Office of the Auditor General of Ontario
April 2021
COVID-19 
Preparedness 
and Management
Special Report on Pandemic 
Readiness and Response 
in Long-Term Care 


Office of the Auditor General of Ontario
To the Honourable Speaker 
of the Legislative Assembly
I am pleased to transmit my Special Report on 
COVID-19 Preparedness and Management, Chapter 5, 
under Section 12(1) of the Auditor General Act.
Bonnie Lysyk, MBA, FCPA, FCA
Auditor General
April 2021
Toronto, Ontario 

ii
ISBN 978-1-4868-4851-5 (PDF)
Cover photograph credit: 
© iStockphoto.com/xavierarnau
Ce document est également disponible en français. 

Table of Contents
Reflections ..................................................................................................... 5
1.0 Summary................................................................................................. 7
Overall Conclusion..................................................................................... 11
2.0 Background.......................................................................................... 13
2.1 Overview of Ontario’s Long-Term-Care Sector...................................... 13
2.2 Provincial Involvement with the Long-Term-Care Sector......................20
2.3 Impact of COVID-19 on Ontario Long-Term-Care Homes.....................26
3.0 Objective and Scope.........................................................................33
3.1 Why We Are Issuing This Report .........................................................33
3.2 What We Did .......................................................................................33
4.0 Detailed Observations .....................................................................35
4.1 Long-Term-Care Homes 
Ill-Equipped to Prevent or Minimize COVID-19 Outbreaks 
Because of Long-Standing Facility, Staffing and Infection 
Prevention and Control Issues ...........................................................35
4.2 Long-Term-Care Sector Largely Disconnected from
Rest of Health-Care System................................................................50
4.3 COVID-19 Pandemic Response Actions Had Unintended 
Consequences on Long-Term-Care Residents and Staff ..................... 57
4.4 Delays, Unclear Communications and Lack of Enforcement 
by Long-Term Care Ministry Hampered Effectiveness of Measures 
to Contain COVID-19 ..........................................................................64
4.5 Ministry’s Oversight of Homes Before and During COVID-19 
Pandemic Ineffective in Addressing Repeat Non-Compliance ............ 67 

iv 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 5
The COVID-19 pandemic has presented a challenge 
to health experts and government decision-makers 
around the world that in many ways is unpreced￾ented in its impact and complexity. Ontario health 
experts, frontline workers and government decision￾makers have worked together to respond to the 
many challenges of the pandemic and its health, 
economic and social impacts on Ontarians.
By late March 2020, when COVID-19 had 
begun its ravage of long-term-care homes, it 
became blatantly obvious that aggressive infec￾tion prevention, detection and patient care actions 
were needed—and needed quickly—to prevent 
staggering death rates from becoming the norm 
across Ontario’s entire long-term-care community. 
Unfortunately, neither the Ministry of Long-Term 
Care, nor the long-term-care sector was sufficiently 
positioned, prepared or equipped to respond to the 
issues created by the pandemic in an effective and 
expedient way. This is the subject of this report—
Chapter 5: Pandemic Readiness and Response in 
Long-Term Care—one in a series of reports our 
Office has published on Ontario’s response to 
COVID-19.
From a big-picture perspective, there were three 
underlying issues that made practical and timely 
action all the more challenging for the stakeholders 
involved. First, despite very specific observations 
and recommendations on preparing for future 
outbreaks made by the Expert Panel on SARS and 
Infectious Disease Control led by Dr. David Walker, 
the SARS Commission led by Mr. Justice Archie 
Campbell, our Office and others, actions taken
over the years have been insufficient to ensure that 
we would be better prepared as a province for the 
‘next time’. 
Secondly, ongoing and repeated concerns raised 
for well over a decade about systemic weaknesses 
in the delivery of long-term care to the elderly have 
not, for the most part, been adequately addressed. 
Thirdly and finally, the long-term care sector’s 
lack of integration within the healthcare sector, 
compounded by the timing of the reorganization of 
the healthcare sector, did not enable long-term-care 
homes to fully benefit from the needed lifesaving 
expertise in infection prevention and control that 
could have been provided to a much greater extent 
by public health units and hospitals.
This report contains 16 recommendations with 
55 action items to address our audit findings. 
There should be no surprises in the content and 
recommendations in this report. Many of the issues 
Reflections
Bonnie Lysyk
Auditor General of Ontario 

6
and other significant and urgent care issues, on 
long-term-care home residents. 
The province has committed to making 
improvements by increasing the provincial average 
direct care time provided per resident per day, 
and has committed to increasing beds available 
for long-term care. Steps are also being initiated to 
address personal support worker training require￾ments and update infection prevention and control 
requirements at long-term-care homes. Continued 
attention to the implementation of these commit￾ments and additional recommendations would 
go a long way toward ensuring seniors living in 
Ontario’s long-term-care homes are accorded the 
well-deserved dignity, safety and comfort that is 
clearly envisioned in Section 1 of the Long-Term 
Care Homes Act, 2007.
Sincerely,
Bonnie Lysyk, MBA, FCPA, FCA
Auditor General of Ontario
and recommendations have either been highlighted 
or recommended previously by this Office, or were 
the subject of public discussions or publications 
amongst the various stakeholders we met with 
during our audit, as well as other interested groups 
and individuals. Given the longstanding nature of 
these issues and the risks of severe outcomes, there 
is a need to keep decision-makers’ attention focused 
on what needs to change, even though vaccines 
have helped to significantly reduce COVID-19
outbreaks and deaths in long-term care homes.
Proactively implementing the recommendations 
in this report, in concert with similar recommen￾dations likely contained in the upcoming report of 
the Long-Term Care COVID-19 Commission, would 
better prepare the Ministry and the long-term-care 
sector for the impact of future disease outbreaks,  

Pandemic Readiness 
and Response in 
Long-Term Care 
7
Special 
Report
Chapter 5:
1.0 Summary
This chapter is one in a series of audits under￾taken by our Office on the province’s response 
to the Coronavirus Disease 2019 (COVID-19) 
pandemic (see Figure 1). Chapter 5, Pandemic 
Readiness and Response in Long-Term Care, looks 
at the preparedness and response of Ontario’s 
long-term-care sector to COVID-19 between the 
onset of the pandemic in January 2020 (when 
the first case was identified in Ontario) up to 
December 31, 2020. Our work addresses some of 
the much-publicized issues surrounding the impact 
of COVID-19 in long-term-care homes and provides 
specific and pragmatic recommendations to address 
these issues.
This chapter covers a significant sector (one that 
has typically operated separately from hospitals 
and public health in the health-care system) that 
Figure 1: Six Key Areas of the COVID-19 Audit by the Office of the Auditor General of Ontario
Prepared by the Office of the Auditor General of Ontario
Laboratory Testing,
Case Management
and Contact Tracing,
Chapter 3
COVID-19
Preparedness and 
Management Overview
Focus of this report
Personal Protective
Equipment,
Chapter 6
Outbreak Planning and 
Decision-Making,
Chapter 2
Pandemic Readiness 
and Response in
Long-Term Care,
Chapter 5
Emergency Management
in Ontario—Pandemic
Response,
Chapter 1
Management of
Health-Related COVID-19
Expenditures,
Chapter 4 

8
experienced severe human health impacts when 
COVID-19 directly affected the lives and well-being 
of many residents and staff in long-term-care facili￾ties. The first cases of COVID-19 were identified 
in four long-term-care homes on March 17, 2020. 
From March 2020 to December 31, 2020, 475 
or 76% of long-term-care homes in Ontario had 
reported cases of COVID-19 among their residents 
and staff.
 Under Section 1 of the Long-Term Care Homes 
Act, 2007, “A long-term care home is primarily the 
home of its residents and is to be operated so that 
it is a place where they may live with dignity and in 
security, safety and comfort and have their physical, 
psychological, social, spiritual and cultural needs 
adequately met.”
To satisfy this fundamental principle of the Act, 
the long-term-care sector has been given respon￾sibilities in many areas (see Figure 2). These include 
providing appropriate living settings, staffing 
levels, quality of care, access to family support and 
other community services, and oversight of homes 
by the Ministry of Long-Term Care (Ministry). 
Long-standing systemic problems in the sector 
were quickly and starkly amplified at the onset and 
during the first and second waves of the pandemic, 
and were contributing factors to the outbreaks 
and spread of COVID-19 in the long-term-care 
homes. Many other studies and reports, including 
some prior audit reports issued by our Office, have 
identified these long-standing systemic issues that 
have remained largely unresolved over the years 
by the province even with the increasing health￾related needs of residents over the last decade. For 
example, as described in our 2019 Annual Report, 
Volume 1, Section 3.05, Food and Nutrition in 
Long-Term-Care Homes, the needs of residents 
in homes have become more complex in the last 
10 years, with residents relying more on personal 
support workers—over 85% of residents need 
Figure 2: Key Areas in Long-Term Care Addressed in This Report
Prepared by the Office of the Auditor General of Ontario
Community Services
• Volunteers, family 
caregivers and 
family-paid caregivers
(Sections 2.1.3, 4.3.3)
• Hospitals 
(Sections 4.2.1, 4.3.2)
• Public health units
(Sections 2.2.5, 4.2.1, 
4.2.2, 4.4.3)
• Home-care 
arrangements and 
supports 
(Section 4.1.1)
Oversight
• Licensing 
(Section 2.2.2)
• Funding 
(Section 2.2.3) 
• Home quality 
inspections 
(Sections 2.2.4, 4.2.2,
4.5)
• Enforcement actions
(Section 4.5.3)
• Public health 
inspections 
(Sections 2.2.5, 4.2.2, 
4.4.3)
• Crisis response
(Sections 4.2, 4.3, 
4.4, 4.5.4)
Long-Term-Care Homes
(Facilities)
• Ownership structure 
(Section 2.1.1)
• Home capacity
(Sections 2.1.1, 4.1.1, 
4.3.1, 4.3.2)
• Bedroom design
(Section 4.1.1)
• Infection prevention 
and control practices
(Sections 4.1.3, 4.2.1, 
4.2.2)
Resident Care and 
Services
• Characteristics of 
residents 
(Section 2.1.2)
• Direct care hours
(Section 4.1.2)
Long-Term-Care Staff
• Nursing and personal 
support staff
(Sections 2.1.3, 4.1.2, 
4.2.1)
• Qualifications and 
training 
(Section 4.1.2)
Long-Term-Care Sector 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 9
• Long-term-care homes had insufficient staff 
and staff training to provide appropriate 
care. Our analysis of the staffing shortages 
reported by homes to the Ministry from March 
19 to June 30, 2020 found that the staff￾ing shortage peaked in late April, when 36 
homes—ranging from a small 56-bed home to 
a large 300-bed home—reported critical short￾ages to the Ministry on the same day. A total of 
76 homes reported critical staffing shortages 
during this period. Furthermore, the Ministry’s 
July 2020 staffing study found that staffing 
shortages, even prior to the pandemic, and 
the rising complexity of residents’ needs have 
resulted in gaps between personal support 
workers’ (PSW) educational training and the 
working requirements at long-term-care homes. 
PSWs are not regulated in Ontario (and in 
Canada). Regulating the profession would help 
protect the health and safety of long-term-care 
home residents by setting standards of practice 
and putting in place accountability mechanisms 
for members.
• Restricting families from visiting homes 
consequently eliminated a valuable source of 
resident care providers. On March 30, 2020, 
Ontario’s Chief Medical Officer of Health issued 
a directive that limited visitors to long-term-care 
homes to only essential visitors. The measure 
was intended to control COVID-19 outbreaks by 
limiting the number of people going into homes. 
However, this lack of contact took an emotional 
and physical toll on residents and their families, 
in many cases resulting in a deterioration in 
residents’ physical and mental condition.
• Infection prevention and control (IPAC) 
were not consistently practised in homes 
even prior to the COVID-19 pandemic. Our 
analysis of the results of Ministry inspections 
between January 2015 and December 2019 
found that a total of 413, or about two-thirds of 
all homes were cited for a total of 765 instances 
of non-compliance with IPAC requirements. 
Examples included residents leaving unlabelled 
extensive or 24/7 daily assistance; about one-third 
of residents have severely impaired cognitive abilities; 
and 64% have dementia.
Some of the contributing factors that we 
confirmed negatively impacted residents of 
long-term-care homes during the pandemic up to 
December 31, 2020 include the following: 
• Residents were living in rooms with three or 
four occupants. Our analysis of self-reported 
COVID-19 data from homes from March 19 to 
August 31, 2020—the initial wave of the pan￾demic—found that, of all the homes where 
at least 30% of the home’s residents became 
infected at the same time, almost two-thirds 
primarily had bedroom designs that housed 
three or four residents in one room. The Min￾istry and the Local Health Integration Networks, 
which are responsible for placing residents in 
long-term-care homes, did not know how many 
residents were actually housed in three- or 
four-bed wards when the pandemic hit the long￾term-care sector in March 2020. The licences 
for over 26,500 beds in 257 or over 40% of the 
626 long-term-care homes in Ontario are set to 
expire in 2025. The Ministry could not tell us 
how many of these beds will need to be reno￾vated to comply with current Ministry bedroom 
standards that limit the number of residents 
sharing a room to two.
• The transfer of patients designated as 
alternate level of care (ALC) from hospitals 
to long-term-care homes contributed to 
crowding in homes. For example, in the 
month of March 2020, 761 transfers of patients 
designated as ALC were made from hospitals 
to long-term-care homes, 50% more than the 
average of 508 patients transferred per month 
throughout 2019. Given that homes were, on 
average, at 98% capacity prior to the pandemic 
according to the Ministry’s occupancy data, 
these transfers of patients designated as ALC 
added pressure to the homes, some of which 
were already struggling to contain the spread 
of COVID-19. 

10
to 2014 to 931 per year from 2015 to 2019. 
Despite this increase, the Ministry still had 
not implemented our 2015 recommendations 
aimed at addressing the issue of repeated non￾compliance. In addition, in fall 2018, the Ministry 
discontinued annual comprehensive inspec￾tions despite the fact they had identified areas 
of significant non-compliance, including IPAC 
non-compliance. 
In this report, we identify other problematic 
areas that are also critical to address to ensure that 
the residents of long-term-care homes are suffi￾ciently protected and cared for, which is especially 
important when an infectious disease outbreak 
occurs in the facility and, in this case, in the com￾munity at the same time. These areas include: 
• A lack of structured collaboration between 
different government bodies and agencies 
on issues such as infection prevention and 
control inspections. The Ministry of Long-Term 
Care has the mandate to inspect homes’ compli￾ance with the requirements of the Long-Term 
Care Homes Act, 2007 and Regulation 79/10, but 
only has three staff who have IPAC expertise. On 
the other hand, public health units, whose staff 
do have the IPAC expertise, are not specifically 
required under the Ministry of Health’s IPAC 
Protocol to conduct regular inspections of long￾term-care homes. Currently, some public health 
units inspect long-term-care homes only if 
they receive an IPAC-related complaint about a 
home, while others conduct inspections on their 
own initiative. 
• Measures to contain COVID-19 were 
initially left up to home operators. The 
Chief Medical Officer of Health issued his first 
mandatory instruction to long-term-care homes 
on March 22, 2020, directing homes not to 
permit residents to leave the home for short-stay 
absences and limit, where possible [emphasis 
added], the number of homes that employees 
were working at. When requirements were 
eventually issued to the long-term-care 
home operators, they were often unclear, 
personal-care items in the sink areas of shared 
washrooms and staff not following proper hand 
hygiene during feeding. Effective IPAC practices 
are important given that, based on our analysis 
of outbreak information prior to the COVID-19
pandemic, 96.5% of homes had reported an 
outbreak related to acute respiratory infections, 
such as influenza, between January 2016 and 
December 2019. During that period, 42% or 
264 homes reported an average of two to 13 
outbreaks per year. As well, during our 2019 
audit of Food and Nutrition in Long-Term-Care 
Homes, we noted that at the 59 homes we 
visited, only 76% of staff and 19% of residents 
were observed practising proper hand hygiene 
before or after a meal.
• Long-term-care homes were initially not 
partnered with hospitals or public health 
units to benefit from their expertise in infec￾tious disease outbreaks. Given the limited 
IPAC specialists in long-term-care homes, many 
homes did not have the capacity to manage the 
COVID-19 outbreaks without external support, 
for example from hospitals. A September 2020 
article in the Canadian Medical Association 
Journal highlighted the strong links between 
hospitals, long-term-care homes and public 
health units in British Columbia as a factor in 
the better outcomes in that province during the 
initial wave of COVID-19. As of July 8, 2020, 
only 347 or 55% of Ontario’s 626 long-term￾care homes had informal partnerships (that is, 
no formal agreement or memorandum of under￾standing) with a local hospital to allow homes 
to access IPAC expertise.
• A problematic enforcement practice cul￾minated with the Ministry completely 
discontinuing, in fall 2018, its proactive 
comprehensive inspections of homes to focus 
on clearing a growing backlog of critical 
incidents and complaints. The number of 
compliance orders issued since our 2015 audit 
of the Ministry’s inspection program increased 
from an average of 783 per year from 2012  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 11
Overall Conclusion
Overall, the Ministry of Long-Term Care and 
the long-term-care homes were not sufficiently 
positioned, prepared or equipped to respond to the 
issues created by the pandemic in an effective and 
expedient way. Despite ongoing concerns raised 
over several years prior to the pandemic, the public 
sector had not yet effectively addressed the sys￾temic weaknesses in the delivery of long-term care 
in Ontario. As well, we noted that, unfortunately, 
the list of emergencies in Regulation 79/10 under 
the Long-Term Care Homes Act, 2007 for which 
homes were required to develop an emergency 
response plan did not require them to be prepared 
for a pandemic emergency like COVID-19 before it 
occurred.
The Ministry’s preparedness, and its ability to 
respond quickly and effectively, was also hampered 
by issues such as the long-term-care sector’s lack of 
integration within the rest of the health-care sector, 
which could have provided the sector life-saving 
expertise on infection prevention and control from 
public health units.
Beginning in February 2020, the province imple￾mented a number of measures to deal with the 
impact of COVID-19 in an attempt to minimize its 
spread. Unfortunately, some of these measures also 
had unintended consequences on long-term-care 
home residents and staff by further contributing 
to crowding and staffing shortages. In addition 
to these unintended consequences, the province 
delayed mandating, as opposed to recommending 
certain measures, did not provide clear directions 
to homes, and did not inspect to ensure that homes 
were complying with containment measures.
There should be no surprises about what is 
noted and recommended in this report. Many of 
the issues and recommendations have either been 
previously highlighted or made by this Office, or 
were spoken about publicly or discussed in publi￾cations by the various stakeholders we met with 
during our audit.
ambiguous and open to interpretation. For 
example, contract staff—temporary staff 
who are hired through employment agencies 
to fill vacancies—were allowed to work in 
multiple homes. This appeared to be incon￾sistent with the intent of the order to restrict 
long-term-care home employees from working 
at multiple sites.
In late 2020, there were 78,824 beds in the 626 
homes across the province. As of August 31, 2020, 
Public Health Ontario had reported that 5,937 
long-term-care home residents and 2,643 staff had 
contracted COVID-19; 1,815 residents and eight 
staff had died from it. As of that date, long-term￾care home residents made up only 20.2% of total 
COVID-19 cases in Ontario but comprised 64.8% of 
all COVID-related deaths. The 1,815 residents and 
eight staff who died due to COVID-19 represented 
a 30.6% and 0.3% case fatality rate for residents 
and staff.
According to data from the National Institute on 
Ageing—a Ryerson University think tank focused 
on issues affecting Canada’s aging population—at 
40%, Ontario had the highest percentage of long￾term-care and retirement homes that were affected 
by COVID-19 in Canada as of October 31, 2020.
September 2020 marked the beginning of 
a second upward trend in the daily number of 
new cases in long-term-care homes, averaging 
eight resident and four staff cases per day. As of 
December 31, 2020, Public Health Ontario had 
reported that 11,143 residents and 4,329 staff in 
Ontario’s long-term-care homes had contracted 
COVID-19. An additional 985 residents died due 
to COVID-19 after August 31, 2020 for a total of 
2,800 residents by December 31, 2020; fortunately, 
the number of staff deaths remained unchanged 
at eight. 
With the arrival of vaccines, the number of 
COVID-19 outbreaks and deaths has been signifi￾cantly reduced in the long-term-care homes, but 
the long-standing systemic issues that place resi￾dents at risk remain to be addressed. 

12
In this context, the Ministry is currently 
working across three areas of focus:
• Pandemic response: while high rates of 
resident and staff vaccination have changed 
the current impact of COVID-19 on the long￾term-care sector, the Ministry and homes 
need to remain vigilant to respond to ongoing 
and emerging outbreaks and developments 
over the course of the pandemic.
• Recovery: developing and implementing an 
action-oriented recovery framework to assist 
the sector to transition into the new normal.
• Modernization: redoubling efforts to 
support sustainable, longer-term change in 
areas such as staffing and capital develop￾ment; improved performance, oversight 
and accountability; and improving quality 
of care, resident quality of life and public 
confidence.
Shortly, the Minister will be receiving the 
final report from the Long-Term Care COVID-19
Commission, which will have further findings 
and recommendations regarding the sector’s 
experience of COVID-19, including recommen￾dations on how to prevent the future spread of 
disease in long-term-care homes. In addition, 
the Ontario Ombudsman is undertaking an 
investigation into the government’s oversight of 
long-term care during the COVID-19 pandemic. 
The Ministry intends to consider and integrate, 
as appropriate, the recommendations from the 
Auditor General in this report, along with the 
recommendations from the Commission and 
the Ombudsman as they become available, as it 
prioritizes key short-, medium- and longer-term 
actions to improve the long-term-care sector, 
making it a safer place for residents to receive 
the care they need and experience a high 
quality of life.
Implementing the recommendations in this 
report should better prepare the Ministry and 
the long-term-care sector for the impact of future 
infectious disease outbreaks and other care issues 
on the residents in long-term-care homes. But 
equally, if not more importantly, implementing 
these recommendations will go a long way to 
ensure that our seniors living in long-term-care 
homes are accorded the dignity, safety and comfort 
that was originally envisioned and set out in 
Section 1 of the Long-Term Care Homes Act, 2007. 
Chapter 6 will examine the impact of insufficient 
PPE on the spread of COVID-19 in long-term￾care homes.
This report contains 16 recommendations with 
55 action items to address our audit findings.
OVERALL RESPONSE
The Ministry of Long-Term Care (Ministry) 
thanks the Auditor General and her team for 
the recommendations. The Ministry shares 
the goal of ensuring long-term-care residents 
are afforded the dignity, safety and comfort 
they deserve.
Prior to COVID-19, the Ministry was under￾taking steps to modernize the long-term-care 
sector to be more resident-centred and to 
provide high quality care responsive to resi￾dents’ needs. The Ministry was focused on the 
development of new long-term-care beds and 
redeveloping older beds to modern design stan￾dards; addressing long-standing and systemic 
challenges with long-term-care staffing and 
addressing the recommendations from the 2019 
Public Inquiry into the Safety and Security of 
Residents of the Long-Term Care Homes System.
The devastating experience and impact of 
COVID-19 on long-term-care residents, staff 
and their families and loved ones has shone a 
spotlight on the long-standing challenges in the 
sector—as well as additional issues that require 
urgent attention and reform. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 13
As shown in Figure 3, 57% of homes in Ontario 
are operated by for-profit entities. Under the Act, 
home operators are responsible for all aspects 
of operating their homes, including developing 
programs—such as those related to nursing and 
personal support, infection prevention and control 
(IPAC), nutrition, recreation and social activities—
and acquiring the necessary supplies, equipment 
(including personal protective equipment (PPE)), 
and staff to deliver those programs. Each home 
must also have an interdisciplinary team respon￾sible for implementing its IPAC program. The team 
must meet quarterly and invite the local medical 
officer of health to attend.
As of October 31, 2020, there were 78,824 
beds in the 626 homes across the province. The 
majority of those beds were classified as long-stay 
(Figure 4), meaning that they were designed 
for those who require care and assistance for an 
indefinite period of time. Long-term-care homes 
may also provide short-stay beds, including interim 
beds for those who are awaiting placement in a 
long-term-care home after their hospital stay, 
convalescent care beds for those who require 
temporary intensive supports, and respite beds to 
provide temporary relief for caregivers.
Bed Classification Based on Occupancy
Long-term-care home beds are also categorized 
based on when the home was built or renovated, 
and whether it was built or renovated according 
2.0 Background
2.1 Overview of Ontario’s Long￾Term-Care Sector 
The 626 long-term-care homes that were operating 
in Ontario at the time of our review are to provide 
accommodation, care and other services for adults 
who require access to 24-hour nursing and personal 
care, and assistance with most or all daily activities 
such as eating, bathing and dressing. 
The Long-Term Care Homes Act, 2007 (Act) 
governs the process for placing individuals into 
homes and the provision of care to residents of 
homes. The fundamental principle of the Act is that 
a long-term-care home is “to be operated so that it 
is a place where [residents] may live with dignity 
and in security, safety and comfort and have their 
physical, psychological, social, spiritual and cul￾tural needs adequately met.” 
All long-term-care homes, regardless of their 
ownership, must comply with the requirements 
under the Act and its regulation, Regulation 79/10 
(see Appendix 1 for key provisions of the Act and 
regulation applicable to this review).
2.1.1 Long-Term-Care Homes 
Homes are operated by either for-profit or 
not-for-profit entities (including municipalities). 
Figure 3: Types of Long-Term-Care Homes in Ontario, as of August 2019
Source of data: Ministry of Long-Term Care
Type of Long-Term-Care Home # of Homes
% of 
Total Homes # of Beds
% of 
Total Beds
For-profit homes 357 57 41,830 53
Not-for-profit homes (other than municipal homes) 169 27 20,117 26
Not-for-profit homes (municipal homes) 100 16 16,156 21
Total 626* 100 78,103 100
* Does not include one home that is licensed to operate but was temporarily closed at the time of our audit due to a flood. Also does not include beds under 
the Extended Care Capital Assistance Program (ELDCAP), which are long-term-care beds located in and operated by acute-care hospitals. The ELDCAP was 
established in 1982 to expand bed capacity in small Northern Ontario communities. 

