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Ministry of Health Reports on Nursing Homes.
Posted on Wed, July 9, 2008 at 11:17 am
On July 3, 2008 both the Toronto Star and The Globe and Mail published articles by Chinta Puxley in which she describes the results of The Canadian Press’ investigation into Ontario Nursing Homes and their compliance with the Ministry of Health and Long-term care (MOHLTC) standards (otherwise known as the Nursing Home Act). The Canadian Press disclosed that the majority of nursing homes have violated some of the standards that are in place to protect the safety, health, and general well-being of residents.
The Nursing Home Act is a long and exhaustive list of 400 standards that cover all aspects of operating a long-term care facility. While it may seem next to impossible to comply with this many standards, I believe that this ensures that nursing homes owners and management are accountable to residents and their family members. For example, if a home violates a standard and residents are deemed to be at risk, or if the home has repeatedly violated a standard, the home will face consequences from the MOHLTC. The MOHLTC can force a home to stop admitting new residents, reduce or withhold funding, take over the home, or suspend the home’s license. Obviously, the home will suffer financially during a suspension, but more than this, it will seriously impact the home’s reputation. Residents in the home, their family and friends, the general community, and those in the nursing home industry will quickly become aware of the sanctions imposed, especially if they are severe. As with anybody or anything, once lost, it is hard to regain a positive reputation.
Compared to other provinces, the government of Ontario’s reporting on long-term care facilities is very easy to access on the MOHLTC’s website (www.health.gov.on.ca). One can easily view the annual and complaint reports of any home in the province. Also, one can compare up to four homes simultaneously to evaluate how these homes measure up against one another. You can also compare each home against the provincial average.
Although the MOHLTC makes the reports easily accessible, they also need to disclose whether or not the violations have been corrected in a timely fashion. Upon being issued the violations, the Administrator of the home must present the Ministry with a Corrective Action Plan that clearly outlines how and when the problem will be resolved. This plan must be approved by the Ministry. As a consumer, I would be very concerned if the home did not abide by the action plan as it would lead to some serious questions: Is there a breakdown in communication within the home or between the home and the owners? Is there a concern with staffing levels such that the home does not have the staffing necessary to carry out the plan? Is there a budgetary problem? The bottom line is that homes which cannot, or do not, abide by the Corrective Action Plan show evidence of some underlying serious issues. The problem from a consumers’ perspective is that a lack of transparency in this part of the process leaves one guessing if the home is adequately dealing with their deficiencies. One practical way of detecting whether serious issues exist just below the surface is to look for a home that has been issued the same violation more than once. This gives some evidence that there may be a much larger problem within the organization.
Additionally, a source in the article claims that “many standards are more concerned with whether paperwork is filed correctly than with actual care residents get”. It is true that all staff, especially registered nurses, have a lot of paperwork to complete. The reality is, however, that documentation is critical to ensuring quality of care in a nursing home. In many cases, it is the only way one can be certain that important tasks have been carried out. For example, when a nurse administers medication to a resident, she must sign her initials on the Medication Administration Record (MAR) sheet. If initials are not recorded, one can only assume that the resident did not receive the medication. If a resident is behaving in an atypical manner, a nurse can rule out possible causes by looking at the MAR – if the medication was given, the behaviour requires some further investigation.
At every meal, a designated staff member, usually a personal support worker, must document the portion of the meal consumed by the resident (for example, quarter, half, full). If a resident is losing weight and the documentation indicates that the resident is eating a full meal, it is obvious that there is an underlying problem and an assessment by the physician is necessary. However, if the resident is only eating a quarter of each meal, and this has been properly recorded, it may simply mean that the resident does not like the food, but is otherwise healthy. These are only two cases among many that underscore the importance of thorough documentation.
According to a source in Chinta Puxley’s article, “The homes also say the provincial standards are subjective and what is deemed a breach varies depending on who is doing the inspection.” In my years as an Administrator, I was fortunate to have a Ministry Compliance Advisor who took the time to explain the modus operandi so that I could understand the process from the Ministry’s perspective. However, some details of an inspection could lead to the belief mentioned in the Puxley article. Compliance Advisors often use an audit system to determine if a violation will be issued, although the exact criteria used to interpret the audit system is not entirely spelled out and there does appear to be some subjective input on the part of the Advisor. For example, will an 85% audited compliance score on one standard be adequate for one Advisor, but lead to a violation for another? The government does need to produce some further clarification so that all homes are operating on a level playing field.
The very nature of how the standards are written can also lead to differences in how many violations a Compliance Advisor issues. Some standards are very general, others are further subdivided into substandards. If the home violates the substandards, the Advisor can either issue one violation (the more general standard), or separately issue a violation for each substandard. Therefore, if two different homes have violated the same standards, and one Compliance Advisor decides to issue one general standard, while the other chooses to issue many substandards violations, the report appears to be much more favourable to the former home. Clearly, this can be misleading and is another area that needs clarifying by the Ministry.
As I previously stated, I believe that the MOHLTC reports are important because they hold nursing home owners and management accountable, and because they compel homes to provide the finest quality of care and services. However, because of the subjective nature involved in determining violations, I believe that the reports are of limited benefit to family members when they are choosing a home for their loved one. I always advise family members to read MOHLTC reports, but this is only one of the many pieces of information on which they need to base a decision. First, they should go on a tour of the home (please refer to our Nursing Home Tour Checklist for a detailed list of what to look for when going on a tour). When you are on a tour, remember to ask for a copy of the activity schedule, a menu, and worship schedule. Also, take the time to read the Family Council minutes and Resident Council minutes. Just as important, read our residents and their family and friends opinions and ratings of their home on our website.
If you are a family member choosing a nursing home for your loved one, this is one of the most important decisions that you will make on their behalf, and you must do your research to ensure that you are well informed.
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