministry must hire enough inspectors to carry out all of these absolutely necessary inspections.

Years of erosion of long-term care inspections

There is a long history, several governments in the making, of erosion in long-term care inspections, and OPSEU/SEFPO has been sounding the alarm every step of the way.

    • In 2010, the McGuinty government announced a new, in-depth inspection regime, but didn’t hire enough inspectors to carry it out.[1]
    • In 2012, after the media reported that inspections were so far behind that it would take five years before every home had an annual RQI, then-Minister of Health Deb Matthews announced that only LTC homes with complaints or critical incidents would receive annual inspections.[2]
    • In December 2014, 60 per cent of LTC homes hadn’t had an annual inspection.[3] Then-Associate Minister of Health Dipika Damerla promised to finish those inspections in six weeks, after taking 11 months to do the previous 40 per cent of inspections.
    • In 2019, under the Ford government, only nine proactive annual RQIs were completed – the rest of the inspections were reactive – triggered by complaints or critical incidents.[4] Unlike RQIs, reactive inspections triggered by complaints and critical incidents are limited to only the issue that triggered the inspection.
    • In September 2020, senior managers from the Inspections Branch of the Ministry of Long-Term Care testified to Ontario’s Long-Term Care COVID-19 commission that they couldn’t remember having ever done an analysis on whether there are enough inspectors to carry out the volume of inspection activity needed to keep residents safe.[5] OPSEU/SEFPO already knows the answer and has been telling successive governments for years that there simply are not enough inspectors.
    • Senior managers have also testified that the Ministry no longer requires each long-term care home to have one proactive, full inspection per year. Instead, the standard has been drastically lowered to one inspection of any kind. This means that if a long-term care home reports a critical incident or has a complaint filed against it that year, the resulting inspection will be limited only to the issue at hand, and that inspection will count as the home’s one inspection per year. The senior manager from the Ministry who testified admitted that a long-term care home could go years without a full inspection as long as they had enough complaints or critical incidents.[6]

This is not only a completely inadequate inspection regime during a pandemic, but also inadequate at all times.

What happened with inspections during COVID-19 crisis?

OPSEU/SEFPO long-term care home inspectors have been doing their best to carry out inspections during COVID-19. There were no work refusals early on, as was briefly reported in the media.

These reports were believed by the Premier until OPSEU/SEFPO corrected the misunderstanding. In fact, many of our members volunteered to go in and do the inspections.

Here is a timeline of what happened with inspections this year during the pandemic: 

March 16, 2020 – Inspectors started working remotely upon the direction of the Director of the Long-Term Care Inspections Branch on March 14, 2020.

March 19, 2020 – Inspectors were instructed by the Director to stay in contact with their assigned homes remotely to finalize outstanding inspection reports. They were told that inquiries and low-risk inspections were on hold and that they will receive instruction on how to move forward with high-risk inspections.

April 1, 2020 – OPSEU/SEFPO asked the Ministry for more information on working conditions that could be expected and what safety precautions would be taken for inspectors who are assigned to in-person inspections. The Ministry responded that long-term care home inspectors will not be physically redeployed and that they should continue their work remotely, and if that direction changed further communication would be provided.

April 16, 2020 – OPSEU/SEFPO received disclosure from the Ministry that inspectors would be returning to the field. In a subsequent call with the employer, they said they do not have firm plans, protocols, or a start date in place at his time. When asked about Personal Protective Equipment (PPE), the employer at first suggested that Inspectors get PPE from the long-term care homes. OPSEU/SEFPO objected, and the Ministry said they would provide equipment but didn’t give any information on what would be provided.

April 17, 2020 – OPSEU/SEFPO had another call with the Ministry and asked what protocols, resources, and health and safety measures would be implemented for inspectors.

April 20, 2020 – OPSEU/SEFPO and the Ministry had a call, and the Ministry had no new information, but they stressed that PPE would be provided to inspectors.

April 30, 2020 – 52 out of 164 inspectors volunteered to do in-person inspections at long-term care homes. They were told they would be working in teams led by public health, and that the inspectors were to be in an observation role only – no interviewing residents or workers.

May 8, 2020 – On-site visits and inspections of “red” coded homes began with inspectors who volunteered. All inspectors continued to conduct off-site inspections remotely as well.

May 13, 2020 – The Ministry informed OPSEU/SEFPO that they are using a volunteer system for on-site high-risk inspections of “red” and “yellow” coded homes. The ministry told the union that regular “business as usual” inspections will continue to be done remotely until further notice.

May 27, 2020 – OPSEU/SEFPO received disclosure from the ministry that inspectors will be doing on-site visits in long-term care homes.

May 28, 2020 – Premier Ford told media that inspectors refused to do onsite inspections during the pandemic. OPSEU/SEFPO responded by correcting the record with this timeline of events, and Premier Ford acknowledged it and praised our inspectors during a press conference a few days later.

May 28, 2020 – Inspections Branch Director told all inspectors in the province that they were to resume onsite visits as usual.

May 31, 2020 – A Long-term care inspector tested positive for COVID-19, was symptomatic, and had to stay home. He had attended one long term care home.

June 2020 – All inspectors except those who couldn’t for medical reasons were back to doing in-person inspections and were shipped PPE, except for fit-tested N95 masks.

October 2020 – All inspectors continue to do onsite inspections, but are still waiting to be fit-tested and provided with N95 masks.