14
has made minor updates to the Design Manual 
since 1999, with the latest updates occurring in 
2015. The current standards are based on the 2015 
Design Manual.
The Ministry classifies long-term-care home 
beds into one of five classifications ranging from 
New (full compliance with 1999 standards) to 
Level D (non-compliance with 1972 and 1999 stan￾dards). Figure 6 shows how beds that are currently 
in use are classified based on compliance with the 
1972 Regulation and 1999 Design Manual standards 
and how many beds are in each classification. 
to home design standards that were in place at the 
time of being built or renovated. 
Long-term-care home design standards were 
first established in 1972 in a regulation under 
the Nursing Homes Act, which was repealed in 
July 2010, when the Long-Term Care Homes Act, 
2007 took effect. In 1999, the then Ministry of 
Health and Long-Term Care released new design 
standards in its Long-Term Care Facility Design 
Manual (Design Manual). Figure 5 summarizes 
key relevant differences between the 1972 regula￾tion and the 1999 Design Manual. The Ministry 
Figure 4:Types of Roomsin Long-Term-Care Homesin Ontario, as of October 31, 2020
Source of data: Ministry of Long-Term Care
Description1 # of Beds
% of 
Total Beds
Long-Stay Beds2
Basic room A two-bed room accommodating two residents with a separate ensuite 
washroom. Also includes ward-style rooms designed to accommodate 
three to four residents, as was permitted under the 1972 Nursing Homes 
Act Regulation.
35,980 45.65
Semi-private room A one-bed room with an ensuite washroom that is shared with another 
one-bed room. 
13,421 17.03
Private room A one-bed room accommodating one resident with a separate ensuite 
washroom.
28,005 35.53
Subtotal 77,4613 98.273
Short-Stay Beds
Interim Beds Created to provide increased long-term-care capacity for Alternate Level of 
Care (ALC) hospital patients (i.e., hospital patients who no longer require 
acute hospital care), and who are eligible for long-stay admission but are 
on a waiting list for a home.
347 0.44
Convalescent-Care 
Beds
For individuals recovering after surgery or serious illness who require 
intensive supports for a temporary period of time. Residents in these beds 
are expected to return to the community within 90 days.
723 0.92
Respite Beds For individuals residing in the community whose caregivers require 
temporary relief from their caregiving obligations or individuals who require 
temporary care in order to continue to reside in the community. Residents 
in these beds are expected to return to their residences within 60 days 
after admission.
293 0.37
Subtotal 1,363 1.73
Total 78,824 100
1. Descriptions of the three types of long-stay beds are based on the Long-Term Care Home Design Manual, 2015, except as otherwise indicated.
2. Long-stay beds are for those residents who require 24-hour nursing care, substantial assistance with activities of daily living, and frequent supervision for an 
indefinite period of time. The vast majority of long-term-care home beds are long-stay.
3. The subtotal for long-stay beds does not equal the total when the number of beds in each room type (i.e. basic, semi-private, and private) are added up. 
The difference is due to known Ministry of Long-Term Care reporting issues. Because of this (and rounding), the individual percentages do not add up to the 
subtotal percentage. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 15
According to a 2019 report by the Financial 
Accountability Office of Ontario, in 2018/19, 
the median wait time for placement into a home 
was 152 days, or about five months. As of 
September 30, 2020, over 37,000 people were 
waiting for placement in a long-term-care home.
As described in our 2019 Annual Report, 
Volume 1, Section 3.05, Food and Nutrition in 
Long-Term-Care Homes, the needs of residents in 
homes have become more complex in the last 10 
years. For example, as noted in that report, as of 
March 31, 2019:
• residents had more complex health issues and 
were more physically frail;
• over 85% of residents needed extensive or 
24/7 daily assistance;
• the majority of residents required wheelchairs 
or walkers, and were dependent on personal 
support workers to move around the home; and
The current standards—limiting rooms to house 
only one or two residents, with a maximum of two 
residents sharing one bathroom—apply to operators 
of new homes as well as to operators who are apply￾ing to renew their licence for existing homes. We 
discuss the licensing process in Section 2.2.2.
2.1.2 Residents of Long-Term-Care Homes
Almost 78,000 residents live in the 626 long-term-care
homes, which typically operate close to capacity, 
across the province. Ontario’s aging population 
will likely increase the demand for safe long-term 
care and/or safe home care in the next 25 years. 
According to Statistics Canada, the proportion 
of the population aged 65 and over in Ontario is 
projected to increase from 16.9% in 2018 to as high 
as 26.1% in 2043. 
Figure 5: Key Waysin Which Bedroom Design Standardsin the 1972 Nursing Home Act Regulation and 
the Long‑Term Care Facility Design Manual, May 1999 Differ 
Prepared by the Office of the Auditor General of Ontario
Key Area of Difference 1972 Nursing Homes Act Regulation Long-Term Care Facility Design Manual, 
May 1999*
The extent to which a 
home-like setting is 
established 
Not applicable. Homes are to have Resident Home Areas: 
smaller, self-contained units within the home that 
give residents more intimate and familiar living 
spaces and support long-term-care home staff in 
providing care to residents.
Existence of rooms with 
three or four beds 
Rooms with three or four beds were allowed. Rooms with three or four beds are not permitted. 
There can be no more than two beds per room.
Bedroom sizes Single-bed rooms had at least 10.22 square 
metres (110 square feet) of floor space.
Two-bed rooms had at least 8.36 square metres 
(90 square feet) of floor space per resident.
Three-bed rooms had at least 8.36 square metres 
(90 square feet) of floor space per resident. 
Four-bed rooms had at least 7.43 square metres 
(80 square feet) of floor space per resident. 
Single bed rooms must have at least 
12.08 square metres (130 square feet) of floor 
space per resident.
Two-bed rooms must have at least 10.68 square 
metres (115 square feet) of floor space per 
resident.
Sharing of resident 
washrooms
One washroom served up to four residents. One washroom is to serve no more than two 
residents.
Note: The areas of differences listed are not exhaustive; only those areas relevant to aspects of this report are included.
* The objective of the 1999 standards was to create less institutional, more residential long-term-care homes that would provide a higher quality of life for 
residents. The standards applied to bedrooms that were new or renovated after May 1999.  

16
cancer. The average duration of a resident’s stay 
in long-term-care homes in Ontario was two years 
and eight months as of March 31, 2019—the most 
recent year for which this information is available.
According to a June 2020 Canadian Institute for 
Health Information (CIHI) report, the proportion of 
seniors (age 65 and older) living in long-term-care 
and retirement homes is higher in Canada than the 
average in Organisation for Economic Co-operation 
and Development (OECD) countries. In addition, 
compared with other OECD countries, residents in 
Canadian long-term-care and retirement homes are 
older, with 91% of residents over 65 years old and 
74% over 80 years old (see Figure 8).
• about one-third of residents had severely 
impaired cognitive abilities—64% had dementia 
(a progressive disease that affects all aspects 
of functioning).
Figure 7 shows a profile of long-term-care 
residents in Ontario from information as of 
March 31, 2009 and March 31, 2020. Over the 
last 11 years, the proportion of residents with 
complex care needs has increased. For example, 
since 2009, the proportion of residents with heart 
disease and dementia has increased by 14.3% and 
12.5%, respectively. As of March 31, 2020, 75.9% of 
residents had heart disease, 63.2% had dementia 
(including Alzheimer’s disease), 28% had diabetes, 
18.3% had lung diseases such as asthma and chronic 
obstructive pulmonary disease, and 9.7% had 
Figure 6: Bed Classifications as Defined under Ministry of Long-Term Care Design Standards
Source of data: Ministry of Long-Term Care
Bed
Classification Description
Term of 
Licence1
(Years)
Total # 
of Beds2
% of
Total 
Beds 
New bed Complies with the 1999 Long-Term Care Facility Design Manual, or 
was upgraded in accordance with the 2002 Long-Term Care “D” Retrofit 
Facility Design Manual, or the 2009 or 2015 Long-Term Care Home 
Design Manual.
3
304 39,508 50.6
A bed Substantially complies with the Long-Term Care Facility Manual, May 1999. 254 6,986 9.0
B bed Substantially exceeds the structural standards of the 1972 Nursing Homes 
Act Regulation (1972 standards), but does not meet “A” bed criteria, which 
limits the room occupancy to two residents.
15 5,628 7.2
C bed Meets the structural standards of the 1972 standards, which allowed 
three- and four-bed wards.
15 24,635 31.5
Upgraded 
D bed
Does not meet the 1972 standards but was upgraded to comply with the 
Ministry’s 2002 D Bed Upgrade Option Guidelines. This involved spending 
at least $3,500 per bed on approved improvements to benefit resident 
health, safety or well-being.
10 1,346 1.7
Total 78,1035 100
1. Licences issued to municipal homes do not expire.
2. As of August 2019. 
3. There were no significant changes in standards from 1999 to 2015 related to bedroom design. 
4. Under the Long-Term Care Homes Act, 2007 (Act), licences are issued for a term of 30 years or less, depending on the bed classification. In January 2015, 
the Act was amended to extend the term of licences for “New” and “A” beds by an additional five years, subject to the requirements of the Act.
5. Does not include beds in one home that is licensed to operate but was temporarily closed at the time of our audit due to a flood. Also does not include beds 
under the Extended Care Capital Assistance Program (ELDCAP), which are long-term-care beds located in and operated by acute-care hospitals. The ELDCAP 
was established in 1982 to expand bed capacity in small Northern Ontario communities. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 17
Figure 7: Profile of Long-Term-Care Residentsin Ontario
Source of data: Canadian Institute for Health Information and Ministry of Long-Term Care
As of March 31, 2009 As of March 31, 2020 % Change
Resident Demographics1
Total # of residents 75,960 77,968 2.6
Average age of residents (years) 83 83 —
% of residents under 65 years old 6.4 6.4 —
% of residents aged 85 years or older 50.0 54.6 9.2
% of female residents 68.8 66.8 (2.9)
% of male residents 31.2 33.2 6.4
% of Residents with the Following Health Characteristics1,2
Cancer 9.2 9.7 5.4
Dementia, including Alzheimer’s disease 56.2 63.2 12.5
Diabetes 24.0 28.0 16.7
Heart disease3 66.4 75.9 14.3
Arteriosclerotic heart disease 11.8 15.6 32.2
Congestive heart failure 12.1 12.7 5.0
Hypertension 50.0 64.1 28.2
Lung disease3 16.0 18.3 14.4
Asthma 3.4 5.0 47.1
Emphysema/chronic obstructive pulmonary disease 
(COPD)
13.8 15.1 9.4
% of Residents with the Following Functioning Characteristics1
Dependent or totally dependent on assistance for eating, 
mobility, toilet use, hygiene4
35.8 35.6 (0.6)
Severe impairment of cognitive performance5 30.7 33.6 9.4
Signs of depression6 28.1 27.4 (2.5)
Limited or no social engagement7 45.5 40.3 (11.4)
Average Duration of Resident Stay 2 years, 7 months8 2 years, 8 months8 —
1. According to the Canadian Institute for Health Information’s (CIHI) Profile of Residents in Residential and Hospital-Based Continuing Care.
2. Percentages are based on total residents divided by total number of residents assessed. Patients may be assessed for multiple health-care characteristics.
3. These percentages are for residents with at least one of any type of heart or lung disease. The most prevalent types of heart or lung disease are shown in 
the indented rows below. Residents with more than one type of heart or lung disease are included in the percentages for each disease. For this reason, the 
percentages of residents with specific types of heart or lung disease add up to more than the percentage of residents with at least one type of heart or lung 
disease.
4. Based on a scale from 0–6, with 0 being independent and 6 being totally dependent, as per aggregate assessment scores recorded by long-term-care 
homes and collected by the CIHI. Includes residents that scored dependent (5) and totally dependent (6).
5. Based on a scale from 0–6, with 0 being cognitively intact and 6 being very severely impaired, as per aggregate assessment scores recorded by long-term￾care homes and collected by the CIHI. Includes residents that scored moderate/severe (4), severe (5), and very severe (6) impairment.
6. Based on a scale from 0–14, with a score of 3 or greater indicating the potential presence of a depressive disorder, as per aggregate assessment scores 
recorded by long-term-care homes and collected by the CIHI. Includes residents scoring 3 (i.e., possible depressive disorder) or higher.
7. Based on a scale from 0–6, with 0 having the lowest social engagement and 6 being the highest social engagement, as per aggregate assessment scores 
recorded by long-term-care homes and collected by the CIHI. Includes residents that scored 1 or lower.
8. Average duration of resident stay as of December 31, 2011 (as per Office of the Auditor General of Ontario, 2019 Annual Report, Volume 1, Chapter 3, 
Section 3.05, Food and Nutrition in Long-Term-Care Homes, page 296) and as of December 31, 2019 (as per the Ministry of Long-Term Care). 

18
• a Director of Nursing and Personal Care who 
is a registered nurse who supervises and directs 
the nursing staff and personal care staff; and
• a Medical Director who is a physician who 
evaluates and addresses medical practices, 
clinical procedures and resident care (this indi￾vidual cannot be the licensee, a person having a 
controlling interest in the licence or a member 
of the board of a corporate licensee).
Either a physician or a nurse practitioner is 
required to conduct a physical examination of each 
resident upon admission and annually. As well, at 
least one registered nurse needs to be on duty and 
present in the home at all times (this individual 
must be an employee of the home and a member of 
the regular nursing staff of the home). 
The Act does not prescribe minimum staffing 
requirements beyond the ones just noted, but does 
require that homes have a staffing plan in place that 
provides for a staffing mix that is consistent with 
residents’ care and safety needs.
According to data from the Ministry of Long￾Term Care’s 2018 staffing report, 61% of homes’ 
employees were personal support workers (PSWs), 
who help residents with activities of daily living 
such as feeding, bathing and hygiene. Registered 
nursing staff—including registered practical 
nurses, registered nurses and nurse practitioners 
combined—comprised the second-largest type of 
staff, making up about 28% of all employees. The 
remaining 11% of employees provided support and 
administrative services.
In addition to paid employees, volunteers, resi￾dents’ family members and private caregivers who 
are hired and paid by residents’ families also help 
provide care and emotional support to residents, 
including feeding, grooming and bathing them, 
and helping them to exercise. According to the 
Ontario Caregiver Organization, there are about 
3.3 million caregivers in Ontario. The Ontario 
Caregiver Organization is a not-for-profit organiz￾ation funded by the Ministry of Health to serve as 
one point of access to information for individuals 
without medical training who provide physical 
2.1.3 Long-Term-Care Staff
According to data from the Ministry of Long-Term 
Care’s latest available staffing study (released in 
July 2020), in 2018 over 82,500 people worked 
in long-term-care homes in Ontario (see Figure 9
for information on staffing, duties and qualifica￾tions). This consisted of 43% full-time employees, 
45% part-time employees, and 12% casual and 
purchased services. An additional 12,500 people 
worked as cleaners and cooks, bringing the total to 
about 100,000 people working in the sector.
The Long-Term Care Homes Act, 2007 (Act) 
requires each home to have a person in the following 
positions: 
• an Administrator who is in charge of the home 
and is responsible for its overall management;
Figure 8: Age of Residents in Long-Term-Care and 
Retirement Homesin Organisation for Economic
Co-operation and Development Countries
Source of data: Canadian Institute for Health Information*
% of Residents
Aged 65+ Aged 80+
Australia 94 75
Belgium 96 78
Canada 91 74
France 90 Data not available
Germany 87 65
Hungary 68 40
Ireland 95 Data not available
Israel 92 65
Netherlands 66 48
Norway 90 68
Portugal 84 50
Slovenia Data not available 57
Spain 87 69
United States 84 54
Average 86 62
* Data tables relating to the Canadian Institute for Health Information’s 
June 2020 report titled Pandemic Experience in the Long-Term Care 
Sector: How Does Canada Compare With Other Countries. These data 
tables provide information on the long-term-care sector in 17 countries in 
the Organisation for Economic Co-operation and Development countries. 
Data was collected as of May 25, 2020 from various international and 
national sources. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 19
Figure 9: Staffing1
 in Long-Term-Care Homes in Ontario, 20182
Source of data: Ministry of Long-Term Care
Type of Staff Duties and Qualifications #
% of 
Total 
Staff
Type of Employment (%)
Full￾Time3
Part￾Time
Casual and 
Purchased 
Services4
Personal support 
workers and health 
care attendants/
aides
• Assist residents with activities of daily 
living such as eating, bathing and walking, 
and perform light housekeeping duties 
and tasks delegated by registered health 
professionals. 
• May have a Personal Support Worker 
Certificate from an accredited college in 
Ontario.
• The profession is unregulated. 
49,978 61 42 48 10
Registered practical 
nurses (RPNs)
• Care for residents with less complex needs. 
• Completed a post-secondary nursing 
program at the college level.
• Profession is regulated under the Nursing 
Act, 1991 and by the College of Nurses of 
Ontario. 
15,263 18 39 45 16
Allied health 
professionals and 
programming 
support staff
• Dietitians, occupational and physical 
therapists, social workers and others 
providing support and administrative 
services.
• Qualifications and education vary according 
to profession.
9,405 11 60 31 9
Registered nurses 
(RNs)
• Care for residents with more complex needs 
and less predictable conditions. 
• Must have a bachelor’s degree. 
• Profession is regulated under the Nursing 
Act, 1991 and by the College of Nurses of 
Ontario.
7,846 10 40 42 18
Nurse practitioners 
(NPs)
• Can diagnose, prescribe medication, 
perform procedures, and order and interpret 
diagnostic tests. 
• Must have an advanced university 
education such as a master’s degree or 
other specialty certificates.
• Profession is regulated under the Nursing 
Act, 1991 and by the College of Nurses of 
Ontario.
67 <1 63 35 2
Total 82,559 100 43 45 12
1. Actual number of staff (not full-time equivalent).
2. Based on the Ministry’s long-term-care staffing report, which is generated from the voluntary submission of a staffing survey completed by long-term-care 
homes. In the latest report (2018), 602 of 626 homes submitted data.
3. For the purposes of the long-term-care staffing report, full-time is defined as an employee who is regularly scheduled for work 75 hours or more on a 
biweekly basis.
4. Casual employees work irregular hours and have no guaranteed hours of work, are not entitled to leave time and are not required to provide statutory notice 
for termination unless otherwise stated in the employment agreement. 

20
The Health Protection and Promotion Act (HPPA) 
provides for the organization and delivery of public 
health programs and services, prevention of the 
spread of diseases, and promotion and protec￾tion of the health of Ontarians. Under the HPPA, 
the Ontario Chief Medical Officer of Health (who 
reports to the Deputy Minister of Health) may 
issue directives specifying precautions and pro￾cedures to be followed by health-care providers, 
which include long-term-care homes. Under the 
HPPA, local medical officers of health (who report 
to local municipal Boards of Health) may order 
institutions, such as long-term-care homes, to take 
specific actions for the purposes of monitoring, 
investigating and responding to an outbreak of 
communicable disease. Local public health units 
have the legislated ability to inspect long-term-care 
homes for public health-related matters, including 
infection prevention and control matters.
The Emergency Management and Civil Protection 
Act authorizes the Premier of Ontario and the 
Executive Council of Ontario to declare a state of 
emergency and issue emergency orders. It also 
requires, under section 6, ministries to develop 
emergency plans for certain types of emergencies 
as assigned to them by the Lieutenant Governor 
in Council through an Order in Council. Order 
in Council (OIC) 1157/2009 assigns the Minis￾ter of Health and the Minister of Long-Term Care 
the responsibility to develop emergency plans in 
respect of human health, disease and epidem￾ics; health services during an emergency; and 
continuity of operations. The OIC requires that 
such emergency plans describe how the minis￾tries will manage human health emergencies and 
ensure continued access to health services through 
continued engagement with partners including 
public health units, long-term-care facilities, and 
hospitals. 
See Appendix 1 for a list of key provisions of the 
above laws that are relevant to this report.
and emotional support to a family member, 
partner, friend or neighbour. A November 2019 
report by the Ontario Caregiver Organization and 
The Change Foundation—an independent health 
policy think tank—stated that 13% of Ontario 
caregivers they surveyed reported providing care 
to their loved one in an institution such as a long￾term-care home. 
2.2 Provincial Involvement with 
the Long-Term-Care Sector 
In June 2019, the province separated the respon￾sibilities of the former Ministry of Health and 
Long-Term Care into two separate ministries: 
the Ministry of Health and the Ministry of Long￾Term Care. 
The Ministry of Health sets the priorities for 
Ontario’s health system, including both public 
health and health care. The Patient Ombudsman 
reports into the Minister of Health. 
The Ministry of Long-Term Care licenses and 
regulates long-term-care homes, including con￾ducting inspections required under the Long-Term 
Care Homes Act, 2007. It also provides funding, 
through Local Health Integration Networks 
(LHINs), to long-term-care homes for beds that are 
co-funded by residents.
Appendix 2 provides a schematic overview of 
Ontario’s health-care system related to long-term 
care as of April 1, 2021.
2.2.1 Legislation
The Long-Term Care Homes Act, 2007 (Act), which 
came into effect on July 1, 2010, and its Regulation 
79/10, set out standards for all long-term-care
homes in Ontario. The Act covers residents’ rights, 
care and services; admission of residents; operation 
of homes; and funding and licensing of homes. 
It also provides the Ministry of Long-Term Care 
(Ministry) with the power to inspect homes to 
ensure that they are complying with the legislation 
and to take enforcement actions, if necessary.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 21
In July 2018, the province announced it would 
invest $1.75 billion to build 15,000 new beds and 
renovate 15,000 old beds by 2023. Subsequently, 
in July 2020, the province announced that the 
$1.75-billion investment would result in 8,000 
new beds and 12,000 renovated beds by 2025. 
In addition, the province announced in the 2020 
Ontario Budget that it would fast track, through its 
Accelerated Build Pilot Program (Pilot Program), 
the planned construction of four long-term-care 
homes in Mississauga, Toronto and Ajax that are 
intended to have 1,280 beds ready for occupancy 
by early 2022. The Pilot Program intends to use 
modular construction (a process in which a build￾ing is constructed offsite in modules and then 
assembled onsite), rapid procurement, and lever￾age hospital lands to complete construction of the 
long-term-care homes years faster than traditional 
construction timelines.
As of September 2020, the licences for over 
26,500 beds in 257 homes across the province were 
set to expire in 2025. The Ministry did not have 
information about how many of the 26,500 beds 
are in rooms that are designed and operated to 
house three or four residents. 
2.2.3 Funding 
In 2019/20, a total of $6 billion was collected by 
long-term-care homes: $4.4 billion in Ministry 
funding and $1.6 billion in resident co-payments. 
Annual provincial funding to long-term-care homes 
has increased by 12.8% between 2015/16 and 
2019/20 (Figure 10). Increases averaged about 
2.7% per year. The Ministry co-funds, along with 
residents, long-term-care home operations in 
Ontario as follows:
• Residents pay room and board charges based on 
rates set by the Ministry, which include the cost 
of food and other accommodation services such 
as housekeeping, food service, maintenance and 
administration. Effective July 1, 2019, the daily 
rate was $62.18 for basic (two- to four-bed rooms 
with a common washroom), $74.96 for semi￾private, and $88.82 for private accommodation. 
2.2.2 Licensing
The Ministry of Long-Term Care issues licences to 
long-term-care home operators under the Long-Term 
Care Homes Act, 2007 for terms of up to 30 years 
based on bed classifications (Figure 6). Home 
operators who want to obtain a new licence or 
renew an existing one are required to build the new 
homes or renovate existing homes to comply with 
current design standards in the Ministry’s Long￾Term Care Facility Design Manual (Design Manual) 
(discussed in Section 2.1.1).
In cases where home operators renewing their 
licence cannot fully comply with current standards 
within the existing structure of the home, home 
operators can request permission from the Min￾istry to follow “Design Variance Standards” when 
renovating the home. For example, two-bed rooms 
may have 9.75 square metres of floor space instead 
of 10.68 square metres, as required by current 
standards. Design Variance Standards do not apply 
to new construction and only apply to renovation 
projects.
In 2002, 2007, 2014, and 2018 the Ministry 
launched bed renewal initiatives to support the 
renovation of Level B, C and D beds to comply 
with the current standards. These initiatives have 
been relatively unsuccessful; as shown in Figure 6, 
nearly one-third of beds are still categorized as C 
or D beds despite the 1999 design standards being 
in place for two decades. Through those initiatives, 
the Ministry provided construction funding subsidies 
to home operators once the renovations were 
completed. 
Home operators were primarily responsible 
for raising the funds for the land and other capital 
costs of the renovation. The Ministry would then 
pay the home operator the subsidy—calculated on 
a per bed per day basis—for a period of up to 25 
years. In September 2020, the Ministry updated its 
funding model to retroactively apply to all projects 
that started since June 2018. The policy now pro￾vides home operators with an upfront development 
grant as well as an enhanced funding subsidy—still 
payable over 25 years. 

22
The actual amount a home receives from the 
Ministry can vary depending on the following:
• its occupancy rate; 
• the complexity of residents’ medical needs, 
measured using the Case Mix Index—the rela￾tive measure of average resources required to 
provide for residents’ needs; and 
• how much money has been collected from resident 
co-payments. Although there is a daily rate set 
for resident co-payments, the actual amount 
collected from resident co-payments may be less 
than the daily rate set by the Ministry because 
the amounts charged to residents are adjusted 
based on their ability to pay the full rate. About 
35% of residents receive financial assistance 
(to subsidize or cover part of their co-payments) 
from the Ministry to pay for accommodation. 
• Homes receive Ministry funding through the 
LHINs for four categories: nursing and personal 
care; program and support services; raw food; 
and other accommodations (Figure 11). While 
most Ministry funding flows through the LHINs, 
some of it is provided directly by the Ministry.
Figure 10: Provincial Funding to Long-Term-Care
Homes, 2015/16–2019/20 ($ billion)
Source of data: Ministry of Long-Term Care
Fiscal Year Amount Change % Change
2015/16 3.9 — —
2016/17 4.0 0.1 2.6
2017/18 4.1 0.1 2.5
2018/19 4.3 0.2 4.9
2019/20 4.4 0.1 2.3
Total 20.7 0.5 12.8
Figure 11: Ministry of Long-Term Care Per Diem Funding Per Resident to Long-Term-Care Homes by Funding
Categories, April 2020
Source of data: Ministry of Long-Term Care
Funding Category Details
Amount 
($)
Allocation 
(%)
Nursing and 
Personal Care
• Includes wages, benefits and training for direct-care staff, as well as any 
equipment or supplies used by direct-care staff to provide nursing and 
personal care to the residents. 
• Staff in this category include registered nurses, registered practical nurses, 
and personal support workers who, beyond clinical duties, provide eating 
assistance to residents.
102.34 57
Program and 
Support Services
• Includes staff, equipment and supplies used to provide services and 
programs to residents. 
• Staff in this category include Registered Dietitians, physiotherapists, 
occupational therapists, social workers, recreational staff and others that 
provide support services to residents.
12.06 7
Raw Food • Strictly for the purchase of raw food materials, including food supplements 
ordered by a physician, a nurse, or a Registered Dietitian.
• Includes the resident portion of food for special events (like Christmas 
dinners), but does not include any non-resident guests like family.
9.541 5
Other 
Accommodations
• Includes other eligible expenditures defined in the Ministry’s policy that are 
not included in the above categories, such as dietary services (i.e., food 
service workers, cooks), housekeeping services, property operations and 
maintenance, and general and administration services.
56.521 31
Total 180.462 100
1. Ministry funds up to this amount after the long-term-care home applies the residents’ co-payments to this category.
2. Amount is the base rate for residents with the lowest complexity of needs. The Ministry uses a formula to adjust this base per diem rate according to the 
overall complexity score of the residents in the long-term-care home. For 2020/21, the Ministry provided additional per diem funding of $4.50 per resident 
to enhance direct-care services and support other operating costs within any of the four categories. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 23
receives and assesses each complaint and critical 
incident report (from any source) and determines 
whether an inspection is required. Complaints 
and critical incidents that require an inspection 
are referred to one of seven regional offices, 
which are located in London, Waterloo, Hamilton, 
Toronto, Sudbury, Oshawa and Ottawa. As of 
December 31, 2020, there were 143 inspectors 
across the regional offices. The number of inspectors 
in each regional office ranged from 17 in Waterloo 
to 26 in Sudbury (Figure 12). There was a total of 
41 vacant positions across the province.
At the time of our 2015 audit of the Long-Term￾Care Home Quality Inspection Program (Program), 
there were four types of inspections: compre￾hensive inspections, critical incident inspections, 
complaints inspections and follow-up inspections. 
Critical incident and complaints inspections are 
conducted in response to reports of critical inci￾dents such as fire, unexpected or sudden death, 
or outbreaks of communicable diseases, and 
complaints related to care received by residents. 
Comprehensive inspections are proactive inspec￾tions designed to look at different aspects of a 
long-term-care home’s operations (Appendix 4). 
Figure 13 shows the number of long-term-care 
Some homes may also receive additional 
funding beyond what they receive from the Ministry 
and their residents. For instance, not-for-profit 
homes may receive additional funding through 
fundraising efforts, and municipal homes may 
receive additional funding from their municipality.
2.2.4 Ministry Inspections of Long-Term￾Care Homes 
The Act requires the Ministry to inspect, without 
prior notice, each long-term-care home at least 
once a year. However, the Act does not specify what 
type of inspection must be done, or that all aspects 
of each home’s operations must be inspected 
annually. 
The Act also requires the Ministry to perform 
inspections if it receives information from any 
source that certain incidents have occurred, such 
as improper or incompetent care of a resident, that 
have resulted in serious harm or significant risk of 
serious harm to the resident. 
The Ministry’s Long-Term Care Inspections 
Branch (Appendix 3) is responsible for inspecting 
long-term-care homes to ensure compliance with 
the Act and its Regulation 79/10. A centralized 
intake unit in Hamilton, with nine triage officers, 
Figure 12: Number of Inspectors by Region, as of December 31, 2020
Source of data: Ministry of Long-Term Care
Region # of Homes # of Beds # of Inspectors
# of Beds per 
Inspector
Central East (Kingston) 88 11,783 19 620
Central West (Waterloo) 88 9,100 17 535
Hamilton 92 11,593 20 580
London 89 10,365 20 518
Ottawa 94 11,393 20 570
Sudbury 87 9,453 26 364
Toronto 88 15,142 21 721
Total 626 78,829 143* 551
* Represents actual number of inspectors. There were a total of 41 vacancies across the province as of December 31, 2020: seven in Central East, eight in 
Central West, six each in Hamilton, London, Ottawa and Toronto, and two in Sudbury. 

24
public health programs that are delivered by 
34 local public health units across the province. 
The local public health units—each led by a 
local medical officer of health and accountable to 
a local board of health—deliver programs focused 
on preventing and controlling communicable 
diseases. The Ministry of Health and municipalities 
fund local public health units. From a govern￾ance perspective, local public health units do not 
report to Public Health Ontario or to the Chief 
Medical Officer of Health. However, the Chief 
Medical Officer of Health has the authority, under 
the Health Protection and Promotion Act (HPPA) 
(discussed in Section 2.2.1), to direct public 
health units to implement public health actions in 
response to a public health risk or emergency.
Under section 10(1) of the HPPA, every local 
medical officer of health has a duty to conduct 
inspections within their jurisdiction for the purpose 
home inspections conducted by Ministry inspectors 
from 2015 to 2020. 
Beginning in August 2016, the Ministry imple￾mented a shorter, more focused comprehensive 
inspection approach, which we described in our 
2017 follow-up report on the Program. In fall 2018, 
the Ministry discontinued comprehensive inspections 
to address its inspection backlog of complaints and 
critical incident reports. Since 2019, the Ministry 
has primarily conducted complaint and critical 
incident inspections. 
2.2.5 Public Health Inspections of
Long-Term-Care Homes 
Public Health
Within the Ministry of Health, the Office of the 
Chief Medical Officer of Health is responsible for 
developing public health initiatives and monitoring 
Figure 13: Numbers of DifferentTypes of Long-Term-Care Home Inspections Conducted, 2015–2020
Source of data: Ministry of Long-Term Care
Type of Inspection 2015 2016 2017 2018 2019 20201
Complaint2 764 756 512 611 1,055 456
Comprehensive3 625 611 636 370 7 0
Critical Incident4 615 559 394 526 1,400 696
Follow-up5 336 254 258 224 331 103
Other6 18 20 13 23 50 21
Total 2,358 2,200 1,813 1,754 2,843 1,276
1. Covers only the eight months from January 2020 to August 2020.
2. The Ministry receives complaints from residents, their family members and the public, mostly by phone (through a toll-free ServiceOntario Action Line), 
but also in person and by email or fax. The Ministry’s centralized intake unit reviews the complaints received to decide whether an inquiry or inspection is 
warranted. If yes, the unit assigns a risk level to each case: from low (level 1—minimal risk) to high (level 4—immediate jeopardy and serious or significant 
risk of harm). The Long-Term Care Homes Act, 2007 (Act) Act stipulates that high-risk complaints be inspected immediately, while the Ministry aims to 
inspect medium-risk (level 3 and 3+) complaints within 30 days. Complaint inspections normally involve one to two inspectors who use the inspection 
protocol(s) that best match the nature of the complaint.
3. Also known as resident quality inspections (RQIs). RQIs are proactive inspections designed to review the entire operation of a long-term-care home and 
involve examining issues more generally than complaint or critical incident inspections. In fall 2018, the Ministry decided to halt conducting RQIs and 
instead perform a greater number of complaint, critical incident and follow-up inspections in order to address the growing backlog of complaints and critical 
incidents that required inspection.
4. Long-term-care homes must immediately report critical incidents to the Ministry. Such incidents include fire, neglect or abuse of residents, improper care, 
misuse of residents’ money, unlawful conduct, unexpected or sudden death, residents missing for more than three hours, missing residents who return with 
an injury or adverse change in condition, outbreaks of reportable or communicable diseases, and contamination of the drinking water supply. For other 
incidents, such as resident falls resulting in a significant change in condition that requires a hospital visit, failures of the home’s security or other major 
systems for more than six hours, and missing medication, homes are required to inform the Ministry within one business day. Homes report critical incidents 
through a web-based tool called the Critical Incident System or through a pager if the incident occurs after business hours. The inspection process to 
address a critical incident is the same as the process for complaint inspections described above.
5. If an inspection results in a long-term-care home being issued a compliance order, the Ministry must conduct a follow-up inspection to ensure that the home 
has followed the order by the deadline given and that the issue has been rectified. This also includes a Director’s Order follow-up inspection, which is to 
follow up on a compliance order that may have been issued by the Director under the Act.
6. These types of inspections may include proactive types of inspections initiated by the service area office. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 25
they receive a complaint relating to infection 
prevention and control at the home. Otherwise, 
the protocol requires boards of health to use a 
“risk-based approach” to determine the prior￾ity and need for additional inspections, which 
could include proactive inspections of long￾term-care homes within their area. 
• The Ministry of Health’s 2018 Institutional/
Facility Outbreak Management Protocol 
(Appendix 5) requires every public health unit 
to assist long-term-care homes in establishing 
and reviewing their written outbreak response 
plans, at a minimum, once every two years.
2.2.6 Health Sector and the Reorganization
Under Way
In March 2019, the province announced its plan 
to create a central agency under the Ministry of 
Health, called Ontario Health, to oversee health￾care delivery across the province, including health 
care delivered in long-term-care homes. 
In December 2019, the following five provincial 
health agencies merged with Ontario Health: 
Cancer Care Ontario, eHealth Ontario, HealthForce 
Ontario Marketing and Recruitment Agency, Health 
Quality Ontario, and Health Shared Services Ontario. 
In addition, the Minister of Health transferred 183 
executive level non-home and community care 
employees of the 14 Local Health Integration Net￾works (LHINs) to Ontario Health. However, unlike 
the five provincial health agencies, the LHINs 
(Crown agencies that are responsible for co-ordin￾ating health services at a local level) did not fully 
merge with Ontario Health. 
Ontario Health was responsible for overseeing 
the operational reorganization of the 14 LHINs 
into five interim geographical regions. In addition, 
delivering home and community care is scheduled 
to eventually move from the LHINs to local Ontario 
Health Teams. First announced in December 2019, 
Ontario Health Teams were established with the 
intention to make it easier for patients to transi￾tion from one health-care provider to another—for 
of “preventing, eliminating, and decreasing the 
effects of health hazards.” Local medical officers of 
health are appointed by the local board of health 
to manage the local public health unit. The HPPA 
specifically requires local medical officers of health 
to inspect food premises, including any food and 
equipment, and premises used or intended to be 
used as a boarding or lodging house. The HPPA 
does not define what constitutes a boarding or 
lodging house. Local public health units are not 
specifically required to proactively inspect long￾term-care homes under the HPPA, but can issue 
precautionary and procedural directives regarding 
communicable diseases to long-term-care homes 
or require long-term-care homes to take corrective 
action to address an identified outbreak.
Also, under section 10(1) of the HPPA, Ontario’s 
public health units are each responsible for imple￾menting programs for infection prevention and 
control, which includes conducting inspections of 
settings associated with a risk of infectious disease 
transmission. These inspections are to be carried 
out in accordance with Ministry of Health protocols 
and guidelines on infection prevention and control.
The Ministry of Health sets infection preven￾tion and control standards and policies through the 
Ontario Public Health Standards. These Standards, 
established under section 7 of the HPPA, identify 
the minimum expectations for public health pro￾grams and services to be delivered by each board of 
health (public health unit). One of those programs 
is infection prevention and control. Specific inspec￾tion requirements for public health units are the 
following:
• The Ministry of Health’s 2019 Infection Preven￾tion and Control Protocol requires every board 
of health to inspect all licensed child care and 
personal service settings at least once every 
12 months. In contrast, there is no similar 
requirement for boards of health to conduct an 
annual inspection of long-term-care homes for 
adherence to infection prevention and control 
practices. However, public health units may be 
required to inspect a long-term-care home if  

26
The most common symptoms of COVID-19 are 
similar to those of the flu or a cold. They include 
fever, a dry cough, difficulty breathing and fatigue. 
It is not yet clear what the long-term implications 
are of contracting COVID-19.
According to the World Health Organization 
(WHO), people over 60 years old and those with 
underlying conditions such as hypertension, dia￾betes, cardiovascular disease, chronic respiratory 
disease and cancer are at the highest risk for severe 
symptoms and death from COVID-19. Mortal￾ity increases with age, with the highest mortality 
among people over 80 years of age. Mortality also 
increases with the presence of comorbidities (that 
is, other diseases or conditions that are present at 
the same time as being infected with COVID-19; 
conditions described as comorbidities are often 
chronic or long-term). 
According to the February 2020 report, World 
Health Organization-China Joint Mission on Corona￾virus Disease 2019, which was intended to enhance 
understanding of the COVID-19 outbreak in China 
to inform international containment measures, as 
of February 20, 2020, the mortality rate was 13.2% 
for those with cardiovascular disease, 9.2% for those 
with diabetes, 8.4% for those with hypertension, 
8% for those with chronic respiratory disease, and 
7.6% for those with cancer. In comparison, the mor￾tality rate for those with no comorbid conditions 
was 1.4%. 
According to Statistics Canada, 54% of the 
over 9,500 individuals who died from COVID-19
between March 1, 2020 and July 31, 2020 in 
Canada were aged 85 or older. About 2,770 or 
29% of these individuals were residents of Ontario 
long-term-care homes. The majority (90%) of 
the 9,500 individuals had at least one comorbid 
condition. The most common comorbid condition 
was dementia, which was present in 38% of all 
COVID-19-related deaths. Other common com￾orbidities were pneumonia (33%), hypertensive 
diseases (15%), heart disease (13%), respiratory 
failure (13%), renal failure (12%) and diabetes 
example, between hospitals and home-care provid￾ers—by having one patient record and one care 
plan. Under Ontario Health Teams, health-care 
providers in the same region are to work as one co￾ordinated team.
All applications and placements in long-term￾care homes in Ontario were previously arranged 
by the 14 LHINs (renamed Home and Commun￾ity Care Support Services effective April 1, 2021). 
The LHINs were also responsible for distributing 
Ministry of Long-Term Care funding to long-term￾care homes. Effective April 1, 2021, the LHINs’ 
planning, funding and integration functions, 
including oversight of funding, were transferred to 
Ontario Health. 
Until the full transition of LHINs into Ontario 
Health Teams is completed, LHINs, operating as 
Home and Community Care Support Services, 
will continue their day-to-day activities in their 
current jurisdictions, including delivering home 
and community care and long-term-care placement 
services.
In April 2019, the province also proposed 
changes to Ontario’s public health system as part 
of the 2019 Ontario Budget, including reducing the 
number of public health units from 35 (at the time; 
now only 34) to 10 by March 2021 and creating 10 
new autonomous boards of health with regional 
and local representation. Consultations were put on 
hold in mid-March 2020 to allow public health to 
respond to the COVID-19 pandemic.
2.3 Impact of COVID-19 on Ontario 
Long-Term-Care Homes
2.3.1 The Global COVID-19 Pandemic
COVID-19 is one strain (type) of seven known 
strains of disease called coronaviruses. Like another 
coronavirus strain familiar to Ontarians, severe 
acute respiratory syndrome (SARS), it presents a 
danger to people’s health and can lead to death in 
severe cases.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 27
residents and 19 staff per day, to an average low of 
one resident and one staff per day in August 2020. 
As of August 31, 2020, Public Health Ontario had 
reported that 5,937 residents and 2,643 staff had 
contracted COVID-19, and 1,815 residents and 
eight staff had died from it. For the purposes of this 
report, the initial wave of COVID-19 refers to the 
period up to August 31, 2020.
As of August 31, 2020, long-term-care home 
residents were reported to make up 20.2% of total 
COVID-19 cases in Ontario, but comprised 64.8% 
of all COVID-related deaths. The 1,815 residents 
and eight staff who were reported to have died due 
to COVID-19 represented a 30.6% and 0.3% case 
fatality rate for residents and staff who had con￾tracted COVID-19. 
September to December 2020 
September marked the beginning of a new upward 
trend in the daily number of new cases, averaging 
eight resident and four staff cases per day. As of 
December 31, 2020, Public Health Ontario had 
reported that 11,143 residents and 4,329 staff in 
Ontario’s long-term-care homes had contracted 
COVID-19, and 2,800 residents and eight staff had 
died from it.
According to data from the National Institute on 
Ageing—a Ryerson University think tank focused 
on issues affecting Canada’s aging population—at 
40%, Ontario had the highest percentage of long￾term-care and retirement homes that were affected 
by COVID-19 in Canada as of October 31, 2020. 
Alberta and Quebec had the second- and third￾highest percentages, with 33% and 32% of 
long-term-care and retirement homes in those 
provinces being affected by COVID-19. 
See Figure 15a for the list of 15 long-term care 
homes with the highest number of resident deaths, 
13 of which are operated by for-profit entities, up to 
December 31, 2020. These 15 homes, having only 
approximately 4.4% of all long-term-care home 
beds, accounted for 28% of all resident deaths. 
Figure 15b lists the 15 long-term-care homes with 
the highest number of resident cases. Figure 16
(12%). In Ontario, 46% of those who died of 
COVID-19 had pneumonia, 36% had dementia, 
16% had hypertensive diseases, 14% had diabetes 
and 12% had heart disease.
COVID-19 is most commonly spread from one 
infected person to (an)other(s) through respira￾tory droplets and close personal contact, as well as 
when someone touches an infected area and then 
touches their mouth, nose or eyes before washing 
their hands. 
On January 27 and 28, 2020, Canada reported 
its first confirmed cases of COVID-19—a couple 
from Toronto who had returned from Wuhan, 
China. Canada’s first COVID-19 death occurred 
in a long-term-care home in British Columbia on 
March 9, 2020. Two days later, on March 11, 2020, 
the WHO declared COVID-19 to be a pandemic—
an infectious disease that has rapidly spread 
worldwide. 
2.3.2 Case and Death Statisticsin Ontario’s
Long-Term-Care Homes 
March to August 2020
The first resident cases of COVID-19 in Ontario’s 
long-term-care sector—two from two homes in 
Toronto, one from a home in Vaughan, and four 
from a home in Oshawa—were recorded on the 
Ministry of Health’s Integrated Public Health Infor￾mation System (iPHIS) on March 17, 2020. The first 
cases of COVID-19 among long-term care staff—
one from a home in Oshawa, two from a home in 
Toronto, and five from a home in Bobcaygeon—
were recorded three days later on March 20, 2020.
COVID-19 spread quickly in some long￾term-care homes from March to April 2020 (see 
Figure 14). In just one month, the number of 
new cases increased from an average of 14 resi￾dents and eight staff per day in March to an 
average of 128 residents and 49 staff per day 
in April, peaking on April 15, when there were 
about 250 resident and 60 staff cases on that day 
(see Figure 14). The number of new cases began 
decreasing in May 2020, with an average of 44  

28
Figure 14: COVID-19 Cases among Long-Term-Care Home Residents and Staff by Episode Date1, March 1, 2020–December 31, 20202
Prepared by the Office of the Auditor General of Ontario based on data from Public Health Ontario’s iPHIS database
1. Episode Date is an approximation of resident or staff symptom onset date.
2. Data was extracted from the Integrated Public Health Information System (IPHIS) on February 11, 2021.
0
50
100
150
200
250
300
350
Staff
Resident
1-Ma
r
13-Mar
19-Mar
25-Mar
31-Mar
6-Ap
r
12-Apr
18-Apr
24-Apr
30-Apr
6-Ma
y
12-May
18-May
24-May
30-May
5-Ju
n
11-Jun
17-Jun
23-Jun
30-Jun
7-Ju
l
13-Jul
20-Jul
29-Jul
5-Au
g
19-Aug
25-Aug
31-Aug
6-Se
p
12-Sep
18-Sep
24-Sep
30-Sep
6-Oc
t
12-Oct
18-Oct
24-Oct
30-Oct
5-No
v
11-Nov
17-Nov
23-Nov
29-Nov
5-De
c
11-Dec
17-Dec
23-Dec
29-Dec 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 29
Home/Long-Term Care Operations COVID Action 
Table—to provide advice in addressing issues 
related to the long-term-care sector, includ￾ing testing and outbreak containment. As of 
December 31, 2020, the table had 63 members. 
On March 22, 2020, Ontario’s Chief Medical 
Officer of Health issued his first mandatory instruc￾tion, through Directive #3, seven weeks after the 
first recommended guidance. The mandatory 
instruction required long-term-care home operators 
to prohibit residents from leaving the long-term￾care home to visit family and to limit the number of 
homes that staff work at. Until then, the guidance 
documents provided recommendations that home 
operators could implement at their own discretion. 
During the pandemic, Directive #3 has been the 
primary means by which the Chief Medical Officer 
of Health communicates mandatory instructions to 
long-term-care home operators. 
illustrates the number and percentage of homes 
that had COVID-19 resident cases and those that 
did not, as of December 31, 2020. 
2.3.3 Ontario’sInitial Response to
COVID-19 in Long-Term-Care Homes
Appendix 6 lists the key federal and Ontario 
government entities involved in responding to the 
COVID-19 pandemic. 
On February 3, 2020, the province began 
recommending measures to long-term-care home 
operators, through guidance documents, meant 
to contain the spread of COVID-19. See Appen￾dix 7 for a chronology of Ontario’s response to 
COVID-19 outbreaks in long-term-care homes up 
to December 31, 2020. 
On March 14, 2020, the province formed the 
Long-Term Care Table—now called the Retirement 
Figure 15a: Fifteen Homes with Highest Number of Resident Deaths, December 31, 2020
Source of data: Ministry of Long-Term Care1
Name City
Total Bed 
Capacity
# of Deaths
Resident Staff Total
1 Orchard Villa2 Pickering 233 70 0 70
2 Camilla Care Community2 Mississauga 236 68 0 68
3 Downsview Long Term Care Centre2 North York 252 64 1 65
4 Carlingview Manor2 Ottawa 303 61 0 61
5 Altamont Care Community2 Scarborough 159 53 1 54
6 Tendercare Living Centre2 Scarborough 254 52 0 52
7 Forest Heights2 Kitchener 240 51 0 51
8 Hawthorne Place Care Centre2 North York 269 51 0 51
9 Extendicare Guildwood2 Scarborough 169 48 0 48
10 Isabel and Arthur Meighen Manor Toronto 168 48 0 48
11 Madonna Care Community2 Orleans 160 46 2 48
12 Eatonville Care Centre2 Etobicoke 247 42 0 42
13 Midland Gardens Care Community2 Scarborough 299 42 0 42
14 Seven Oaks Scarborough 249 41 0 41
15 Westside2 Etobicoke 242 40 0 40
Total 3,480 777 4 781
1. COVID-19 data is constantly being updated as the Ministry gathers more information. The numbers in this figure are based on self-reported data from 
homes, extracted on December 31, 2020. The data compiled as of this date may be different from publicly reported data at the time of the release of 
this report. 
2. Home is operated by a for-profit organization. 