Recommendations for an effective long-term care inspection system

    1. Immediately re-implement annual RQIs for every long-term care home. Relying solely on complaints from a vulnerable resident population or long-term care staff who fear for their jobs, or waiting for critical incidents to occur before inspecting homes has clearly been catastrophic during the pandemic, and is completely inadequate at all times.
    2. All homes should receive an IPAC inspection. Any time an inspector goes into a home for any other reason, they should be officially doing a proactive infection prevention and control inspection.
    3. Hire the appropriate number of inspectors to do an annual RQI inspection for each home every year as well as all of the initial inspections and follow-up inspections triggered by complaints and critical incidents.
    4. Ensure that the Ministry stocks an ample supply of appropriate PPE, including properly fitted N95 masks, as well as a contingency supply for inspectors to do in-person inspections safely.
    5. Create a safety protocol for long-term care home inspections, train inspectors on the protocol, and inform all long-term care homes of the protocol they must follow while being inspected.
    6. Assign inspectors to specific long-term care homes so that they get to know the issues in those homes.
    7. Ensure that long-term care homes are provided with support to implement changes after they are inspected.
    8. Levy fines against long-term care homes that do not comply with orders.
    9. Provide additional oversight of MLTC managers when they direct inspectors to downgrade their findings and orders in their inspection reports. The Ministry should not shield long-term care homes from accountability. Ensure that the inspection system protects long-term care home residents and staff rather than shielding homes from accountability. Legislate proper staffing levels and care hours in long-term care homes to ensure high-quality care, and give long-term care home inspectors adequate staffing levels, tools and the authority to enforce it.
    10. Bring long-term care into the public health care system and remove for-profit care from the system. Making long-term care a publicly provided service with more ministry control means better care for residents, and fewer violations and critical incidents for inspectors to investigate. Providers from the for-profit sector have a financial incentive to cut corners on staffing, on resident care, and on PPE. As a result, during this pandemic, residents are dying four times more often in for-profit long-term care homes.[7]  Even before the pandemic, for-profit homes had 16 per cent higher death rates than publicly run facilities and 33 per cent higher hospitalization rates. They also experienced higher rates of falls, incontinence, and use of restraints.[8]
    11. During COVID-19, make arrangements for travel, child care, elder care and temporary housing (e.g. hotels) for inspectors who are inspecting long-term care homes in person, especially if they have to isolate from vulnerable family members after potential exposure to COVID-19.
    12. During COVID-19, in order to avoid cross-contamination of long-term care homes, do not send inspectors to more than one long-term care home without adequate self-isolation time between visits to different homes.

Conclusion

The long-term care system in Ontario is in urgent need of a complete overhaul. As a province, we need to have the courage to make the big changes needed to create long-term care homes that are not only safe and healthy, but where residents can thrive and live happy lives.

But that kind of long-term care home can’t happen when homes are run by for-profit owners who have consistently chosen to fill their pockets over investing in the proper care of residents. This can’t happen without full inspections conducted on every home, every year in order to catch problems quickly.

It’s time for the public sector to own, operate, and properly fund all long-term care homes. It’s time for the government to legislate proper care standards. And it’s time to hire enough long-term care home inspectors to enforce those standards. The lives of long-term care residents are depending on it.

[1] Diablogue, June 16, 2013. “Matthews seeks to enhance nursing home inspections – how about enough inspectors to get the job done?” https://diablogue.org/2013/06/06/matthews-seeks-to-enhance-nursing-home-inspections-how-about-enough-inspectors-get-the-job-done/

[2] Toronto Star, June 12, 2012.  “Nursing homes with most complaints to get toughest inspections.” https://www.thestar.com/news/canada/2012/06/12/nursing_homes_with_most_complaints_to_get_toughest_inspections.html

[3] CTV, December 4, 2014. “Ontario promises long-term care home inspections will be completed.”  https://london.ctvnews.ca/ontario-promises-long-term-care-home-inspections-will-be-completed-1.2133504

[4] CBC, April 15, 2020. “Ontario scaled back comprehensive, annual inspections of nursing homes to only a handful last year.” https://www.cbc.ca/news/canada/seniors-homes-inspections-1.5532585

[5] Ontario’s Long-Term Care COVID-19 Commission, September 15, 2020. “Government of Ontario MLTC Long-Term Care Inspections Transcript.” Pages 44-45.  http://www.ltccommission-commissionsld.ca/transcripts/pdf/GovOntario_MLTC_LongTermCareInspections_Transcript_September_15_2020.pdf

[6] Ontario’s Long-Term Care COVID-19 Commission, September 15, 2020. “Government of Ontario MLTC Long-Term Care Inspections Transcript.” Pages 48-50.  http://www.ltccommission-commissionsld.ca/transcripts/pdf/GovOntario_MLTC_LongTermCareInspections_Transcript_September_15_2020.pdf

[7] Toronto Star, May 8, 2020. “For-profit nursing homes have four times as many COVID-19 deaths as city-run homes, Star analysis finds.” https://www.thestar.com/business/2020/05/08/for-profit-nursing-homes-have-four-times-as-many-covid-19-deaths-as-city-run-homes-star-analysis-finds.html

[8] Toronto Star, October 7, 2015. “Death rates higher in for-profit nursing homes, report says.” https://www.thestar.com/news/canada/2015/10/07/death-rates-higher-in-for-profit-nursing-homes-report-says.html