30
On September 29, 2020, the Ministry released 
its COVID-19 fall preparedness plan, which included 
the additional commitment of $540 million for 
infection prevention and control, along with testing 
and surveillance measures to protect residents, 
staff and caregivers. As part of the $540-million 
investment, $405 million was to support oper￾ations, including staffing and supplies, and up 
Emergency Funding in Initial Wave of COVID-19
From March to June 2020, the province approved 
$526.7 million in emergency funding for the 
long-term-care sector as part of its initial response 
to the COVID-19 outbreaks in long-term-care
homes. As of December 31, 2020, an estimated 
$470.8 million had been spent (Figure 17). 
Figure 15b: Fifteen Homes with Highest Number of Resident Cases, January 4, 2021
Source of data: Ministry of Long-Term Care and Ministry of Health
Name City
Bed 
Capacity
# of 
Resident 
Cases
1 Altamont Care Community Scarborough 159 227
2 Orchard Villa Pickering 233 206
3 Eatonville Care Centre Etobicoke 247 188
4 Camilla Care Community Mississauga 236 187
5 Villa Colombo Homes for the Aged North York 160 171
6 Carlingview Manor Ottawa 303 170
7 Forest Heights Kitchener 240 161
8 Downsview Long Term Care Centre North York 252 152
9 Grace Villa Nursing Home Hamilton 184 142
10 Hawthorne Place Care Centre North York 269 138
11 The Village at St. Clair Windsor 256 134
12 Extendicare Starwood Nepean 192 132
13 Midland Gardens Care Community Scarborough 299 128
14 Extendicare Guildwood Scarborough 169 123
15 Humber Valley Terrace Etobicoke 158 120
Total 3,357 2,379
Figure 16: Long-Term-Care Homes with and without Reported Resident COVID-19 Cases
Prepared by the Office of the Auditor General of Ontario based on information from the Ministry of Long-Term Care*
Wave
For-Profit Homes Not-for-Profit Homes All Homes
# % # % # %
Mar 18, 2020–Aug 31, 2020
No reported resident cases 235 66.2 181 67.5 416 66.8
At least one resident case 120 33.8 87 32.5 207 33.2
Sep 1, 2020–Dec 31, 2020
No reported resident cases 258 72.7 194 72.4 452 72.6
At least one resident case 97 27.3 74 27.6 171 27.4
* COVID-19 data is constantly being updated as the Ministry gathers more information. The numbers in this figure are based on self-reported data from 
homes, extracted on December 31, 2020. The data compiled as of this date may be different from publicly reported data at the time of the release of this 
report. Statistics on number of beds were provided by the Ministry of Long-Term Care. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 31
medical supplies, deficiencies in facilities, and con￾cerns about standards of care. 
From June 2020 to July 2020, the Ministry 
appointed hospitals to temporarily manage four 
more long-term-care homes—in Kitchener, Scar￾borough, Vaughan and North York.
2.3.4 Other Investigations on COVID-19 in 
Long-Term-Care Homes
In June 2020, Ontario’s Patient Ombudsman 
announced that her Office planned to investigate 
the COVID-19 crisis in long-term-care homes. 
The Patient Ombudsman released her report in 
October 2020 with preliminary recommendations 
on staffing levels, visitor restrictions, infection 
prevention and control procedures, and com￾munication of information. See Appendix 8 for 
a summary of issues discussed in the Patient 
Ombudsman’s preliminary report and the corres￾ponding sections in this report where we discuss 
the issues.
The Patient Ombudsman, an office situ￾ated within Ontario Health, established under 
the authority of the Excellent Care for All Act, 
2010, receives and looks into complaints about 
health-care services, including those provided 
in long-term-care homes. From 2016/17 to 
2019/20—the most recent period for which data 
is available—the Patient Ombudsman received an 
average of 228 complaints per year related to long￾term-care homes, with the largest number (22%) 
regarding the quality of care provided to residents. 
On July 29, 2020, the province, under the 
authority of the Health Protection and Promotion 
Act, launched an independent commission—the 
Long-Term Care COVID-19 Commission (Com￾mission)—to investigate the spread of COVID-19
within long-term-care homes; how residents, staff 
and families were impacted; and the adequacy of 
measures taken by parties, including the province, 
long-term-care homes and other parties, to prevent, 
isolate and contain the spread. The three-member 
Commission, led by Associate Chief Justice Frank 
to an eight-week supply of personal protective 
equipment. The funding was to be spent between 
October 2020 and March 2021.
Operational Support to Long-Term-Care Homes in 
Initial Wave of COVID-19
On April 22, 2020, the province requested the 
Canadian Armed Forces to help five long-term-care
homes with COVID-19 outbreaks—Altamont Care 
Community (Scarborough), Eatonville Care Centre 
(Etobicoke), Hawthorne Woods Care Community 
(Brampton), Holland Christian Homes (Brampton) 
and Orchard Villa (Pickering). In June 2020, the 
province requested the Canadian Armed Forces 
to help in two additional homes—the Downsview 
Long-Term Care Home (Toronto) and Woodbridge 
Vista Care Community (Vaughan). Under Oper￾ation LASER, which ran from April to July 2020, 
the Canadian Armed Forces deployed teams made 
up of nurses, medical technicians and additional 
personnel to provide staffing support, help with 
infection prevention and control, and assist with 
other duties such as cleaning and food preparation. 
The Canadian Armed Forces delivered its interim 
report on the first five homes on May 26, and its 
final status report on all seven homes on August 14. 
See Appendix 8 for a summary of observations in 
the Canadian Armed Forces report and the corres￾ponding sections in this report where we discuss 
the issues.
On May 12, 2020, the province issued an 
emergency order empowering the Ministry to tem￾porarily replace management at long-term-care 
homes struggling to contain COVID-19 outbreaks. 
On May 25, the Ministry appointed two hospitals 
to take over two long-term-care homes for 90 days. 
On May 27, the Ministry announced that it would 
be appointing hospitals to temporarily manage five 
more long-term-care homes—in Brampton, Etobi￾coke, North York, Pickering and Scarborough. At 
four of those homes, the Canadian Armed Forces 
had reported examples of homes not adhering to or 
not having infection prevention and control poli￾cies, inadequately trained staff and shortages of  

32
Figure 17: Breakdown of Ontario’s Emergency Funding to Long-Term-Care Sector, March–June 2020
($ million)
Prepared by the Office of the Auditor General of Ontario based on information from the Treasury Board Secretariat
Funding 
Category Details
Amount 
Allocated as of 
Jun 30, 2020
Estimated* 
Amount Spent as 
of Dec 31, 2020
Emergency Surge 
Capacity 
Intended to add approximately 1,560 long-term-care beds, or 
about a 2% increase in capacity. The increased capacity was 
intended to help in the prevention and treatment of COVID-19 
by: 
• providing more single-bed rooms to isolate infected residents; 
and 
• allowing patients in hospitals who qualify for placement in 
long-term-care homes to be discharged to one in order to 
take pressure off hospitals.
21.8 4.5
Prevention and 
Containment 
Intended to cover the immediate and extraordinary operating 
costs of COVID-19 screening, staffing and equipment in 613 
long-term-care homes, including:
• 24/7 COVID-19 screening of staff and visitors to prevent 
anyone ill from entering the long-term-care home; 
• screening of residents on an ongoing basis to contain new 
infections; 
• additional staff on all shifts to replace sick staff; and 
• cost of supplies related to nursing, personal care, 
housekeeping and laundry.
138.3 125.1
Pandemic Pay Intended to provide eligible front-line workers—nurses, 
PSWs, and support staff in services such as dietary and 
housekeeping—with a $4-an-hour pay increase from April 24, 
2020 to August 13, 2020, plus $250 per month up to a 
maximum of $1,000 for working at least 100 hours per month. 
The pandemic pay provided to long-term-care home workers was 
part of the larger pandemic pay initiative that included front-line 
workers in retirement homes, home and community care, social 
services congregate care settings and hospitals; and providing 
ambulance services (paramedics), mental health and addictions 
services and correctional services. 
346.6 321.2
Coverage of Cost of 
Deferred Resident 
Payments
Intended to compensate long-term-care homes for the six￾month deferral—from July 1, 2020 to January 1, 2021—of the 
scheduled 1.9% increase to residents’ copayments. The six￾month deferral was intended to provide temporary financial 
relief to long-term-care home residents and their families, as 
they may have been experiencing financial difficulties due to the 
COVID-19 pandemic.
20.0 20.0
Total 526.7 470.8
* Amounts spent as of December 31, 2020 are unaudited.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 33
in accordance with applicable legislation, 
regulation and best practices; and
• identify and implement lessons learned to 
inform its response to infectious disease 
outbreaks and pandemics.
In conducting our work, we identified criteria 
(see Appendix 9) to address our objective. These 
criteria were established based on a review of 
applicable legislation, policies and procedures, 
internal and external studies, and best practices. 
Senior management at the Ministry reviewed and 
agreed with the suitability of our objective and 
associated criteria.
Other Special Chapters on COVID-19
Preparedness and Management
This report is one in a series of special chapters on 
COVID-19 preparedness and management from our 
Office. The objective of preparing these chapters 
is to inform Ontarians about lessons learned and 
to recommend actions to better prepare Ontario 
should we face another such event. See Figure 1
identifying the other chapters.
Our upcoming special report on Personal Protect￾ive Equipment (PPE) will address the issue of PPE in 
long-term-care homes. 
3.2 What We Did 
We conducted our work from mid-June 2020 to 
March 2021. We obtained written representation 
from Ministry senior management that, effective 
April 27, 2021, they had provided us with all the 
information they were aware of that could sig￾nificantly affect the findings or the conclusion of 
this report.
To better understand the long-term-care sector 
and the Ministry’s oversight role and activities, we: 
• reviewed key relevant legislation, regula￾tions, policies and other relevant documents 
and reports;
• met with senior Ministry management and staff, 
and interviewed a sample of inspectors from the 
Ministry’s Long-Term Care Inspection Branch;
Marrocco, began hearing testimonies from stake￾holders on September 2, 2020. It released a list 
of interim recommendations on October 23 and 
December 4, 2020, and is expected to deliver its 
final report by April 30, 2021. 
3.0 Objective and Scope
3.1 Why We Are Issuing This Report 
Over the last 12 years, our Office has audited 
various aspects of the long-term-care sector. 
Our audit of Infection Prevention and Control 
at Long-Term-Care Homes in 2009, the 
Long-Term-Care Home Quality Inspection Program 
in 2015, and most recently Food and Nutrition 
in Long-Term-Care Homes in 2019 found issues 
related to insufficient infection prevention and 
control (IPAC) expertise and poor IPAC practices 
in long-term-care homes, lack of space to allow 
for proper cohorting of infectious residents, and 
ineffective Ministry oversight of homes. 
During our 2020 continuous follow-up of 
our 2015 audit, Long-Term-Care Home Quality 
Inspection Program, the COVID-19 pandemic 
impacted Ontario and was particularly devastat￾ing to residents and staff of certain long-term-care 
homes. Our objective in preparing this report was 
to expand our follow-up on the status of recom￾mendations we made in our 2015 audit of the 
Long-Term-Care Home Quality Inspection Program, 
and assess whether the Ministry of Long-Term 
Care, in conjunction with long-term-care homes 
and other health-care-sector partners, had effective 
systems and procedures in place to: 
• ensure that inspections of long-term-care homes 
proactively identify risks and issues, and resolve 
non-compliance with legislation, regulation, 
and policies;
• respond to the impacts of the COVID-19 pandemic 
in the long-term-care sector in a timely manner,  

34
stakeholder groups made at the Commission 
from September 2, 2020 to March 10, 2021.
We also researched COVID-19 information and 
the response in other Canadian provinces to under￾stand the impact of the pandemic and the measures 
that were implemented to manage it in the long￾term-care sector in those jurisdictions. Our research 
also aimed to identify potential best practices. 
We engaged Dr. David Walker, who chaired the 
province of Ontario’s Expert Panel on SARS and 
Infectious Disease Control and the subsequent 
Expert Panel on the Legionnaires’ Disease Outbreak 
in the City of Toronto, as our independent advisor 
to assist us with our work.
Our scope did not include assessing the Ministry 
of Long-Term Care’s handling of specific individual 
complaints and critical incident reports that they 
received. 
Data Sources
Long-term-care data, including information 
related to COVID-19, is captured and reported 
through various systems (Appendix 11). In late 
September 2020, the province announced that 
Ontario had entered the second wave of the 
COVID-19 pandemic, with the number of new 
cases in the province averaging 450 per day. In the 
long-term-care sector, there was an average of eight 
new resident cases and four staff cases per day that 
month. On December 31, 2020, 212 long-term-care
homes were in an ongoing outbreak situation. 
The statistics in this report are based on infor￾mation reported by long-term-care homes to the 
Ministry of Long-Term Care, the Integrated Public 
Health Information System (iPHIS, now called the 
Case and Contact Management System), Public 
Health Ontario Daily Epidemiologic Summaries, 
publicly reported data during our fieldwork up to 
December 31, 2020. As with any ongoing outbreak 
situation, COVID-19 data is constantly being 
updated as the Ministry and public health officials 
gather more information. The data extracted repre￾sents information that was known at a certain point 
in time. Therefore, the data is subject to variability 
• analyzed financial, long-term-care home, resident 
and inspection data from the Ministry from 
January 2015 to September 2020; 
• reviewed relevant past reports by our Office and 
the status of the Ministry’s implementation of 
recommendations in those reports including 
our 2015 audit Local Health Integration Net￾works; and 
• reviewed information and reports, such as those 
from the Canadian Institute for Health Informa￾tion (CIHI), the Royal Society of Canada, the 
Canadian Patient Safety Institute, the Canadian 
Medical Association Journal and the Journal of 
the American Medical Association.
Our work to understand the impact of COVID-19
on the long-term-care sector and evaluate the prov￾ince’s response to it focused on the initial wave of 
the pandemic up to August 31, 2020. We conducted 
the following work: 
• analyzed COVID-19 data from the Ministry and 
Public Health Ontario;
• reviewed directives, orders and communications 
from the province to the long-term-care sector;
• contacted and obtained information from a 
sample of long-term-care homes; 
• met with senior management and staff from the 
Ministry, Ontario Health, Public Health Ontario; 
• surveyed five of the 34 public health units in the 
province. The five public health units accounted 
for 63% of COVID-19 cases in Ontario’s long￾term-care homes between January 15, 2020 and 
February 28, 2021. They were Durham, Ottawa, 
Peel, Toronto and York Region;
• met with experts in the field of geriatrics 
and infectious diseases, as well as repre￾sentatives from various stakeholder groups 
(Appendix 10);
• met with the Chief Coroner for Ontario, whom 
the province had appointed as Coordinator of 
the Provincial Outbreak Response; and
• reviewed documentation provided by the Min￾istry to the Long-Term Care Commission, as 
well as testimonies that various individuals and  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 35
Licences are issued for terms of up to 30 years 
depending on the bedroom design (Figure 6). 
In order for home operators to obtain a licence 
for a new home or renew a licence for an existing 
one, they must build the new home or renovate 
existing homes in accordance with current design 
standards. The Ministry released its new resi￾dency standards in 1999 in its Long-Term Care 
Design Manual. However, home operators were 
not required to renovate an existing home until 
its licence expired. As such, Ontario currently has 
many long-term-care homes that are operating 
under older design standards. The licences for 
about 26,500 beds in 257 homes across the province 
are set to expire in 2025. The Ministry could not 
tell us how many of these beds will need to be reno￾vated to meet the new design standards that limit 
room occupancy to two residents.
Our analysis of self-reported COVID-19 data 
from homes from March 19 to August 31, 2020
found that almost two-thirds of the homes with 
the most severe outbreaks during that period had 
primarily older bedroom designs. For the purposes 
of our analysis we define severe outbreak and older 
design as follows: 
• A severe outbreak is when at least 30% of a 
home’s residents were infected at the same time 
during the period we reviewed.
• A home has a primarily older bedroom design 
when 70% of its beds are classified as C or D 
beds, meaning that they were designed and 
operated to accommodate up to four residents 
in one room (Figure 5 and Figure 6). 
The older bedroom design allowing for up to 
four residents in one room contributed to crowding 
and insufficient physical distancing in the homes, 
which increased the risk of COVID-19 spreading 
through the home. The Ministry and the LHINs, 
who are responsible for placing residents in long￾term-care homes, did not know how many residents 
were actually housed in three- or four-bed wards 
when the pandemic hit the long-term-care sector in 
March 2020.
depending on the date at which the underlying 
data was extracted. Additional factors, such as time 
lag in case reporting and changes in data collection 
methodology may further alter the data.
This report includes statistical information 
about the number of COVID-19 cases and deaths, 
as well as the measures put in place by the prov￾ince during the second wave of COVID-19 up to 
December 31, 2020 (see Section 2.0). 
4.0 Detailed Observations
4.1 Long-Term-Care Homes 
Ill-Equipped to Prevent or Minimize 
COVID-19 Outbreaks Because of 
Long-Standing Facility, Staffing 
and Infection Prevention and 
Control Issues 
Our review confirmed that the following long￾standing issues have not been resolved after years 
of little to no effective action and have negatively 
affected long-term-care residents’ quality of life. 
Long-standing issues include up to four residents 
living in a bedroom in homes that do not meet current 
Ministry standards of limiting room occupancy to 
two residents; residents not consistently receiving 
the needed level of supports with daily activities of 
living because of insufficient staff to provide care; 
and residents being at risk of contracting infections 
because of insufficient infection prevention and 
control practices. 
4.1.1 Many Residents Share Rooms with
up to Three Other Residents, Not Meeting
Residency Standardsin Ministry’s 1999
Long-Term Care Design Manual
Up to 257, or over 40%, of the 626 long-term-care
homes in Ontario need to be renovated to comply 
with current bedroom standards that limit the 
number of residents sharing a room to two.  

36
in a room to only two, helped prevent the spread 
of COVID-19 in homes that complied with the 
June 10, 2020 directive. We analyzed the same self￾reported data from March 19 to August 31, 2020, 
and noted that 58 homes had at least one con￾firmed case of COVID-19 and were able to keep the 
infection rates at below 1% of residents during that 
period. Two-thirds of these 58 homes that were able 
to contain the spread of COVID-19 had primarily 
newer bedroom designs, meaning that about 70% 
of these homes’ beds were classified as new beds or 
A beds (see Figure 6). In fact, the November 2020 
study in the Journal of the American Medical Asso￾ciation found, through simulations, that converting 
all four-bed rooms to two-bed rooms could have 
prevented 998 or 19% of the COVID-19 infections 
and 263 or 18% of the COVID-19 deaths in the 
618 long-term-care homes included in the study.
Planned Additional BedsInsufficient to Meet
Growing Demand 
As shown in Figure 6, one-third of beds across the 
province are currently classified as C or D beds, 
meaning that residents occupying those beds are 
sharing a room with up to three other residents. 
The risk of homes having COVID-19 cases started to 
be lowered with vaccine administration to residents 
and employees in early 2021. However, the risk of 
homes having other infectious disease outbreaks in 
the future remains. 
In July 2020, the province committed to add 
8,000 new and 12,000 renovated beds by 2025. 
However, it is unclear whether the current plan is 
sufficient to address the increasing demand and 
whether plans take into account the use of alterna￾tive options such as increasing home care services, 
and/or increasing the use of assisted living or 
retirement home accommodations in Ontario. 
Over 37,000 people were waiting to be placed in a 
long-term-care home as of September 30, 2020. In 
addition, Statistics Canada is projecting that the 
proportion of the population aged 65 and over in 
Ontario will increase from 16.9% in 2018 to as high 
as 26.1% in 2043. Ontario’s aging population will, 
We also noted in our analysis that 15 of the 16 
homes where over half of the home’s residents 
contracted COVID-19 in the period we reviewed 
(March 19 to August 31, 2020) were for-profit 
homes that had primarily older bedroom designs. 
For-profit homes housed 53% of the beds in the 
province (Figure 3), but accounted for 70% of the 
resident deaths from March 19 to August 31, 2020. 
More than half of for-profit long-term-care homes 
in Ontario have primarily older bedroom designs. 
In comparison, about 15% of non-profit and muni￾cipal homes have primarily older bedroom designs. 
According to a September 2020 article in the 
Canadian Medical Association Journal, 63% of 
Ontario long-term-care home residents were in 
a shared room with one to three other residents 
prior to the COVID-19 pandemic. In compari￾son, only 24% of long-term-care home residents 
in British Columbia were in a shared room 
before COVID-19. The article indicated that, as 
of September 10, 2020, British Columbia had a 
resident infection rate of 1.7% compared with 
Ontario’s rate of 7.6%. 
On June 10, 2020, the Chief Medical Officer of 
Health issued a temporary directive to prohibit new 
residents from being placed in three- or four-bed 
rooms in order to allow for sufficient physical dis￾tancing among residents. The temporary directive 
was still in effect as of December 31, 2020. 
A study published in the Journal of the Amer￾ican Medical Association in November 2020 found 
that residents in Ontario long-term-care homes 
that were “highly crowded,” where the majority of 
residents are housed in shared bedrooms and wash￾rooms were more than twice as likely to develop 
infection and die from COVID-19 than residents in 
homes with mainly single-occupancy rooms. The 
study was conducted on 618 homes where a total 
of 5,218 residents developed COVID-19 infections 
and 1,452 died of COVID-19 from March 29 to 
May 20, 2020.
We wanted to know whether the newer 
bedroom design, limiting the number of residents  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 37
RECOMMENDATION 1 
So that all long-term-care home facilities 
provide residents with accommodations that 
meet current Ministry of Long-Term Care stan￾dards and are places where residents live in 
security, safety and comfort, as envisioned in 
the Long-Term Care Homes Act, 2007, with the 
intent of preventing future disease outbreaks 
(such as respiratory infections and gastro￾intestinal infections), we recommend that the 
Ministry re-assess its long-term-care home 
licensing process to require home operators to 
renovate their facilities within a realistic, but 
shorter defined time frame to be in compliance 
with current standards, as well as when home 
design standards change. 
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry agrees that the timely upgrading of 
homes is important to providing residents with a 
safe and comfortable home. In September 2020, 
the Ministry concluded a call for application 
that solicited interest in both redevelopment 
and building new capacity. Shortly thereafter in 
November 2020 and March 2021 the Ministry 
made a significant investment in redeveloping 
or upgrading beds. To date, $2.6 billion has 
been committed to the redevelopment program, 
which includes 20,161 new beds and 15,918 
redeveloped beds. 
Approximately 50% of eligible beds have 
been approved for upgrading. Further advance￾ment on redeveloping beds will be contingent 
on future funding availability. As part of the 
recently concluded call for applications, the 
Ministry was over-subscribed in terms of 
requests to redevelop beds compared with 
funding available at this time. 
The Ministry, in collaboration with the 
federal government, through the Investing 
in Canada Infrastructure Program, is making 
therefore, likely increase the demand for long-term 
care in the next 25 years unless additional long-term 
care/home care strategies are put in place. The 
Conference Board of Canada estimated in 2017 that 
by 2035—when the baby boomer generation (those 
born between approximately 1946 and 1964) are 
71 to 89 years old—238,000 Ontarians will need 
long-term care. In 2019, the Financial Accountability 
Office of Ontario estimated that the province would 
need to add 55,000 new long-term-care beds by 
2033/34 to meet demand and that even with these 
additional beds, there would still be a wait list of 
approximately 36,900 Ontarians. 
The province’s ultimate long-term goal is to 
develop a total of 30,000 new beds and redevelop 
15,000 beds by 2028. However, as of the March 
2021 Budget, the province had committed to devel￾oping about 20,200 new beds and redeveloping 
15,900 beds. Taking into account the over 26,500 
beds for which the licences are set to expire in 
2025, we calculated that, by 2028, these commit￾ments will result in a net increase of about 9,600 
beds (number of new and redeveloped beds less the 
number of expiring beds). This assumes that the 
licences, for the 10,600 expiring beds that are not 
yet funded to be renovated, will not be renewed. 
Whether long-term-care home operators will 
have the ability to raise the necessary funds to 
cover renovation costs to their existing facilities is 
also uncertain. Home operators are responsible for 
funding the costs of renovating their homes to meet 
the current design standards before their licences 
expire. Home operators receive a construction 
funding subsidy from the Ministry only once the 
renovations are completed. In September 2020, the 
Ministry revised its Capital Development Funding 
Policy to provide development grants, ranging 
from 10% to 17% of total project costs, to help 
cover upfront costs like land and other construc￾tion expenses. Under this revised funding policy, 
the Ministry approved a total of $761 million in 
additional funding to 74 homes to create 3,957 new 
beds and renovate 6,796 older beds. 

38
November 2020 and March 2021 the Ministry 
made a significant investment to add new cap￾acity. To date, $2.6 billion has been committed 
to the development program, which includes 
20,161 new beds and 15,918 redeveloped beds. 
This is roughly two-thirds of the Ministry com￾mitment to add new capacity.
To supplement the supports available in 
their homes for people on, or eligible to be on, 
the long-term-care wait list, the Ministry has 
provided funding to 33 communities to enable 
them to implement a Community Paramedicine 
for Long-Term Care program. This initiative will 
help more seniors on long-term-care wait lists 
stay safe while living in the comfort of their own 
homes for a longer period of time. 
Continuous assessment of the demands 
for long-term care and how that demand can 
be best met is required and the Ministry will 
continue to work with the Ministry of Health, 
the Ministry of Seniors and Accessibility and 
other partners to consider opportunities to best 
meet needs.
4.1.2 Insufficient Experienced Staff
Available to Provide Needed Level of Care
for Residents in Long-Term-Care Homes
We confirmed that staffing shortages, another long￾standing issue that was highlighted as far back as 
the Ministry’s staffing report in 2008, impacted the 
health and safety of residents in long-term-care
homes during the period of our analysis. Staff￾ing levels were insufficient to help residents with 
activities of daily living such as bathing, toilet￾ing, dressing and feeding to the extent needed for 
timely and fulsome care.
Stakeholder groups and the Ministry’s own 
July 2020 staffing study have highlighted the 
serious issue of long-term-care staffing not keeping 
pace with the increasing demand for long-term care 
and the increasing complexity of residents’ care 
needs. According to the Ministry’s staffing study, 
a decreasing labour supply, challenging working 
immediate investments to assist eligible homes 
with upgrades that will address the pandemic.
Further, the Ministry will evaluate future 
options/methods to upgrade physical facilities 
so that they are more comfortable and meet 
safety standards.
RECOMMENDATION 2
So that there will be sufficient beds available 
to meet the growing demand for long-term 
care (in conjunction with any future changes to 
home care, retirement home, and assisted living 
considerations), we recommend that the Ministry 
of Long-Term Care: 
• re-assess whether its long-term plan to add 
approximately 45,000 new or renovated beds 
by 2028 (taking into account the number of 
expiring licences) will be sufficient to meet 
future demands, given the current wait-list 
backlogs and the projected growth in the 
number of individuals who will need long￾term care in the next 25 years; 
• assess how this plan will fit into an integrated 
plan with home care and alternative housing 
in retirement homes and assisted living 
facilities; and
• annually revisit its long-term plan and update 
as necessary, integrating other potential 
options and supports to providing care, such 
as home-based care where feasible.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry agrees that it is critical to consider 
how best to meet growing demand across 
a variety of care settings, including long￾term care.
The government has committed to building 
30,000 beds in a decade. In September 2020, 
the Ministry concluded a call for application 
that solicited interest in both redevelopment 
and building new capacity. Shortly thereafter in  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 39
79/10 under the Act to provide exceptions to the 
regulatory requirement that at least one registered 
nurse—who is an employee of the home and a 
member of the home’s nursing staff—is on duty 
and present in the home at all times. The amend￾ment allows homes to fulfil the requirement by 
having a registered nurse who is not an employee 
of the home or a registered practical nurse under 
supervision of the Director of Nursing. As per the 
Ministry, this change was made to accommodate 
the situation where a home would not be able to 
have a registered nurse present.
Some stakeholders told us that staffing short￾ages at homes worsened when some workers 
refused to come to work for fear of contracting 
COVID-19, and when homes had difficulties hiring 
temporary staff to fill vacant positions. Stakehold￾ers told us that, with fewer staff to provide care for 
and assist residents, the level and quality of care 
dropped significantly. This was confirmed by home 
operators who were consulted during the Ministry’s 
staffing study. They reported missed baths, missed 
personal care, and a lack of toileting, among other 
basic care functions. They also reported that PSWs 
had to “cut corners to optimize the times they 
[had] available” because they were “often rushed.” 
Stakeholder testimonies at the Long-Term Care 
COVID-19 Commission also described the impact of 
the staffing shortage, citing the following examples: 
• only one registered nurse was on duty to care for 
99 residents, which meant that the nurse could 
spend, at most, four-and-a-half minutes with a 
resident, assuming there were no interruptions 
from other units and no breaks, and the nurse 
did not perform any other work;
• only one PSW was on duty to care for 30 resi￾dents, making it difficult for the PSW to change 
PPE between resident visits, stop residents from 
wandering and enforce infection control; and
• there were only four staff on a floor where there 
were normally seven to eight staff, which meant 
that staff had to go to multiple floors, including 
units that had COVID-19-positive residents and 
units with residents who did not have COVID-19.
conditions (including pay considerations), and a 
negative public image, have contributed to difficul￾ties recruiting and retaining qualified staff. The 
study found that, each year, about 40% of new per￾sonal support worker (PSW) graduates leave their 
job within one year of graduation. In addition, the 
Ministry estimated that about 25% of PSWs who 
have two or more years of experience leave the pro￾fession each year.
Our analysis of the staffing shortages reported 
by homes to the Ministry from March 19 to 
June 30, 2020 found that the staffing shortage 
peaked in late April, when 36 homes— ranging 
from a small 56-bed home to a large 300-bed 
home—reported critical shortages on the same 
day. A total of 76 homes reported critical staff￾ing shortages during this period. Some homes 
reported shortages throughout March to June. The 
determination of a critical shortage is based on 
the following: the size of the home; the number of 
vacant shifts, especially in key roles; whether the 
home had exhausted all options; and impact on 
resident care. 
According to the Ministry’s July 2020 staffing 
study (discussed in Section 2.1.3), one 128-bed 
home reported missing 10 registered nurses 
during a 24-hour day. The staffing shortages were 
confirmed in a September 2020 Ontario Nurses’ 
Association (ONA) survey of its members who 
were employed in long-term-care homes. Fifty 
percent of respondents indicated that staffing 
decreased during the pandemic. The ONA surveyed 
approximately 3,300 of their nurses who work in 
long-term-care homes. About 1,200 nurses started 
and partially completed the survey. Of those nurses, 
766 completed the entire survey. Over 90% of 
respondents reported experiencing shortages in 
PSWs at least occasionally to frequently.
Most significantly, 43% of nurses reported 
occasions where there was no registered nurse 
on staff, which would have been a violation 
of the Long-Term Care Homes Act, 2007 (Act) 
until the province amended its regulation. On 
March 20, 2020, the province amended Regulation  

40
The Act does not prescribe a minimum number 
of hours of direct care to be provided by nursing 
staff or PSWs per resident. In 2018, homes reported 
providing an average of 3.73 paid hours of care per 
resident per day, which amounts to an average of 
two hours and 18 minutes from PSWs, one hour 
and two minutes from RNs or RPNs, and 24 minutes 
from other health professionals. This is slightly 
lower than the average of up to four hours that 
many stakeholders and the Ministry’s own previous 
staffing report from 2008 have recommended, and 
represents an average; meaning that some residents 
were receiving less than 3.73 hours of direct care 
per day and some were receiving more. Given the 
different needs of residents, it is highly likely that 
homes where some residents require significant 
levels of care may not be providing enough care 
time for those individuals and may also be provid￾ing less than a minimum of four hours of care for 
other residents.
The optimal staffing mix, staff-to-resident ratio, 
or hours of direct care would vary depending 
on the specific needs of residents. Nonetheless, 
establishing and enforcing per resident standards 
(considering their specific level of care needs) 
would better ensure that residents receive the 
minimum level of care and support they need, 
consistent with the fundamental principles of the 
Act. This is especially critical given that, as shown 
in Figure 7, residents’ needs have increased over 
the last 10 years. 
Our 2014 audit of Palliative Care found that 
access to palliative care services was not equitable 
across the province. There were no minimum edu￾cation requirements for physicians or nurses who 
primarily provided palliative care, which could 
impact patient care and comfort. We recommended 
then that educational requirements for health-care 
providers providing palliative care be included in an 
overall palliative care policy framework for Ontario. 
Palliative care is an important consideration for 
residents in long-term-care homes. 
In November 2020, the province committed to 
increasing the hours of direct care for long-term-care 
The results of the Ministry’s inspection 
of Sunnycrest Nursing Home in Whitby on 
November 28, 2020 illustrated the significant 
adverse consequences of staffing shortages 
on resident care. A Ministry inspector visited 
the home in response to a report of a COVID-19
outbreak, which is considered a critical incident. 
Staff members told the inspector that staffing was 
down to less than 50% of its normal level. The 
inspector’s review of the staffing schedule for 
November 28 and 29 found gaps in PSW and 
nursing staff on both days. The floor where most 
of the COVID-19-positive residents were located 
was the most impacted by the shortage. Nursing 
staff, who had to administer medications to 80 resi￾dents, were up to two hours late in administering 
medications, including medications such as insulin 
where delays pose a high risk. Staff members also 
told the inspector that wound dressings were not 
being completed due to the staffing shortage. 
The September 2020 Canadian Medical Asso￾ciation Journal article cited studies conducted 
between June and August 2020 in nursing homes in 
the United States that showed low staffing and low 
care hours were associated with poor resident out￾comes, such as higher rates of COVID-19 infection. 
For example, California nursing homes with total 
registered nurse staffing levels below the recom￾mended minimum standard of enough nurses to 
provide 0.75 hours of care per resident per day 
were twice as likely to have COVID-19 resident 
infections. Conversely, among homes in Connecticut 
with at least one confirmed COVID-19 case, every 
20-minute increase in registered nurse care per 
resident per day was associated with 22% fewer 
confirmed cases. Among those with at least one 
COVID-19-related death, every 20-minute increase 
in registered nurse care was associated with 26% 
fewer deaths.
While there are no minimum staffing require￾ments under the Long-Term Care Homes Act, 2007
(Act) beyond those described in Section 2.1.3, the 
Act requires homes to have a staffing plan in place 
that provides for a staffing mix that is aligned with 
residents’ care and safety needs.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 41
require students to pass a licensing exam to obtain 
a PSW certificate. 
PSWs are not regulated in Ontario (and in 
Canada). Regulating the profession would help 
protect the health and safety of long-term-care 
home residents by setting standards of practice 
and putting in place accountability mechanisms 
for members when they do not abide by those stan￾dards. Given that PSWs comprise more than half of 
long-term-care home staff, and are responsible for 
the direct day-to-day care of vulnerable individuals 
with complex needs, these standards of practice 
and accountability mechanisms would help ensure 
that residents are receiving appropriate care. The 
Ministry’s July 2020 staffing study suggested that 
consideration be given to further professionalize 
the PSW role within the long-term-care sector. In 
addition to nurses, dietitians, and pharmacists, 
other professions such as, foresters, land surveyors, 
and real estate agents are also regulated in Ontario.
Individuals can earn a PSW certificate from 
a community college, private career college or 
school board. The individual education institutions 
determine how their program will be delivered; 
the standards only list learning outcomes and per￾formance objectives—skills that graduates of the 
program are expected to be able to demonstrate. 
For example, the standards require that graduates 
reliably demonstrate the ability to: 
• assist clients across life span with routine activities 
of daily living;
• assist clients with medication in keeping with 
the direction of the care plan and under the 
monitoring of a regulated health professional; 
• provide client-centred and client-directed care 
that is based on ethical principles, sensitive to 
diverse client and family values, beliefs and 
needs, and which follows the direction of the 
client care plan; 
• establish and maintain helping relationships 
with clients and their families, reflecting open 
communication, professional boundaries, 
residents to an average of four hours per day. 
The four-hours-per-resident per-day commitment is 
based on worked hours instead of paid hours (which 
was the basis for the 3.73 hours in the previous 
paragraph). Using worked hours, the 2018 average 
was 2.75 direct care hours by RNs, RPNs and PSWs 
per resident. Worked hours are hours when staff 
are present at the home and available for work. 
Paid hours include vacations, statutory holidays 
and benefits in addition to worked hours.
The announcement committed to increase overall 
funding to long-term-care homes by $500 million 
in 2021/22, $1 billion in 2022/23, $1.5 billion in 
2023/24 and $1.9 billion in 2024/25.
Personal SupportWorkers’ (PSWs) Education
May Not Sufficiently Prepare Them for Work
Environment 
The Ministry’s July 2020 staffing study highlighted 
gaps between PSWs’ educational training and 
the working conditions in long-term-care homes. 
Specifically, the study notes that “educators tend 
to teach to the ideal environment,” but PSWs face 
more challenging working conditions than what 
they are prepared for through their training. The 
primary reasons for the gap are the rising complex￾ity of residents’ needs and staffing shortages, which 
often result in PSWs being given responsibilities for 
which they did not receive training. 
Regulation 79/10 under the Long-Term Care 
Homes Act, 2007 requires that PSWs hired by 
long-term-care homes must have successfully 
completed a personal support worker program 
that meets the standards set out by the then Min￾istry of Training, Colleges and Universities, and 
comprises at least 600 hours of in-class instruction 
and practical experience combined. Neither the 
regulation nor the standards (called the Personal 
Support Worker Program Standard and the Per￾sonal Support Worker Training Standard) specify 
the minimum number of hours of practical experi￾ence required (out of the 600 total hours) in order 
to complete the program. The standards do not  

42
RECOMMENDATION 3 
So that long-term-care homes can consistently 
have the necessary and appropriate overall staff￾ing level and mix to provide a sufficient level 
and quality of care to residents, in compliance 
with the Long-Term Care Homes Act, 2007 (Act), 
we recommend that the Ministry of Long-Term 
Care (Ministry): 
Strategic Actions
• develop and implement a provincial staffing 
strategy addressing the root causes of staff￾ing shortages in long-term-care homes as 
identified in the Ministry’s July 2020 staffing 
study and as experienced during COVID-19
(including consideration of ways to further 
professionalize the role of PSWs, for 
example, by regulating the PSW profession); 
• after a period of time under the new stan￾dard of a provincial average of four hours 
of direct care from RNs, RPNs and PSWs 
per resident per day, revisit its operational 
sufficiency to confirm that residents are 
receiving the necessary care given the 
increasing complexity of residents’ needs, 
which can vary between individuals and 
between homes; 
• incorporate into a staffing strategy specific 
short- and long-term objectives and targets 
related to staffing levels and staffing mix 
in long-term-care homes (considering 
the necessary training and experience of 
employees, including training and experience 
in treating dementia and providing geriatric 
and palliative care);
Operational Actions
• regularly monitor the effectiveness of its 
strategy against the established objectives 
and targets, and take corrective action when 
objectives and targets may not be met;
employers’ policies and adhering to confidenti￾ality and privacy legislation;
• promote and maintain a safe and comfortable 
environment for clients, their families, self and 
others, including implementing infection pre￾vention and control measures and emergency 
first aid procedures that are in keeping with the 
client care plan, policies, procedures and applic￾able legislation; and
• use best practices to support positive and safe 
behaviour in clients experiencing cognitive 
impairment and mental health challenges.
We reviewed the full-time PSW certificate 
programs in Ontario offered by all 24 community 
colleges and the 15 private career colleges that had 
the highest enrolment to determine whether there 
were any differences in how the PSW programs 
were delivered. We noted all community colleges 
offered two-semester programs, which run for 
about 24 to 30 weeks, and include 140 to 438 hours 
of practical experience. Programs offered at private 
career colleges run for about 29 to 52 weeks, 
totalling between 700 and 800 hours. In general, 
practical experience comprises about half of the 
total program hours. Differences in PSW programs 
may be due to, for example: 
• the quality of instructors and instruction 
materials;
• location and type of practical experience 
(practical experience may be obtained through 
placements in long-term-care homes, hospitals, 
or other community settings);
• number of hours of instruction received in 
specific subject matter such as managing clients 
with cognitive impairments or behavioural 
issues; and
• availability of lab environments to facilitate 
simulations and demonstrations. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 43
The Ministry will develop guidance to LTC 
homes on staffing models, as committed in 
the Staffing Plan, which may include staff-to￾resident ratios and/or linking the requirement 
for 24/7 oversight by a registered nurse to 
the size of the home. The Staffing Plan recog￾nizes that each home needs some flexibility to 
develop staffing approaches that meet residents’ 
specific and diverse needs. The Ministry will 
evaluate tying expected levels of care to Case 
Management Index (CMI) values for individuals 
or groups of residents as an effective way to 
support increased and appropriate care for resi￾dents. This will be undertaken in the content of 
the commitment in the Staffing Plan to review 
components of the long-term-care funding 
model, including CMI.
The Ministry will regularly assess progress 
against the short- and longer-term objectives, 
and annual public targets related to direct 
care in the Staffing Plan and has committed to 
regularly track progress and ‘course correct’ 
along the way.
RECOMMENDATION 4
So that the supply of Personal Support Workers 
(PSWs) needed is available and that PSWs are 
sufficiently trained to provide the necessary 
level and quality of care to residents, in compli￾ance with the Long-Term Care Homes Act, 2007, 
we recommend that the Ministry of Long￾Term Care: 
• work with Ontario Health, the Ministry of 
Health and the Ministry of Labour, Training 
and Skills Development to establish a long￾term plan for the demand and supply of 
PSWs in Ontario as part of a provincial long￾term care staffing strategy recommended in 
Recommendation 3;
• develop and provide guidelines to homes 
regarding the appropriate staffing level and 
mix depending on the level of care required 
by residents as per the Case Mix Index; 
• document the expected level of care required 
for a resident depending on their Case Mix 
Index in regulations that are reviewed and 
updated annually if needed, depending on 
the overall level of care of residents in long￾term care homes; and
• require its inspectors to annually assess 
whether homes have staffing plans in place, 
as required by the Act and the reasonableness 
of those plans; as well as confirming that 
homes are operating in accordance with 
those plans.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry will implement the directions set 
out by the government in its Long-Term Care 
Staffing Plan released in December 2020. This 
Plan was informed by the July 2020 staffing 
study and the experience of COVID-19 in long￾term-care homes.
The Plan and the government’s 2021 Budget 
reaffirm a commitment to provide an average 
of four hours of daily direct care (measured as 
worked hours) provided by PSWs, RPNS and 
RNs. This increase from the 2018 level of 2.75 
worked hours is a higher standard than that 
recommended in the 2008 study. The invest￾ment of $4.9 billion over four years will support 
achievement of specific year-by-year targets and 
the creation of the more than 27,000 new full￾time equivalent positions that will be required. 
It will also support an additional 20% increase 
in direct care time from other health-care 
professionals such as physiotherapists and 
social workers. 

44
• mechanisms to ensure PSWs working in 
homes are properly trained; and
• new initiatives as necessary.
The Ministry will work with the Ministry 
of Health to regularly monitor and assess the 
supply and demand of PSWs.
4.1.3 Infection Prevention and Control
Not Effectively Entrenched in Homes Prior
to COVID-19 Pandemic
Our review of information about non-COVID-related
infectious disease outbreaks and Ministry 
inspection results confirmed concerns about the 
effectiveness of infection prevention and control 
(IPAC) practices in long-term-care homes pre￾COVID, and the extent to which poor existing IPAC 
practices contributed to the spread of COVID-19 in 
homes. Ensuring that proper IPAC practices are 
followed is especially critical given that more than 
two residents are still sharing one room up to 257, 
or over 40%, of the homes in the province (dis￾cussed in Section 4.1.1). 
Our analysis of outbreak information prior 
to the COVID-19 pandemic found that 96.5% of 
homes had reported an outbreak related to acute 
respiratory infections, such as influenza, between 
January 2016 and December 2019. An outbreak is 
defined as three cases occurring within 48 hours. 
Although older adults are at higher risk from 
respiratory infections, we noted the following 
concerning trends in the outbreaks reported by 
homes during the period we reviewed:
• 43% (271 homes) reported an outbreak every 
year from 2016 to 2019. 
• 42% (264 homes) reported an average of two 
to 13 outbreaks per year from 2016 to 2019. 
• 28% (176 homes) reported 10 or more 
outbreaks from 2016 to 2019. Seven of 
the 15 homes with the highest number of 
resident COVID-19-related deaths as of 
December 31, 2020 (Figure 18) reported 
10 to 18 outbreaks from 2016 to 2019. 
• annually monitor and revisit and update the 
demand and supply information of PSWs to 
track to the long-term plan; 
• work with the Ministry of Colleges and 
Universities to evaluate the PSW train￾ing programs in Ontario and establish a 
standard training curriculum for use in the 
delivery of consistent training and practical 
experience requirements as part of its staff￾ing strategy; and
• require inspectors to assess, as part of annual 
long-term-care home inspections, whether 
home operators are confirming that PSWs 
working in their homes are properly trained 
on current standards. 
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry agrees that having an appropri￾ate supply of well-trained PSWs is critical to 
achieving the targets in the Long-Term Care 
Staffing Plan and to improve quality of care. 
In January 2021, the Ministry began working 
with the Ministry of Health, the Ministry of 
Colleges and Universities and the Ministry of 
Labour, Training and Skills Development on 
these issues, including the suitability of current 
and newly announced educational programs.
Consistent with the government’s Staffing 
Plan, released in December 2020, work began in 
January 2021 to accelerate and expand educa￾tion and training pathways in order to prepare 
and train the tens of thousands of new staff that 
will be required. As an initial step, the govern￾ment has announced an investment of more than 
$115 million in 2021/22 to accelerate the train￾ing of nearly 8,200 personal support workers 
(PSWs) through publicly funded colleges.
As part of this work, the Ministry will work 
with Ministry partners to put in place:
• mechanisms to improve the suitability and 
quality of educational programs to prepare 
PSWs for work in long-term care; 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 45
ments in the Act was the fourth-most-cited type of 
non-compliance in the Ministry’s comprehensive 
inspections (Figure 19) that the Ministry decided 
to halt in the fall of 2018.
We also reviewed long-term care inspectors’ 
inspection reports from 2015 and 2019 for all homes 
where at least half of their residents contracted 
COVID-19 and where members of the Canadian 
Armed Forces were temporarily deployed to provide 
emergency support. We found that three-quarters 
of these homes (Altamont Care Community, 
Downsview Long-Term Care Centre, Eatonville 
The 20 homes that reported the highest 
number of outbreaks from 2016 to 2019 reported 
an average of six outbreaks per year. Among the 
20 homes was Midland Gardens Care Community, 
which had a total of 17 outbreaks from 2016 to 
2019. This home had 128 COVID-19 resident cases 
as of January 4, 2021. Our analysis of the results 
of Ministry inspection data from January 2015 to 
December 2019 found that a total of 413 homes, 
or about two-thirds of all homes, were cited 
for 765 instances of non-compliance with IPAC 
requirements. Non-compliance with IPAC require￾Figure 18: Historical Acute Respiratory Outbreaks among 15 Homes with Highest Number of Resident Deaths
Related to COVID-19, as of December 31, 2020
Source of data: Ministry of Long-Term Care
# of Acute Respiratory Outbreaks* (2016–2019)
Name City 2016 2017 2018 2019
Total # 
of Acute 
Respiratory 
Outbreaks
Average # 
of Acute 
Respiratory 
Outbreaks 
per Year
1 Orchard Villa Pickering 3 7 1 2 13 3.3
2 Camilla Care Community Mississauga 2 2 2 0 6 1.5
3 Downsview Long-Term Care 
Centre
North York 0 2 2 0 4 1.0
4 Carlingview Manor Ottawa 0 0 2 2 4 1.0
5 Altamont Care Community Scarborough 3 3 3 6 15 3.8
6 Tendercare Living Centre Scarborough 1 4 5 7 17 4.3
7 Forest Heights Kitchener 1 3 5 0 9 2.3
8 Hawthorne Place Care Centre North York 0 1 0 3 4 1.0
9 Extendicare Guildwood Scarborough 0 3 3 1 7 1.8
10 Isabel and Arthur Meighen 
Manor
Toronto 0 0 0 0 0 0.0
11 Madonna Care Community Orleans 0 1 3 2 6 1.5
12 Eatonville Care Centre Etobicoke 2 1 1 4 8 2.0
13 Midland Gardens Care 
Community
Scarborough 5 5 5 2 17 4.3
14 Seven Oaks Scarborough 2 3 4 7 16 4.0
15 Westside Etobicoke 2 2 4 5 13 3.3
Total 21 37 40 41 139 n/a
Note: Seven homes that had between 10 and 18 outbreaks in the period 2016 to 2019 are highlighted in gray.
* Each outbreak may involve one or more resident(s). The number of residents with acute respiratory infection is unknown. 

46
Figure 19:Top 10 Legislative Requirements Not Met by Inspection Type, January 1, 2015–August 31, 2020
Source of data: Ministry of Long-Term Care
Rank Legislative Requirement Not Met
Source of Legislative 
Requirement1
# of Written 
Notifications 
Issued
Comprehensive Inspection
1 Plan of care for resident Act (s.6) 1,595
2 Required policies and records under the Act and regulations must be 
followed2
Regulation (s.8) 992
3 Skin and wound care Regulation (s.50) 645
4 Infection prevention and control program Regulation (s.229) 608
5 Administration of drugs Regulation (s.131) 541
6 Safe storage of drugs Regulation (s.129) 526
7 Residents’ Bill of Rights is respected and promoted Act (s.3) 468
8 Policy to promote zero tolerance of abuse and neglect of residents Act (s.20) 456
9 Accommodation services Act (s.15) 452
10 Medication incidents and adverse drug reactions Regulation (s.135) 410
11 Reporting certain matters to Director Act (s.24) 410
Critical Incident System Inspection
1 Plan of care for resident Act (s.6) 1,186
2 Required policies and records under the Act and Regulations must be 
followed2
Regulation (s.8) 506
3 Reporting certain matters to Director Act (s.24) 483
4 Policy to promote zero tolerance of abuse and neglect of residents Act (s.20) 466
5 Duty to protect from abuse and neglect Act (s.19) 458
6 Reporting of critical incidents Regulation (s.107) 396
7 Transferring and positioning techniques Regulation (s.36) 253
8 Licensee must investigate, respond and act on incidents Act (s.23) 203
9 Requirements for residents with responsive behaviours Regulation (s.53) 200
10 Administration of drugs Regulation (s.131) 196
Complaint Inspection
1 Plan of care for resident Act (s.6) 1,221
2 Required policies and records under the Act and Regulations must be 
followed2
Regulation (s.8) 453
3 Skin and wound care Regulation (s.50) 274
4 Dealing with complaints about the care of a resident or the operation of the 
home
Regulation (s.101) 255
5 Administration of drugs Regulation (s.131) 235
6 Reporting certain matters to Director Act (s.24) 217
7 Residents’ Bill of Rights is respected and promoted Act (s.3) 192
8 Duty to protect from abuse and neglect Act (s.19) 189
9 Authorization for admission to a home (for a prospective resident) Act (s.44) 184
10 General requirements for programs (e.g., health, recreational and social) Regulation (s.30) 168
1. Requirements under the Long-Term Care Homes, Act 2007 (Act) and its Regulation 79/10.
2. Comprises a range of policies and records that long-term-care homes must have in place. Policies include, for example: to promote zero tolerance of abuse 
and neglect; to minimize restraining of residents; that deal with when doors leading to secure outside areas must be unlocked or locked to permit or restrict 
unsupervised access to those areas; and that address the location of the supply, procedures and timing for reordering drugs, and drug administration. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 47
• one (Extendicare West End Villa in Ottawa) had 
84 COVID-19 resident cases and 18 resident 
deaths; and
• one (Hillsdale Terraces in Oshawa) had 36 
COVID-19 resident cases and 13 resident deaths. 
None of the five homes had staff cases. The 
homes in Mississauga and Toronto, which had the 
highest number of cases and deaths, were in hot 
spots in the province, where COVID-19 was more 
prevalent than in other regions.
The Ministry’s staffing study in July 2020 
noted that the rapid spread of COVID-19 in some 
homes suggests that many initial IPAC efforts were 
insufficient. This was corroborated by the IPAC 
assessments conducted by Public Health Ontario 
from March to December 2020 in 76 long-term-care 
homes. The IPAC assessments, performed at the 
request of the homes, found 222 deficiencies in 
IPAC practices, including improper use of personal 
protective equipment, lack of cleaning products, 
and failure to follow hand hygiene best practices.
Representatives from stakeholder groups such 
as the Ontario Nurses’ Association (ONA) and 
the Ontario Personal Support Workers Associa￾tion (OPSWA) informed us there is minimal and 
inconsistent IPAC training for staff working in long￾term-care homes. According to the OPSWA, IPAC 
training provided by long-term-care homes to staff 
can vary from minimal to extensive depending on 
the home. 
This was also confirmed in a September 2020 
ONA survey of its members who were employed in 
long-term-care homes:
• fewer than half (47%) of respondents indicated 
that the IPAC training they received fully met 
their needs as an employee to prevent and 
control infection in the home;
• only 21% of respondents said they received 
in-person training, including how to put on 
and remove gowns, gloves, masks and respir￾ators; and
• 5% of respondents reported not receiving any 
IPAC training at all.
Care Centre, Grace Manor, Hawthorne Place Care 
Centre, and Woodbridge Vista Care Community) 
were previously cited for one to six instances of 
non-compliance with IPAC requirements in the 
Act. Examples of such previous non-compliance 
included: 
• residents and staff not observing proper 
procedures when contact precaution warnings 
were placed on residents’ doors; 
• residents leaving unlabelled personal care 
items such as toothbrushes, denture cups and 
disposable razors in the sink areas of shared 
washrooms; and 
• staff not observing proper hand hygiene 
during feeding.
We raised the issue of handwashing in homes 
in our 2019 audit, Food and Nutrition in Long-Term￾Care Homes. Given the vulnerability of residents 
to infectious disease, it is critical for staff to con￾sistently wash their hands. At the 59 homes we 
visited during that audit, only 76% of staff and 
19% of residents were observed practising proper 
hand hygiene directly before or after a meal. More 
concerning were the rates at individual homes, 
which varied between 0% and 35% at four of the 
five homes where we conducted detailed work. 
Our report also noted that inspections between 
January 2017 and March 2019 by public health 
inspectors at the five homes cited issues like no 
paper towels and no liquid soap at handwash￾ing stations in the kitchen, food storage and 
dining areas. 
We looked at how the five homes fared during 
COVID-19 for the purposes of this review. One 
of the five homes (Hogarth Riverview Manor in 
Thunder Bay) did not have any cases of COVID-19
among its residents. Of the four other homes: 
• one (Tyndall Nursing Home in Mississauga) 
had 118 COVID-w resident cases and 34 resi￾dent deaths;
• one (Weston Terrace Care Community in 
Toronto) had 92 COVID-19 resident cases and 
34 resident deaths;  

48
The COVID-19 experiences of long-term-care 
homes in Kingston illustrated the value of such 
exercises. Prior to the pandemic, in August 2019, 
long-term-care homes in Kingston participated 
in an exercise with other health-care providers to 
walk through how to prepare for a severe influenza 
season. As of December 31, 2020, there had been 
a total of only seven cases of COVID-19—five staff 
and two residents—in the 11 long-term-care homes 
in Kingston. 
As noted in Section 2.1.3, 61% of homes’ 
employees are PSWs. However, they receive little 
or no IPAC training. Nurses typically receive more 
IPAC training, but comprise only 28% of homes’ 
staffing complement. In his testimony at the 
Long-Term Care COVID-19 Commission, Dr. Gary 
Garber—the former Medical Director of Infection 
Prevention and Control at Public Health Ontario—
attributed the lack of IPAC expertise at homes to 
staffing turnovers, stating that, “It is very difficult 
to maintain the level of basic IPAC expertise within 
the homes due to the dramatic turnovers. You could 
train the staff in hand hygiene, and three months 
later, the staff turnover was such that you’d be 
starting from scratch.”
RECOMMENDATION 5
So that the required infection prevention 
and control (IPAC) programs and practices 
are in place and are effective in preventing 
and controlling infectious disease incidences 
and outbreaks at long-term-care homes, we 
recommend:
• the Ministry of Long-Term Care consult 
with local public health units to:
• develop and clearly communicate IPAC 
directives that outline clear and detailed 
requirements that all long-term-care 
homes must incorporate in their IPAC 
programs, including, for example, the 
level of IPAC education and experience 
required of the home’s designated IPAC 
Regarding IPAC programs and practices at long￾term-care homes, about 9% of the respondents to 
the ONA survey reported that their home did not 
have an IPAC program prior to March 2020, despite 
it being a requirement under the Act. The ONA 
also surveyed approximately 60 nurses who were 
redeployed to long-term-care homes from other 
institutions (i.e., hospitals and LHINs). Of these 
redeployed nurses, 39% of respondents stated 
they were not satisfied with IPAC practices in their 
homes, and 51% reported witnessing failures to 
comply with IPAC best practices.
The Registered Nurses Association of Ontario 
had similar findings in its November 2020 survey it 
sent to all 626 long-term-care homes. Specifically:
• only 15% of respondents reported having a staff 
member fully dedicated to IPAC;
• 30% of respondents reported that their homes’ 
IPAC leads did not have any formal IPAC 
training; and
• 9% of respondents indicated that they did not 
have a staff member responsible for overseeing 
IPAC practices at the home, despite it being a 
requirement under the Act.
Regulation 79/10 of the Act specifies the IPAC 
program requirements homes must meet. Homes 
must have a designated IPAC lead, a system to 
monitor and analyze symptoms of infection, an 
outbreak management system, a hand hygiene 
program and an immunization program for various 
infectious diseases (Appendix 1). However, 
the regulation does not specify the level of IPAC 
education and experience that is required of the 
designated IPAC lead, nor has the Ministry pro￾vided further guidance on this. In addition, the 
regulation states that the IPAC program must be 
in accordance with evidence-based or prevailing 
(current) practices, but the Ministry has not clearly 
defined what these practices are in a policy that all 
long-term-care home operators must adhere to. 
Regulation 79/10 also does not require long￾term-care homes to conduct regular exercises to 
simulate infectious disease outbreaks and response.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 49
aspects of long-term care is critical to achieve 
positive resident outcomes. 
The following responses reflect collaboration 
with and review from the Ministry of Health and 
the Office of the Chief Medical Officer of Health, 
Public Health. 
The Ministry of Long-Term Care released a 
new IPAC guidance document to the sector in 
January 2021 that is aligned with current best 
practice guidance from the Provincial Infectious 
Diseases Advisory Committee (PIDAC). The 
document includes recommendations for the 
level of education for IPAC personnel, up to and 
including certification. It also addresses recom￾mended components of evidence-based IPAC 
programming in homes.
As well, the Ministry of Long-Term Care is 
working collaboratively with the Ministry of 
Health and Ontario Health to establish hubs 
of IPAC expertise in Ontario Health Regions. 
Funding for the hubs was approved in 2020/21. 
All IPAC hub programs began in Decem￾ber 2020, and were in place by January 2021. 
Most hubs are housed in hospitals with 
advanced IPAC expertise. The hubs provide a 
range of supports to Long-Term Care Homes, 
including expertise, knowledge dissemination 
and capacity development. Hubs engage with 
public health units and Ontario Health at the 
local level.
Public Health Ontario has been a key partner 
supporting long-term-care homes during the 
pandemic, including conducting IPAC assessments 
and developing training and educational resour￾ces. As well, it has supported the training of the 
IPAC specialists who were deployed to homes.
The Ministry will review the elements of 
this recommendation along with any related 
recommendations from the LTC COVID-19
Commission, as it continues to work with Public 
Health Ontario, Ontario Health and other 
partners to review and improve IPAC practices 
and protocols on an ongoing basis.
lead as well as initial and ongoing IPAC 
training requirements; 
• develop supporting guidance documents 
that provide additional resources for 
long-term-care homes to help them 
meet the requirements in the Long-Term 
Care Homes Act, 2007 (Act) and its 
regulations; and
• establish mandatory IPAC training 
requirements for long-term-care staff 
at the home level, especially those 
involved in providing direct care to resi￾dents, to determine and address gaps and 
to have them provide continual training 
to coincide with their staff turnover.
• the Ministry of Long-Term Care, in conjunction 
with the Ministry of Health:
• require all long-term-care homes to 
conduct annual exercises, prior to the 
influenza season, that simulate infectious 
disease outbreaks and response;
• require public health units to co-ordinate 
and participate with long-term-care 
homes within their jurisdictions in these 
annual exercises; and
• require public health units to conduct 
at a minimum, annual IPAC assessments 
of all long-term-care homes within their 
jurisdictions, and provide such assessments 
to the Ministry of Long-Term Care; and
• the Ministry of Long-Term Care use the IPAC 
assessments conducted by public health 
units to inform its inspection process.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry agrees with the goal of ensuring 
long-term-care homes have suitable and effective 
IPAC practices in place. Collaborating with the 
Ministry of Health and public health experts to 
embed IPAC practices and protocols within all  

50
Columbia as a factor in the better outcomes in that 
province during the initial wave of COVID-19. 
Reports Highlighted Integration Gap Between 
Long-Term-Care and Rest of Health Sector
In 2015, our Office noted in our audit of LHINs—
Local Health Integration Networks—that the then 
Ministry of Health and Long-Term Care had “not 
clearly determined what would constitute a ‘fully 
integrated health system,’ nor ha[d] it developed 
ways of measuring how effectively LHINs [were] 
performing specifically as planners, funders and 
integrators of health care.” We recommended that 
the then Ministry of Health and Long-Term Care: 
(1) develop LHIN-specific performance targets, 
and (2) implement performance indicators that 
measure the co-ordination of health services. In our 
2017 follow-up, the Ministry committed to imple￾ment these recommendations by March 2018. 
When we followed up on the Ministry’s com￾mitment in 2018, we found that the Ministry had 
set performance indicators to measure the co-ordin￾ation of health services. The Ministry told us during 
our follow-up that it would not create LHIN-specific 
performance targets because it had established 
provincial-level targets that all LHINs were expected 
to demonstrate improvement toward. We confirmed 
that the indicators and targets that were set did not 
include anything specifying integrating health ser￾vices for the long-term-care sector with the entirety 
of health services publicly provided in Ontario. 
In this time of transition from the LHIN system to 
a more centralized health oversight system, it is 
all the more important for those with oversight 
responsibility to act with a clear and measurable 
vision of health integration where Ontarians’ needs 
for long-term care, retirement homes, assisted-living 
and home care are fully considered and relationships 
are integrated.
Subsequent reports written by others have 
also recently noted the disconnect between the 
long-term-care sector and the rest of Ontario’s 
health-care system. For example, the Royal Society 
of Canada Working Group’s June 2020 Policy 
4.2 Long-Term-Care Sector Largely 
Disconnected from Rest of Health￾Care System 
4.2.1 Lost Opportunity for Many Homes
to Have Staffing and Infection Prevention
and Control Support from Hospitals, Public
Health Units
We confirmed that most long-term-care homes 
did not have access to potentially life-saving infec￾tion prevention and control (IPAC) expertise and 
support during the initial stages of the COVID-19 
crisis because they were largely disconnected from 
other sectors of the health-care system. 
Prior to the pandemic, most long-term-care 
homes did not have formal partnerships with local 
public health units and hospitals that would have 
enabled them to benefit from the IPAC expertise 
of hospital and public health unit staff. Dr. Gary 
Garber confirmed the disconnect between long￾term-care homes and hospitals in his testimony 
at the Long-Term Care COVID-19 Commission, 
stating that, “until spring [2020], there was no real 
connection between hospitals and long-term-care 
regarding IPAC.” Various stakeholder groups noted 
that, given the limited IPAC specialists in long-term￾care homes, many homes did not have the capacity 
to manage the COVID-19 outbreaks without exter￾nal support.
Long-term-care homes are overseen by the 
Ministry of Long-Term Care. Hospitals are over￾seen by the Ministry of Health, Ontario Health and 
the former LHINs, while local public health units, 
which are responsible for public health response, 
primarily report to their respective municipal gov￾ernments. In comparison, long-term-care homes in 
British Columbia are overseen by regional health 
authorities that also oversee both hospitals and 
local public health units (see Appendix 12).
A September 2020 article in the Canadian Medical 
Association Journal (discussed in Section 4.4.1) 
highlighted the strong links between hospitals, 
long-term-care homes and public health in British  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 51
two weeks earlier, than the provincial mandate 
ordering these measures. Prior to the pandemic, 
the City of Toronto conducted regular IPAC reviews 
of the 10 long-term-care homes it owned. In addi￾tion, during the pandemic, each home created an 
interprofessional team to support outbreak plan￾ning, and designated a manager to work with the 
Toronto Public Health Unit, Ontario Health, and the 
Ministry regarding outbreak statistics, laboratory 
testing, contact tracing, mortality, staffing and 
PPE inventory. 
We analyzed the number of COVID-19 cases 
in all long-term-care homes in Toronto, which 
includes the 10 homes owned by the City of 
Toronto, 39 for-profit homes, and 36 non-profit 
homes. We found that the peak COVID-19 infection 
rate in the 10 municipal homes averaged at 9% of 
the homes’ total bed capacity, compared with 13% 
for the 36 non-profit homes and 15% for the 39 for￾profit homes. The peak COVID-19 mortality rate was 
also lower in the 10 municipal homes, averaging at 
3%, compared with 6% for non-profit homes and 
7% for for-profit homes. We also note that other 
factors likely contributed to this more positive 
result for the municipal homes.
As of July 8, 2020, only 347 or 55% of Ontario’s 
626 long-term-care homes had informal partnerships 
(i.e., no formal agreement or memorandum of 
understanding) with a local hospital. Such partner￾ships allow homes to access not only IPAC expertise 
but also staffing resources, which would have been 
valuable to the many homes without them in the 
initial wave of the pandemic. None of the homes 
had formal partnerships with hospitals prior to the 
pandemic to assist them in an emergency.
For example, we noted that the partner￾ships that Altamont Care Community (effective 
June 8, 2020) and Extendicare Guildwood 
(effective June 11, 2020) had with the Scar￾borough Health Network involved the hospitals 
providing mentorship support for IPAC and clinical 
care, and improved consultation access to specialists, 
including those working in palliative care, geriatric 
Briefing Report on COVID-19 and the future of 
long-term care in Canada noted the importance 
of integrating the various parts of the health-care 
system, noting that what happens in one of these 
settings, such as an outbreak of communicable 
disease, can and does affect all other sectors. The 
report A Perfect Storm—issued in December 2020 
by an expert advisory panel led by Dr. Bob Bell 
(the Deputy Minister of Health and Long-Term 
Care from June 2014 to June 2018) based on the 
experiences at Revera homes—commented that 
COVID-19 exposed the broken links between the 
long-term-care sector and the health system as a 
whole. Revera is a Canadian for-profit operator of 
long-term-care and retirement homes; it operates 
53 long-term-care homes in Ontario. The panel 
stated in the report that home operators must rely 
on input and co-operation from across the health 
system to function well. 
Benefits EvidentWhere Homes Had Partnerships
with Hospitals and Public Health Units
Representatives from some stakeholder groups, 
such as the Canadian Patient Safety Institute, 
informed us that some homes that were informally 
associated with hospitals were able to access 
support from local public health units and were 
able to implement better IPAC measures. This is 
illustrated by the example highlighted in Section 
4.1.3 about the August 2019 planning exercise for 
severe influenza with long-term-care homes in 
Kingston.
In addition, a June 2020 report by the City of 
Toronto’s Senior Services and Long-Term Care 
Division on the COVID-19 response of 10 long￾term-care homes that are owned and operated by 
the City of Toronto (i.e., municipal homes) noted 
that the homes’ relationship with the Toronto 
Public Health Unit allowed them to put in place 
outbreak protocols and preventative measures, 
such as active screening for COVID-19, before they 
were provincially mandated to do so. The City of 
Toronto homes made masks mandatory more than 
a week earlier, and restricted non-essential visitors  

52
2019 Provincial Emergency Response Plan requires 
the Ministry of Long-Term Care to develop a plan 
to respond to emergencies related to human health 
and diseases. At the time of the pandemic, no separ￾ate plan for the long-term-care sector was in place. 
Emergency plans must include procedures for 
evacuating and relocating residents if necessary, 
setting aside necessary supplies and equipment, 
and identifying relevant community agencies, 
partner facilities and resources that will be involved 
in responding to the emergency. During the initial 
wave of the COVID-19 pandemic, it was clear that 
many homes had not identified or established rela￾tionships with community agencies and partners that 
could have readily assisted in the event of a severe 
outbreak. An emergency plan that, for example, 
outlines procedures and sites to relocate residents 
with COVID-19, prescribes the necessary amount 
of PPE, and identifies partner agencies such as 
hospitals and public health units, would provide 
long-term-care home staff with a clearer and sys￾tematic way to deal with outbreaks. 
We obtained documentation from eight out of 
10 long-term-care homes we contacted and found 
that they had written plans for responding to infec￾tious disease outbreaks (other than pandemics), 
as required under Regulation 79/10. These plans 
covered topics such as maintaining an adequate 
amount of PPE and collaborating with health system 
partners like public health units. However, these 
plans were not integrated as part of the homes’ 
emergency planning because it is not required under 
legislation. Including pandemics as emergencies 
and integrating outbreak plans with emergency plans 
would provide a clearer and more systematic way of 
responding to events like the COVID-19 pandemic.
RECOMMENDATION 6 
So that long-term-care homes are better pre￾pared to manage the impact of future infectious 
disease outbreaks including pandemics, we 
recommend that the Ministry of Long-Term 
Care work with the Ministry of Health, Ontario 
psychiatry and internal medicine. In particular, 
hospital staff went into Extendicare Guildwood at 
the height of this home’s outbreak, when almost 
half of its staff were not reporting in to work 
and the home had trouble recruiting temporary 
staff. At the start of its formal partnership con￾tract on June 11, Extendicare Guildwood had the 
eighth-highest number of resident deaths due to 
COVID-19 in the province at 47. The hospitals sub￾sequently helped Extendicare Guildwood develop 
a management plan, implement a resident quality 
improvement program, perform a situational 
analysis, develop recommendations, identify 
key performance indicators and create a transi￾tion plan to assist in the next wave of COVID-19. 
During the term of the initial formal partnership 
contract (June 11 to September 10) and up to 
December 31, 2020, one more resident died due 
to COVID-19.
Emergency Planning at Long-Term-Care Homes
Did Not Include Pandemic or Significant
Infectious Disease Planning
Under Regulation 79/10, long-term-care homes 
are required to have in place a written plan for 
responding to infectious disease outbreaks within 
the facility. However, we noted that the list of emer￾gencies in Regulation 79/10 of the Long-Term Care 
Homes Act, 2007 for which homes must develop a 
response plan does not include a pandemic. The 
Act and its regulation require all long-term-care
homes to have emergency plans outlining how they 
will respond to emergencies such as fires, commun￾ity disasters, bomb threats, chemical spills, and 
the loss of one or more essential services. The 
Ontario Health Plan for an Influenza Pandemic 
requires long-term-care homes to report to the 
Ministry of Health respiratory infection outbreaks 
and laboratory-confirmed cases of influenza. 
There are no other requirements for long-term-care
homes under Ontario’s Heath Plan for an Influ￾enza Pandemic. As per our 2020 special report on 
Emergency Management in Ontario—Pandemic 
Response, the Emergency Management Office’s  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 53
• standardize expectations for homes’ contin￾gency plans; and
• explicitly include pandemic planning in the 
statutory framework governing LTC.
4.2.2 IPAC Expertise Resides with Public
Health Units, but Inspectionsfor IPAC
Practices at Homes Done by Ministry
Our review found that Ontario’s current health-care 
system makes the Ministry primarily responsible 
for inspecting that homes are properly carrying out 
infection prevention and control (IPAC) practices, 
even though public health units are the experts 
on IPAC. 
Ministry Has Oversight and Mandate to Inspect
IPAC Programs But Does Not Have the Expertise
to Do It Effectively
The Long-Term Care Homes Act, 2007 (Act), which 
governs the operations of long-term-care homes, 
dictates that homes must have an IPAC program 
(see Appendix 1). The Ministry is then responsible 
for inspecting homes’ compliance with the require￾ments of the Act and its regulations.
We found that there are only three staff 
in the Ministry’s Inspection Branch who have 
IPAC expertise (discussed later in this section). 
Of the 140 inspectors who were active as of 
September 30, 2020, 74% were nurses, 21% 
were dietitians, and the remainder were mainly 
physiotherapists. Depending on their profession 
and the specialties pursued during their education, 
these inspectors received varying amounts of IPAC 
training, from basic to more extensive. 
The Ministry inspectors we interviewed told 
us they did not have sufficient knowledge of and 
training in IPAC to know what to look for beyond 
the limited requirements in the Act. Specifically, 
Regulation 79/10 of the Act requires that long￾term-care homes have a written plan for detecting, 
managing and controlling infectious disease 
outbreaks, a hand hygiene program, and an 
immunization and screening program for various 
infectious diseases. The regulation also requires 
Health, and the Local Health Integration 
Networks to: 
• develop a pandemic plan for the entire long￾term-care sector that clearly outlines roles 
and responsibilities, specific actions to be 
taken, and the timing of such actions in the 
event of a pandemic; 
• require all long-term-care homes to develop 
and regularly review and update a pandemic 
plan as part of its emergency planning; 
• establish formal partnership agreements 
between long-term-care homes, local hospi￾tals and public health units, with clear roles 
and provisions for sharing expertise and 
resources in specifically identified situations 
such as outbreaks of infectious disease and 
pandemics; and
• update Regulation 79/10 to include pan￾demics in the list of emergencies for which 
long-term-care homes must develop a 
response plan.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry accepts the recommendation and 
will work with partners to improve sector pre￾paredness for managing during a pandemic.
In March 2021, the Ministry established the 
Response and Recovery Advisory Committee to 
provide expert advice and input for the develop￾ment of an action-oriented recovery framework 
for the long-term-care (LTC) sector. The recovery 
framework will reflect LTC homes as being part 
of the broader health-care system, with connec￾tions to Ontario Health Teams, and will include 
specific actions to strengthen emergency pre￾paredness. The work will also be informed by 
any relevant recommendations from the LTC 
COVID-19 Commission. 
Recovery planning will explore opportunities to: 
• formalize partnerships between LTC homes 
and hospitals or other organizations; 

54
Public Health Units Have the IPAC Expertise but
Not the Specific Inspection/Oversight Mandate
for Long-Term-Care Homes
As discussed in Section 2.2.5, the Health Promotion 
and Protection Act (HPPA) requires public health 
units to conduct inspections within their jurisdiction 
for the purpose of “preventing, eliminating, and 
decreasing the effects of health hazards.” The 
HPPA specifically requires local medical officers 
of health to inspect food premises and premises 
used or intended to be used as a boarding or 
lodging house. 
The Ministry of Health’s Infection Prevention 
and Control Protocol (IPAC Protocol), which out￾lines inspection requirements for public health 
units, requires every public health unit to inspect 
all licensed child care and personal service set￾tings at least once every 12 months. However, we 
noted that the IPAC Protocol does not require public 
health units to conduct regular inspections of long￾term-care homes for adherence to IPAC practices. 
Currently, public health units inspect long￾term-care homes on their own initiative and when 
they receive an IPAC-related complaint about a 
home. The Ministry of Health’s Institutional/Facil￾ity Outbreak Management Protocol (see Appendix 
5), developed under the authority of the HPPA 
(the Act from which public health units derive 
their authority), does require public health units 
to assist homes in preparing and reviewing their 
outbreak response plans every two years. However, 
this requirement is not specifically mentioned in 
the HPPA, and therefore, it may not be as clear a 
requirement as it may need to be. 
We surveyed the five public health units 
in the province with the largest population 
coverage—Peel, Toronto, York, Durham and 
Ottawa—to understand the nature and extent of 
their involvement in monitoring IPAC practices in 
long-term-care homes prior to the COVID-19 pan￾demic. The five public health units reported varying 
levels of involvement:
that each home have an interdisciplinary team to 
implement its IPAC program.
The Ministry inspectors we interviewed also told 
us that the Act and supporting regulation were not 
specific enough to allow inspectors to ensure that 
homes had good IPAC programs in place. They also 
said that the current inspection protocols needed to 
be improved to give inspectors a better understand￾ing of what to look for when observing practices 
that should be included in a home’s IPAC program. 
Inspectors are to go through a number of checklists 
to assess homes’ compliance with the Act’s require￾ments. However, the Ministry has not provided 
inspectors guidance on what constitutes “a good 
job” or a best practice for some items on the check￾list, such as:
• observe staff’s handling of supplies and isola￾tion precautions;
• observe how staff use IPAC practices while 
caring for and assisting residents;
• review whether the home’s IPAC program 
includes measures to prevent the transmission 
of infections; and
• determine whether the designated IPAC lead 
has appropriate education and experience in 
infectious diseases, cleaning and disinfection, 
data collection and trend analysis, reporting 
protocols and outbreak management. 
We found that there are three specialized 
inspectors within the Ministry’s Long-Term Care 
Inspection Branch who have backgrounds in public 
health and IPAC. Prior to 2010, this role provided 
IPAC expertise during annual inspections of homes. 
However, over time, the role was reduced and 
changed from field inspection to mostly developing 
policy and providing education. In November 2019, 
the Ministry implemented a process that allowed 
inspectors to request the help of one of these spe￾cialized inspectors on a variety of environmental 
areas, including IPAC. Our review of Ministry logs 
found that between November 2019 and Novem￾ber 2020, there had only been 10 requests for help 
on IPAC-related issues. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 55
care homes prior to the COVID-19 pandemic. 
For example, the Toronto Public Health Unit 
holds annual “Long-term Care Home Education 
Day” during which it provides information and 
resources regarding best practices and consider￾ations in maintaining a healthy environment, 
including infection control. The Ottawa and Peel 
Public Health Units hold annual Outbreak 101 
or IPAC education days to provide information 
about managing outbreaks and provide IPAC 
training. The Durham Public Health Unit pro￾vides IPAC education sessions, such as reviewing 
how to complete outbreak reports, cohorting, 
and laboratory sample testing, when requested 
by homes. 
RECOMMENDATION 7 
To improve oversight of infection prevention 
and control (IPAC) programs and practices at 
long-term-care homes, we recommend that 
the Ministry of Long-Term Care work with 
the Ministry of Health to review and revise 
the Ministry of Long-Term-Care’s inspection 
program and the Ministry of Health’s Inspection 
• Only two public health units—York and Ottawa— 
stated that they had conducted proactive IPAC 
inspections in long-term-care homes prior to 
the pandemic. Our review of the forms used to 
conduct proactive inspections in the two public 
health units noted differences in methodology and 
topics covered (see Figure 20). For example, 
Ottawa’s form assesses whether the home has 
an outbreak surveillance and management 
program in place, while York’s does not. On the 
other hand, York’s form assesses whether the 
home has waste disposal protocols in place, 
while Ottawa’s does not. 
• Three public health units—Peel, York and 
Ottawa—stated that they had limited co-ordin￾ation with Ministry of Long-Term Care home 
inspectors. Examples of limited co-ordination 
include informing the Ministry of instances 
of non-compliance found during public health 
inspections or referring a home for Ministry 
inspection. The other two public health units—
Toronto and Durham—told us they had not 
co-ordinated work with Ministry of Long-Term 
Care home inspectors prior to COVID-19.
• All five public health units reported conducting 
educational outreach activities in long-term￾Figure 20: AreasInspected byTwo of the Five Public Health UnitsThat Conducted Proactive Inspections
of Long-Term-Care Homes Prior to COVID-19 Pandemic
Prepared by the Office of the Auditor General of Ontario based on data from the York and Ottawa Public Health Units
Areas inspected Ottawa York
Existence of outbreak surveillance and management program 
Accuracy of line list data (detailed information about outbreak incidents) 
Availability of personal protective equipment  
Safe sample collection
Presence of vaccination/immunization policy 
Existence of cleaning and disinfection protocols  
Existence of hand hygiene protocols  
Existence of visitor policy  
Existence of waste disposal protocols 
Availability of signage for residents, staff and visitors  
Existence of food safety protocols  

56
and long-term-care homes in preparing and 
reviewing outbreak response plans.
The Ministry, with the Ministry of Long-Term 
Care and public health partners, will implement 
lessons learned from the pandemic to make the 
health system stronger. As part of the health 
system and the long-term care recovery process, 
the ministries will develop proposals for gov￾ernment consideration regarding structural 
and operational requirements to enhance IPAC 
practices in the long-term-care sector, including 
potential legislative proposals related to the 
Health Protection and Promotion Act, its regula￾tions, and the Ontario Public Health Standards, 
as well as the Ministry of Long-Term Care’s 
legislative and regulatory mechanisms.
In March 2021, the Ministry of Long-Term 
Care established the Response and Recovery 
Advisory Committee to provide expert advice 
and input for developing an action-oriented 
recovery framework for the LTC sector. This 
committee will advise on opportunities to 
support improved IPAC.
4.2.3 Health Sector Reorganization Raised
Concerns Regarding Timely Provincial
Response to Outbreaks in Long-Term￾Care Homes
Some of the reports we reviewed and stakeholders 
we interviewed raised concerns that the reorganiz￾ation of the health sector still in process at the time 
of our review work (described in Section 2.2.5) may 
have slowed the province’s response to COVID-19 in 
long-term-care homes. Stability in leadership and 
governance structures facilitate appropriate measures 
to be taken when a crisis occurs. 
The Ministry of Long-Term Care was separ￾ated from the Ministry of Health in June 2019, 
less than a year before the initial wave of the 
pandemic. A new Deputy Minister of Long-Term 
Care was appointed by the Secretary of Cabinet 
on March 9, 2020, replacing the previous Deputy 
Prevention and Control Protocol so that, 
as suggested in Recommendation 5: 
• public health units are required to co-ordinate 
and participate with long-term-care homes 
within their jurisdictions in IPAC annual 
exercises; 
• public health units are required to conduct 
regular IPAC assessments of all long-term￾care homes within their jurisdictions, and 
provide such assessments to the Ministry of 
Long-Term Care; and 
• Ministry of Long-Term Care inspectors use 
the IPAC assessments conducted by public 
health units to inform their inspections.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry will engage with Ontario Health, 
the new IPAC hubs and Public Health Ontario 
to ensure clear roles and responsibilities with 
respect to IPAC, including IPAC review and 
assessment processes. This will include con￾firming the role the hubs will have to support 
homes to further develop IPAC capacity and 
respond to assessment findings.
RECOMMENDATION 8 
To improve oversight of infection prevention 
and control (IPAC) programs and practices at 
long-term-care homes, we recommend that the 
Ministry of Health update the Health Promotion 
and Protection Act to require local public health 
units to assist long-term-care homes in preparing 
and reviewing their outbreak response plans, 
which is currently in the Ministry of Health’s 
Institutional/Facility Outbreak Management 
Protocol. 
MINISTRY OF HEALTH RESPONSE
The Ministry is supportive of strengthening 
partnerships between public health units  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 57
behaviours that are essential for building a 
skilled, diverse and effective public service.
Sector-specific knowledge and experience 
will continue to be part of the criteria used to 
assess candidates for senior executive roles, 
but selection decisions will always be made in 
consideration of all the leadership competen￾cies of a candidate. In this regard, we note that 
senior executives are appointed as an enterprise 
resource who can be strategically deployed, and 
are able to rely on their ministry teams for in￾depth knowledge from subject-matter experts.
AUDITOR GENERAL RESPONSE
 The long-term-care sector would benefit from 
the Ministry having senior leadership with 
operational experience in long-term care.
4.3 COVID-19 Pandemic Response 
Actions Had Unintended 
Consequences on Long-Term-Care 
Residents and Staff
Beginning in February 2020, the province imple￾mented a number of measures to deal with the 
impact of COVID-19 and minimize its spread 
(see Appendix 7). These measures had unintended 
consequences on long-term-care home residents 
and staff by contributing to crowding and staffing 
shortages. Subsequent steps taken were insufficient 
to lessen the resulting negative impact of the initial 
measures.
4.3.1 Lack of Space Prevented Homes
from Isolating Residents with COVID-19
Effectively
The Ontario Long Term Care Association informed 
us that when COVID-19 arrived in Ontario, homes 
were already at capacity, and did not have the 
space or bed capacity to effectively and safely 
isolate residents who eventually contracted or 
Minister. In addition, in July 2020, the position of 
Assistant Deputy Minister (ADM) responsible for 
overseeing long-term-care home operations was 
filled by a new individual. The ADM who previously 
oversaw the inspection process and long-term-care 
home operations was re-assigned to be the ADM 
responsible for long-term-care capital projects.
While these individuals need to possess the 
administrative competencies to hold deputy and 
assistant deputy minister positions, having experience 
in the long-term-care sector would have given them 
on-the-ground understanding of the long-standing 
critical issues and challenges they would have to 
address during the pandemic.
Another consequence of the Ministry of 
Long-Term Care separating from the Ministry of 
Health was that the Long-Term Care Table (now 
called the Retirement Home/Long-Term-Care 
Operations COVID Action Table) was estab￾lished on March 14, 2020—two weeks after 
the Health Command Table was established on 
February 28, 2020.
RECOMMENDATION 9 
To better inform the Ministry of Long-Term 
Care’s decision-making, we recommend that 
the Secretary of Cabinet include in the hiring 
criteria for this ministry that future Assistant 
Deputy Ministers and Deputy Ministers have 
knowledge and experience in the long-term￾care sector.
SECRETARY OF CABINET RESPONSE
Hiring decisions for senior executives in the 
Ontario Public Service (OPS) necessarily take 
into consideration a wide variety of leadership 
qualities and competencies. Sectoral knowledge 
and experience are an important part of the 
selection criteria for senior executives, along 
with other important qualities, such as innova￾tive, responsible and collaborative leadership  

58
According to the stakeholders we met with, 
homes could not effectively implement the CMOH 
directive because of lack of space. Maintaining 
physical distancing was even more challenging 
at facilities where residents, for example, eat in 
communal areas. Stakeholders cited the following 
examples of challenges and improper cohorting 
practices:
• assuming when a resident in a unit or bedroom 
tested positive for COVID-19 that other resi￾dents in the same unit or bedroom were also 
likely infected, and therefore allowing them to 
interact; and
• difficulties ensuring that residents were 
properly self-isolating and not wandering 
from their rooms.
Similar examples were cited by stakeholder 
testimonies at the Long-Term Care COVID-19
Commission (discussed in Section 2.3.4). For 
example: 
• Dr. Gary Garber, former Medical Director of 
Infection Prevention and Control at Public 
Health Ontario, testified about a call he had 
with one of the long-term-care homes that was 
experiencing an outbreak. When asked whether 
the home was able to cohort and separate 
COVID-19-positive residents from the rest of the 
residents, the home stated it was not able to do 
so. He said the home ended up having a 90% 
COVID-19 infection rate. 
• The Ontario Health Coalition described a case 
in a long-term-care home in Ottawa where 
one resident in a two-bed room had tested 
positive for COVID-19. The other resident was 
not moved to another room and contracted 
COVID-19.
• The Ontario Nurses’ Association gave an 
example of another home in Ottawa that con￾tinued receiving new residents even after one 
resident developed COVID-19 symptoms. 
In the Ontario Nurses’ Association’s Sep￾tember 2020 survey of its members, 20% of 
respondents reported that residents who showed 
symptoms of COVID-19 were not isolated, and an 
were exhibiting symptoms of COVID-19. This was 
because long-term-care homes were designed to 
operate at full occupancy. Based on the Ministry 
of Long-Term Care’s most recent (March 2020) 
occupancy information, homes were, on average, 
operating at 98% bed capacity. The Ministry of 
Long-Term Care did not initially provide specific 
guidance or assistance to help homes in isolating 
COVID-19-positive residents to prevent the spread 
of COVID-19 in homes. As of December 31, 2020, 
the occupancy rate at long-term-care homes 
was 90%.
On March 30, 2020, the Ontario Chief Medical 
Officer of Health (CMOH) updated Directive #3 
to require homes to cohort residents and staff to 
prevent the spread of COVID-19. On May 23, 2020, 
the CMOH added a requirement for homes to 
have a plan for resident cohorting in the event of a 
COVID-19 outbreak (see Appendix 7). Cohorting 
options for residents included, for example, moving 
residents to alternative accommodation to maintain 
physical distancing of two metres at all times; 
grouping residents by COVID-19 status; and using 
other rooms to accommodate residents, including 
respite and palliative care beds and rooms. With 
respect to staff cohorting, options included desig￾nating staff to work in specific areas in the home 
and designating staff to work only with specific 
cohorts of residents based on their COVID-19 status 
in the event of a suspected or confirmed outbreak. 
On April 1, 2020, the Ministry issued a guidance 
document, which contained limited direction on 
cohorting; for example, suggesting that additional 
rooms such as those for recreation be used to isolate 
residents. On April 15, 2020, the Ministry provided 
more detailed guidance in line with Directive #3 
indicating that, in long-term-care homes where it 
was not possible to maintain physical distancing, 
all staff and residents were to be managed as if they 
were potentially infected with COVID-19. Both 
versions of the guidance document did not address 
off-site alternatives to help homes implement the 
cohorting directive, even when a home’s lack of 
space made cohorting impossible.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 59
the intensity of care provided in a hospital setting 
but who are still occupying a hospital bed because 
they have no other place to go while they wait to be 
discharged to their home, a rehabilitation facility or 
a long-term-care home. 
At the onset of the pandemic, decision-makers 
were concerned about the risk that hospitals could 
be overrun by an overwhelming influx of patients. 
While this did not transpire, the following steps 
were taken in case it would, with the follow￾ing results:
• On March 16, 2020, the provincial Health 
Command Table (renamed to Health Co￾ordination Table) informed health system 
organizations that it had been decided to 
quickly maximize the number of available 
acute-care beds, reduce the number of patients 
designated as ALC in hospitals and maximize 
placements in long-term-care homes. 
• In the month of March 2020, 761 transfers of 
patients designated as ALC were made from 
hospitals to long-term-care homes, 50% more 
than the average of 508 patients transferred per 
month throughout 2019. (This was based on our 
analysis of transfers from hospitals to long-term￾care homes from January 2019 to August 2020.) 
On March 30, 2020, after the transfers, the 
average acute-care occupancy rate in hospitals 
was at 70.9% (an 80% acute care occupancy 
rate is considered high). A September 2020 
report by the Ontario Hospital Association 
noted that, prior to the COVID-19 pandemic, 
the acute care occupancy rate at many hospitals 
regularly exceeded 100%. 
• In the month of April 2020, 691 transfers 
were made, 36% more than the 2019 monthly 
average. As of April 13, 2020, the hospital 
acute-care occupancy rate was at 64%.
Given that homes were, on average, at 98% 
capacity prior to the pandemic according to Ministry 
of Long-Term Care’s occupancy data, these transfers 
of patients designated as ALC added pressure 
to some homes already struggling to contain the 
spread of COVID-19. By the time the Ministry of 
additional 7% reported that there were delays in 
isolating those residents. Forty-four percent of 
respondents said that staff assignments were not 
based on residents’ COVID-19 status—that is, a 
staff member who worked with COVID-19-positive 
residents also had to work with residents who did 
not have COVID-19. This is not unexpected given 
the staffing complements at long-term-care homes.
In our 2007 report, Outbreak Preparedness and 
Management, we raised the importance of identify￾ing suitable quarantine sites for infected individuals 
not requiring hospital care in order to ease the 
burden on hospitals during an infectious-disease 
outbreak. We similarly recommended in our 2009 
report Infection Prevention and Control at Long￾Term-Care Homes that the then Ministry of Health 
and Long-Term Care develop guidance to help 
long-term-care homes isolate and group together 
residents who have or are at high risk of having an 
infectious disease, given the limited availability 
of private rooms. The Ministry responded that it 
planned to renovate 35,000 beds in older homes 
over the next decade, making them parts of larger 
rooms with a maximum of two beds each (versus 
four-bed wards in older homes), and that this “will 
assist homes in keeping residents with infectious 
diseases adequately separated.” Between 2009 and 
2019, only 3,766 beds were renovated. More than 
10 years later, little progress had been made and 
the issue remains, now with significantly greater 
risks and consequences for the safety of residents. 
4.3.2 Transfer of Patients Designated
as Alternate Level of Care from Hospitals 
to Long-Term-Care Homes Contributed 
to Crowding in Homes; Alternative 
Accommodations Not Used
We found that transfers of patients designated 
as alternate level of care (ALC) from hospitals 
to long-term-care homes further contributed to 
crowding in homes that were already dealing with 
COVID-19 challenges (see Section 4.1.1). Patients 
designated as ALC are those who no longer require  

60
of care before returning to their long-term-care 
home. Another 100 beds were created for non￾COVID-19-positive patients who could not return to 
their long-term-care homes. 
In May 2020, the International Long-Term 
Care Policy Network—a network of researchers, 
policy-makers and other stakeholders that aims 
to promote the global exchange of evidence and 
knowledge on long-term-care—published a report 
on international policy and practices to prevent 
COVID-19 in care homes. According to the report, 
many countries had taken measures to limit direct 
hospital discharges to care homes during the pan￾demic, sometimes using “step-down” quarantine 
centres prior to admitting patients into a home. 
For example, people discharged from hospitals in 
the German state of Lower Saxony were sent to 
rehabilitation hospitals to quarantine and receive 
short-term care, prior to being placed in a long￾term-care home.
In Ontario, we found one example of an 
alternative placement for patients designated 
as ALC: St. Joseph’s Continuing Care Centre in 
Sudbury transferred them to the Clarion Hotel 
beginning in April 2020.
RECOMMENDATION 10 
To minimize the spread of infectious diseases 
when long-term-care homes are at capacity, 
we recommend that the Ministry of Long-Term 
Care, in developing its future pandemic plan 
(in Recommendation 6): 
• develop a strategy that would be followed 
for capacity and placement considerations 
in both long-term-care homes and hospitals 
regarding patients designated as alternate 
level of care;
• work with the Solicitor General to identify 
and establish agreements for alterna￾tive housing sites to facilitate proper 
cohorting; and
• develop emergency staffing plans to ensure 
that residents, whether in long-term-care 
Health, Ministry of Long-Term Care and Ontario 
Health ordered hospitals on April 15, 2020 to 
suspend transfers of patients designated as ALC 
to long-term-care homes, Public Health Ontario 
had reported that more than 933 residents and 
530 staff had contracted COVID-19 in 104 differ￾ent outbreaks. However, the Ministry of Health’s 
expectation was that none of the patients designated 
as ALC were transferred to homes where there were 
active outbreaks of COVID-19—admission to homes 
experiencing an outbreak was prohibited under 
Directive #3.
On June 10, 2020, the province began allowing 
transfers of patients designated as ALC to homes 
again. This nearly two-month suspension of ALC 
transfers to long-term-care homes resulted in 
higher ALC transfers from hospitals to long-term 
care homes in July and August 2020. Total ALC 
transfers were 998 in July and 829 in August, 
which were 96% and 63% higher, respectively, 
than the 2019 monthly average. The number of 
new COVID-19 cases in long-term-care homes was 
down to an average of two residents and one staff 
per day in July, and an average of one resident and 
one staff per day in August 2020. In September, the 
number of new confirmed COVID-19 cases in long￾term-care homes increased to an average of eight 
residents and four staff per day. In October, the 
numbers rose further to an average of 27 residents 
and 11 staff per day. As of December, this upward 
trend remained, with the number of new cases 
averaging 81 residents and 38 staff per day. 
Our research found that other jurisdictions 
have identified alternative placements for patients 
designated as ALC. For example, in April 2020 in 
Saskatchewan, some rural hospitals were specif￾ically dedicated to house patients designated as 
ALC. In Quebec, about 200 “transition” beds were 
created for seniors in the previously closed l’Hôtel￾Dieu de Montréal hospital between April and 
August 2020. There were 100 beds to treat patients 
who tested positive for COVID-19, but were in 
stable condition. These patients no longer required 
urgent medical care, but still needed some form  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 61
The negative impact of the directive was that resi￾dents’ family members could not visit their loved 
ones for the months the directive was in effect (it 
was lifted on June 10, 2020). 
This lack of contact took an emotional toll on 
residents and their families, in many cases resulting 
in a deterioration in residents’ physical condition. 
Dr. Samir Sinha, Director of Geriatrics at Sinai 
Health System and the University Health Network 
in Toronto, stated in testimony at the Long-Term 
Care COVID-19 Commission that visitor restrictions 
had not always balanced the risks of COVID-19
infection with the risks of social isolation. A range 
of stakeholders testifying at the Commission 
described examples of the impact of social isolation 
on residents: 
• Dr. Sinha testified about increased rates of mal￾nutrition, increased rates of functional decline, 
increased rates of behavioural issues and 
increased administering of anti-psychotics to the 
residents because of the lack of family caregiving.
• Dr. Andrea Iaboni—Geriatric Psychiatrist and 
Clinical Researcher at the Toronto Rehabilitation 
Institute—testified that isolating residents put 
them at risk of harm. For example, residents 
developed psychological symptoms, would 
no longer speak, would not get out of bed, or 
would have no motivation to continue life after 
being isolated.
• The Ontario Nurses’ Association testified that 
residents become depressed and those with 
dementia often deteriorate as a result of 
social isolation.
• Revera representatives testified that residents 
had functional and cognitive decline because 
of the isolation and lack of contact with 
their families.
A November 2020 study by Cold Spring 
Harbor Laboratory (a research and educational 
institution) of all Ontario long-term-care home 
residents, found that compared with January 
and February 2020, there was a 1.6% increase in 
the proportion of residents who were prescribed 
antipsychotics as well as a 1.6% increase in the 
homes or in alternative housing sites, receive 
proper care.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry will work with partners to implement 
ways to minimize or protect residents from the 
spread of infectious diseases within long-term￾care (LTC) homes as part of future pandemic 
planning.
In March 2021, the Ministry established the 
Response and Recovery Advisory Committee to 
provide expert advice and input for the develop￾ment of an action-oriented recovery framework 
for the long-term-care sector. Taking into account 
the recommendations in this report, as well as 
any relevant recommendations arising from the 
Long-Term Care COVID-19 Commission, recovery 
planning will include: 
• capacity necessary to support isolation needs 
within homes consistent with strong infection 
prevention and control practices;
• ways to improve the process of matching 
people, including alternative level of care 
patients, to available beds; and
• the inclusion of emergency staffing and 
decanting strategies in homes’ contin￾gency plans.
4.3.3 Restricting Family Caregiversfrom
Visiting Homes Eliminated Valuable Source
of Care Providers, Contributing to Decline in
Residents’ Mental, Physical Health
On March 30, 2020, the Chief Medical Officer of 
Health issued a directive that limited visitors to 
long-term-care homes to only essential visitors. 
They were defined as those performing essential 
support services, such as food delivery, inspection, 
maintenance and health-care services; or those 
visiting a very ill or palliative resident. The measure 
was intended to control COVID-19 outbreaks by 
limiting the number of people going into homes.  

62
4.3.4 Inadequate Provisions Made for
Severe Understaffing when Employees
Restricted from Working in Multiple Homes 
On April 14, 2020, the province issued a temporary 
order restricting long-term-care staff from working 
in more than one home—referred to here as the 
single-site order. Similar to the provisions related 
to essential visitors in Directive #3 (discussed in 
Section 4.3.3), the order was intended to control 
the spread of COVID-19 by limiting the number of 
people going into homes. 
Although intentions were good, stakeholders 
expressed concerns that the province’s single-site 
order further worsened the staffing shortage in 
the sector when home operators experienced dif￾ficulties hiring temporary staff to fill the vacant 
positions. According to the Ministry’s July 2020 
staffing study, some of the reasons for the difficulties 
in new hirings included potential staff’s fear and 
anxiety about contracting COVID-19 at the long￾term-care home; people’s concerns about accessing 
adequate personal protective equipment; and 
certain employment agencies’ unwillingness to staff 
certain homes. The direct impact of this restriction 
is unknown by the Ministry.
Another consequence of the single-site order 
was the potential of lost wages for staff who had 
to give up employment at other homes in order to 
comply with the order. According to the Ministry’s 
July 2020 staffing study, almost one-third of 
registered nurses and registered practical nurses, 
and an unknown proportion of personal support 
workers working in long-term-care homes held two 
or more jobs in order to supplement their income. 
The actual impact of the single-site order varied 
depending on the staff person’s individual situa￾tion. For example, while some workers may have 
lost wages due to reduced hours, some may have 
received increased hours at their chosen site, which 
would have lessened the impact of the order. 
The province announced in late April that front￾line workers would receive a temporary pandemic 
proportion of residents who were prescribed 
antidepressants from March to September 2020. 
Findings from a survey by the Office of the 
Seniors Advocate in British Columbia released in 
November 2020 found that between March and 
September 2020, there was a 7% increase in the 
administration of antipsychotic drugs and a 3% 
increase in the administration of antidepressant 
drugs for residents who struggled to cope without 
adequate contact with their family caregivers. In 
addition, the UK Alzheimer’s Society published 
survey results in June 2020 in which 79% of 128 
care homes reported that lack of social contact was 
attributed as a cause of deterioration in the health 
and well-being of residents with dementia. 
Given that family caregivers, private caregivers 
paid by residents’ families and volunteers often 
help provide care to residents that includes feeding, 
grooming and bathing them, and helping them 
to exercise, the restriction also placed additional 
strain on some homes’ already-stretched resources. 
A 2015 study by Statistics Canada found that 
over 20% of family caregivers assisting their loved 
one in a care facility gave over 10 hours of care 
a week, with even more hours provided when a 
resident was older and had more severe health 
conditions such as dementia. More recently, a 
July 2020 report by the Canadian Patient Safety 
Institute and the Canadian Foundation for Health￾care Improvement noted that family members 
reported spending 20 hours a week in the past 
helping care for their loved ones in long-term-care 
homes. The report further states that such support 
is essential, particularly for residents with later￾stage dementia or those who do not speak the same 
language as their paid care providers. We describe 
examples of the impact of staffing shortages in 
Section 4.1.2. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 63
RECOMMENDATION 11 
So that measures taken to control the spread 
of COVID-19 and future infectious disease out￾breaks in long-term-care homes do not result 
in significant staffing shortages nor contribute 
to the deterioration of residents’ mental and 
physical conditions, should the homes be 
impacted by future serious infectious disease 
outbreaks, we recommend that the Ministry of 
Long-Term Care, in developing its pandemic 
plan (under Recommendation 6): 
• identify and implement ways that residents’ 
family caregivers and caregivers paid by 
residents’ family members can continue 
to provide care to their loved ones while 
ensuring the health and safety of the home’s 
residents; 
• based on lessons learned from the imple￾mentation of the single-site order in Ontario 
and other provinces, assess what approach 
can most effectively keep residents and 
staff safe while still allowing staff to work 
the hours they did prior to the single-site 
directive;
• develop backup staffing strategies that may 
be needed if staffing issues result from future 
outbreak and emergency situations; and
• assess whether monies provided to long￾term-care homes for staffing remedies was 
used for the purposes intended. 
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry will work with partners to imple￾ment strategies to ensure engagement of families 
and other caregivers, as well as sufficient staffing 
to provide effective care for residents, as part of 
future pandemic planning.
In March 2021, the Ministry established the 
Response and Recovery Advisory Committee to 
provide expert advice and input for developing 
payment of a $4-an-hour pay bump for 16 weeks, 
from April 24 to August 13, 2020, along with a 
monthly lump sum payment of $250 for those 
working more than 100 hours in that month. The 
Ministry indicated at the time that issuing these 
financial supports on a timely basis was critical, 
especially for workers who relied on multiple jobs 
and were likely experiencing financial hardships 
after giving up employment at other homes. 
By June 30, 2020, however, $105.7 million, or 
30%, of the $346.6 million that was approved had 
still not been paid to the homes. Further, the Min￾istry did not have information on the proportion 
of eligible workers who had not yet received their 
pandemic pay and the Ministry did not track when 
monies were paid to eligible workers. The Ministry 
distributed the pandemic pay to the home oper￾ators, who were then responsible for paying their 
staff. Chapter 4 of our Special Report on COVID-19
Preparedness and Management, Management of 
COVID-19 Health-Related Expenditures, found 
that when the Ministry advanced funds to long￾term-care homes, it did not determine how much 
pandemic pay was earned by eligible front-line 
workers during the period. The amounts advanced 
were estimates based on historical data maintained 
by the Ministry. After funds were transferred, the 
home operators provided summaries of the pan￾demic pay earned by long-term-care workers.
While Ontario’s single-site order was issued on 
April 14, it did not require long-term-care homes 
to comply with the order until April 22, 2020. 
British Columbia’s Provincial Health Officer issued 
an order requiring long-term-care home staff to 
work at a single facility on March 26, 2020, almost 
one month before Ontario. In addition, British Col￾umbia took more timely action to support home 
staff whose wages were reduced due to the order. 
On April 10, British Columbia issued a ministerial 
order requiring government, bargaining associa￾tions, unions and employers to work together to 
protect the wages of long-term-care home staff 
during the term of the single-site order. 

64
Our review found that initial direction from the 
province was framed as guidance, suggestions or 
recommendations; therefore, it was ultimately up 
to home operators to decide what actions to take to 
protect their elderly, frail and ailing residents, even 
though the province was aware in March 2020 that 
98% of COVID-19 deaths in Italy had been elderly 
people with serious preconditions. In addition, 
two doctors who were on the front lines during the 
2003 severe acute respiratory syndrome (SARS) 
outbreak highlighted the vulnerability of the long￾term-care sector in advice to the province published 
in media outlets as early as March 14, 2020. They 
warned that mortality would be very high if long￾term-care residents became infected, and that the 
likelihood of COVID-19 spreading to both residents 
and staff was high. They added that homes would 
need support to determine how best to prevent 
infection and treat their residents. 
The province issued its first mandatory instruc￾tion on March 22, when the Chief Medical Officer 
of Health (CMOH) issued a directive to long￾term-care homes to not permit residents to leave 
the home for short-stay absences and limit, where 
possible [emphasis added], the number of homes 
that employees were working at. In its testimony 
to the Long-Term Care COVID-19 Commission, the 
Ontario Nurses’ Association stated that, “putting 
aside the question of why [it was not] even manda￾tory by March 22, the problem is using words like 
‘where possible’ creates so much wiggle room for 
employers not to comply.” 
In light of how quickly COVID-19 spread in 
long-term-care homes, every day that implementing 
mandatory requirements was delayed made a 
difference in the effort to control its spread. For 
example, our report on Outbreak Planning and 
Decision-Making (see Chapter 2 of our Special 
Report on COVID-19 Preparedness and Manage￾ment) noted that an Associate Medical Officer of 
Health at one of the public health units in Ontario 
emailed the CMOH on March 18, 2020 and stated 
that requiring long-term-care home workers to 
wear masks at all times while in the facility was an 
an action-oriented recovery framework for the 
LTC sector. Recovery planning will include:
• the criteria by which to assess whether to 
change the staffing restrictions that were 
implemented, including restricting staff to 
a single home; and 
• visitor and caregiver policies.
Long-term-care homes are required to report 
on the use of funding in their annual report. In 
addition, long-term-care homes are required to 
provide quarterly reports of incremental spend￾ing on prevention and containment measures 
including staffing. These reports are being used 
to inform targeted audits of the use of funding 
and funding not used for eligible purposes will 
be recovered. The Ministry will also consider 
additional measures as appropriate to increase 
accountability for the use of funding.
4.4 Delays, Unclear 
Communications and Lack of 
Enforcement by Long-Term Care 
Ministry Hampered Effectiveness 
of Measures to Contain COVID-19
4.4.1 Measuresto Contain COVID-19
Initially Left Up to Home Operators to 
Implement
We discuss in Outbreak Planning and Decision￾Making (Chapter 2 of our Special Report 
on COVID-19 Preparedness and Management) 
the province’s delay in following the precautionary 
principle during the first wave of the pandemic. 
The precautionary principle dictates that, where 
there is reasonable evidence of an impending threat 
to public harm, reasonable efforts to reduce risk 
should be taken without waiting for scientific cer￾tainty. The delay in requiring long-term-care homes 
to implement containment measures is an example 
of the precautionary principle not being followed in 
as timely a manner as needed.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 65
resulted in homes interpreting the instructions 
inconsistently. For example: 
• Directive #3’s restriction on admissions to 
homes during the pandemic did not initially 
differentiate new admissions from re-admis￾sions. Therefore, in some cases, residents who 
left the home for an essential medical treatment 
were initially not able to return to it. 
• Home operators, long-term-care home workers 
and other stakeholders interpreted the visitor 
restrictions (discussed in Section 4.3.3) differ￾ently. At the extreme, contract staff—temporary 
staff who are hired through employment agencies 
to fill vacancies—were allowed to work in mul￾tiple homes. In comparison, British Columbia’s 
order regarding long-term-care facility staff 
movement limitation applied to contracted 
staff as well.
Homes also struggled with mixed and con￾fused messages coming from local public health 
units, regarding cohorting, admitting residents 
into hospitals and the use of personal protective 
equipment (PPE). In its testimony to the Long-Term 
Care COVID-19 Commission, AdvantAge Ontario, 
which represents not-for-profit providers of long￾term care, service and housing for seniors, pointed 
out an inconsistency between provincial require￾ments. Specifically, “the visitor policy put out by 
the Ministry of Long-Term Care says that all essen￾tial caregivers and visitors in long-term care must 
attest to having a COVID test that is negative. But, 
urgent priority. By the time the CMOH issued the 
directive to homes to require all staff and essential 
visitors to wear masks on April 8, three weeks later, 
Public Health Ontario had reported 498 resident 
and 347 staff cases of COVID-19, and 86 resident 
deaths, in long-term-care homes. 
Our review of the response in other select 
Canadian jurisdictions found differences in the 
timing of when certain measures became man￾datory (Figure 21). Although not the slowest 
province to mandate measures to control the spread 
of COVID-19 in long-term-care homes, Ontario was 
generally behind, or slower than, British Columbia. 
A September 2020 Canadian Medical Association 
Journal article (discussed in Section 4.2.1) com￾paring Ontario and British Columbia’s response 
to COVID-19 in long-term-care homes noted that 
during the first wave of the pandemic, British 
Columbia’s response in that period was faster and 
more decisive, co-ordinated and consistent in how 
it was communicated overall. 
4.4.2 Confusing Communications Led to
Different Interpretations of Requirements 
by Home Operators
We heard from the stakeholder groups we met with 
that Directive #3, which contained most of the 
mandatory instructions for long-term-care homes 
(see Appendix 13), contained unclear language 
and guidance despite the frequent updates. This 
Figure 21:Timing of Mandatory Measuresin Select Canadian Jurisdictions, March 2020—June 20201
Prepared by the Office of the Auditor General of Ontario
Measure ON BC AB SK MB QC
Restrict visitors to homes to essential visitors only Mar 30 Mar 172 Mar 20 Mar 17 Mar 173 Mar 14
Require all staff to wear masks within homes Apr 8 Mar 25 Apr 15 Apr 28 Apr 13 May 25
Restrict staff to working in one home only Apr 22 Mar 262 Apr 23 Apr 28 May 1 n/a4
1. Timing dates are for when enforcement of the measure became effective. Some measures became effective on a later date than when the measure was 
announced.
2. Based on letter from British Columbia’s Provincial Health Officer to all long-term-care homes in the province restricting visitors to essential visitors only and 
an order issued under the British Columbia Public Health Act by the Provincial Health Officer restricting staff to work in one home only.
3. Manitoba public health officials recommended immediate suspension of visitors to long-term-care homes.
4. As of June 30, 2020, Quebec public health officials had not issued orders to restrict staff movement between homes.  

66
during this pandemic and will continue to 
inform responses in long-term care, including 
containment measures.
4.4.3 Lack of Monitoring by Ministry,
Public Health Inspectorsto Enforce
COVID-19 Measures
Given that unclear and mixed messages can result 
in homes not properly following measures and 
ultimately experiencing a greater number of 
infections and deaths, we asked the Ministry what 
actions it took to ensure that homes understood and 
consistently complied with the various directives 
and orders made by the province from the onset of 
the pandemic. We were especially concerned about 
whether steps had been taken to ensure homes 
understood and stayed current with the various 
IPAC-related measures mandated in the many 
updates and iterations of Directive #3. The Ministry 
of Long-term Care responded that, because Direc￾tive #3 was issued under the Health Protection and 
Promotion Act, the province’s 34 local public health 
units were responsible for interpreting and ensur￾ing compliance with it. 
We asked select public health units—Peel, 
Toronto, York, Durham and Ottawa—about what 
they interpreted their responsibility is for enfor￾cing Directive #3 (see Appendix 12). The five 
public health units are the largest in the province, 
responsible for the health of a combined 6.8 million 
Ontarians. The Toronto Public Health Unit told us 
that it does not perform routine inspections of long￾term-care homes for the purposes of monitoring 
compliance with Directive #3. Its understanding 
is that “the directive (or [its] mandate generally) 
does not require such inspections.” Ten of the 15 
long-term-care homes with the highest number of 
resident deaths were in Toronto. 
The other four public health units (Peel, York, 
Durham and Ottawa), however, did consider them￾selves responsible for enforcement, and reported 
taking actions to do so, such as unannounced visits 
to homes, providing homes with further training 
Directive #3, which is put out by the Chief Medical 
Officer of Health, only requires screening. Both the 
Ministry of Long-Term Care and the Directive say 
that theirs should take precedence.”
The Canadian Patient Safety Institute and 
Canadian Foundation for Healthcare Improvement’s 
July 2020 report on the impact of the COVID-19
pandemic in the long-term-care sector included 
interview results where many home operators 
said that communications in the early days of the 
pandemic were often confusing and unclear, and 
conflicted with each other. For example, home 
operators reported a lack of direction with respect 
to the single-site directive, use of PPE, dedicated entry 
points into the homes and cohorting residents. 
RECOMMENDATION 12
So that long-term-care home operators can 
effectively implement the measures to control 
the spread of COVID-19 and other potential 
future infectious diseases in a timely manner, 
we recommend that the Health Co-ordination 
Table, the Chief Medical Officer of Health and 
the Ministry of Long-Term Care:
• in an expedient manner, clarify to whom 
the requirements and restrictions apply, and 
the precautions that must be taken by home 
operators where requirements allow for 
exceptions; and
• follow the precautionary principle when 
determining whether to make infectious 
disease containment measures voluntary 
versus mandatory.
MINISTRY OF HEALTH AND MINISTRY 
OF LONG-TERM CARE RESPONSE
The ministries will expediently clarify 
requirements and restrictions to support long￾term-care home operators to effectively prevent 
and control the spread of COVID-19. Taking a 
precautionary approach has been a key con￾sideration in the province’s decision-making  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 67
• a PSW went in and out of a resident’s room and 
into the hallway of an outbreak unit without 
taking off their used PPE and putting on new PPE. 
At the time of the inspection on November 28, 
seven residents and three staff had COVID-19. By 
December 4, 105 residents and 52 staff had tested 
positive for COVID-19. Between November 28 and 
December 31, 2020, 34 Sunnycrest residents died 
from COVID-19, which is equivalent to one-quarter 
of Sunnycrest’s 136 bed capacity. 
RECOMMENDATION 13
To confirm that long-term-care homes are 
sufficiently implementing mandated measures 
to control the spread of COVID-19 in long-term￾care homes, we recommend that the Ministry of 
Long-Term Care work with public health units 
to clarify roles and responsibilities and work 
in formal partnerships to conduct inspections 
of long-term-care homes for compliance with 
Directive #3, which is issued under the Health 
Protection and Promotion Act. 
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry accepts the recommendation. The 
Ministry will work with the Ministry of Health, 
Public Health units as well as the Ministry of 
Labour, Training and Skills Development to 
address intersecting legislative requirements 
and to clarify roles and responsibilities in rela￾tion to IPAC inspections and compliance with 
Directive #3.
4.5 Ministry’s Oversight of 
Homes Before and During 
COVID-19 Pandemic Ineffective 
in Addressing Repeat 
Non-Compliance
The Ministry’s oversight of the operation of homes 
is primarily to be achieved using inspections and 
on IPAC, and undertaking ongoing communication 
with homes through memos. 
Any confusion around the roles and responsibil￾ities for enforcing Directive #3 had the potential 
to create a gap in promoting and enforcing IPAC 
principles in homes. Public health units consistently 
told us that more clarity was needed because they 
found that the oversight of long-term-care homes 
was unclear and fragmented.
Examples of poor IPAC practices (described in 
Section 4.1.3) and improper cohorting practices 
(described in Section 4.3.1) highlight the import￾ance of monitoring and enforcing the requirements 
in Directive #3. In the September 2020 Ontario 
Nurses’ Association survey of its members, only 
27% of respondents reported that their employers—
the home operators—put policies and procedures 
in place to implement government directives and 
orders relating to the COVID-19 pandemic. More 
significantly, of the approximately 60 nurses 
redeployed to long-term-care homes, 22% of 
respondents reported witnessing failures to comply 
with these government directives and orders.
The results of the Ministry of Long-Term Care’s 
inspection of Sunnycrest Nursing Home in Whitby 
on November 28, 2020 (discussed in Section 4.1.2) 
illustrates the significant adverse consequences 
of failure to comply with government directives 
and orders. The Ministry inspection was triggered 
by a critical incident report, specifically that the 
home had experienced a COVID-19 outbreak. 
The inspector concluded that the home operator 
had failed to ensure that the home was a safe and 
secure environment for its residents based on the 
following observations:
• there was no designated screener wearing full 
PPE at the front of the building to screen people 
entering the building;
• when a staff member asked the home admin￾istrator to wheel a resident into their room in 
the outbreak unit, the administrator did not 
perform hand hygiene or wear PPE; and 

68
We reviewed documentation provided to us by 
the Ministry regarding its decision to discontinue 
comprehensive inspections and found that the 
decision was made by Ministry management in 
order to address the growing backlog of complaints 
and critical incident reports that required inspection 
or inquiry by the same staff that would have been 
involved in the comprehensive inspections. The 
Ministry did not have the level of staff needed in 
order to continue to conduct comprehensive inspec￾tions while simultaneously addressing the backlog.
In September 2018, there was a backlog of 
about 7,800 complaints and critical incidents that 
required follow-up or inspection. This backlog was 
almost 5,000 more than the backlog at the time 
of our 2015 audit, Long-Term Care Home Quality 
Inspection Program. By halting comprehensive 
inspections, the Ministry was able to substantially 
reduce the backlog. In December 2019, the backlog 
had decreased to 1,280.
Proactive comprehensive inspections can yield 
more meaningful information and result in more 
profound improvements to a home’s systemic 
operations than complaint and critical incident 
inspections. The latter are reactive and occur only 
after a potentially harmful incident has occurred 
involving a resident, whereas the former can help 
identify risks and problems before they result in 
more serious outcomes for residents. However, 
complaints and incident reports require timely 
follow-up to protect residents from immediate 
concerns that cannot always wait for a comprehen￾enforcement to address non-compliance, particu￾larly repeated non-compliance with legislation, 
regulations and policies and procedures. Inspections 
are intended to enable the Ministry to proactively 
identify risks and problems, and recommend 
measures to reduce and resolve them. However, our 
review found that recent changes to the Ministry’s 
inspection program, as well as the manner in which 
the Ministry used its inspection function during 
the COVID-19 pandemic, prevented the Ministry 
from reducing risks and resolving issues before 
they resulted in negative outcomes for residents. 
We also found the Ministry’s handling of repeated 
non-compliance by home operators to be weak. 
4.5.1 Proactive Comprehensive Inspections
Discontinued in Fall 2018 to Address
Growing Backlog of Complaints and Critical
Incident Reports
Our review found that, in fall 2018, the Ministry 
significantly changed its overall inspection approach 
by discontinuing comprehensive or resident quality 
inspections (described in Section 2.2.4). This 
occurred despite the fact that inspectors had 
identified over 18,200 instances of non-compliance 
through those inspections between January 2015 and 
June 2019 (see Figure 22a, 22b and Figure 23). 
With comprehensive inspections off the table, the 
bulk of inspections were focused only on responding 
to complaints and critical incident reports.
Figure 22a:Types of Enforcement Actions Resulting from Comprehensive Inspections
Source of data: Ministry of Long-Term Care
Enforcement Action Description Follow-Up Requirement
Written notification Specifies the details of each instance of non-compliance. A follow-up inspection is not 
required. Voluntary plan of 
correction
Requests that the home prepare a written plan of correction for 
achieving compliance, but there is no requirement for the home 
to submit the plan to the Ministry.
Compliance order Requires the home to take action, stop doing an action or 
prepare a plan in order to achieve compliance by a deadline.
A follow-up inspection is required 
once the deadline has passed.
Director referral The matter has been referred to the Ministry's Program Director, 
who may issue an order.
Not applicable. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 69
context of these inspections can be less than in a 
comprehensive inspection. For example, as shown 
in Figure 19, although non-compliance with IPAC 
requirements was the fourth-most-cited type of 
non-compliance in comprehensive inspections 
between January 2015 and December 2019 (seven 
comprehensive inspections were completed in 2019), 
it was not a top-10 issue identified in complaint or 
critical incident inspections. 
Non-compliances related to residents’ plans 
of care were identified as the number one issue 
through comprehensive inspections. However, we 
noted that the Ministry does not have a specific 
inspection protocol focused on reviewing a sample 
of plans of care to confirm that the resident is 
receiving care in accordance with his or her 
plan of care.
sive inspection. The Ministry told us during our 
2015 audit of its inspection program that one of 
the desired outcomes of annual comprehensive 
inspections of long-term-care homes was a reduction 
in complaints and critical incidents. However, as 
noted above, complaints and critical incidents 
continued to increase.
In their initial design, comprehensive inspec￾tions looked at residents’ level of satisfaction and 
the homes’ overall compliance with requirements 
in the Act across 31 different areas or protocols, 
including IPAC (see Appendix 4). In contrast, 
complaint and critical incident inspections focus 
only on the subject of the complaint or the cir￾cumstances of the critical incident. As a result, the 
likelihood of broad, profound, systemic problems 
being identified and addressed in the narrow 
Figure 22b: Enforcement Actions Resulting fromDifferentTypes of Inspections, January 1, 2015–August 31, 2020
Source of data: Ministry of Long-Term Care
Type of 
Inspection
# of Written 
Notifications Issued
# of Voluntary Plans of 
Correction Requested
# of Compliance 
Orders Issued
# of Director 
Referrals
Complaint 6,821 3,066 948 41
Comprehensive 18,213 9,547 2,049 99
Critical Incident 6,848 2,569 1,043 31
Follow-up 1,504 471 823 162
Other 199 80 57 3
Total 33,585 15,733 4,920 336
Figure 23: Enforcement Actions Resulting from Comprehensive Inspections, January 1, 2015–June 30, 2019
Source of data: Ministry of Long-Term Care
Year1
# of Written 
Notifications Issued2
# of Voluntary Plans of 
Correction Requested
# of Compliance 
Orders Issued
# of Director 
Referrals
2015 6,346 3,066 647 12
2016 4,743 2,569 542 26
2017 4,110 2,260 453 25
2018 2,955 1,626 394 35
2019 59 26 13 1
Total 18,213 9,547 2,049 99
1. The year in which an inspection was started. Some inspections were not completed until the following year.
2. A written notification is issued for all instances of non-compliance. As indicated by the numbers, many written notifications do not go beyond specifying the 
non-compliance to include a further enforcement action. Roughly half include requests for voluntary plans of correction, while substantially fewer include 
requiring the stronger enforcement actions following from compliance orders and potentially following from director referrals. 

70
it was conducting comprehensive inspections at 
every home each year (Figure 24).
The Ministry informed us that it discontinued 
comprehensive inspections because it did not see 
the desired reduction in the number of complaints 
and critical incident reports it received. We found, 
however, that the Ministry discontinued compre￾hensive inspections without a thorough review to 
determine whether the comprehensive inspection 
process could be improved to achieve the objective 
of fewer complaints and critical incidents. Such a 
review could have, for example: 
• analyzed the instances of non-compliance 
identified through comprehensive inspections 
and compared them to the types of complaints 
and critical incidents reported; and
• elicited feedback from inspectors, who have 
on-the-ground knowledge of the homes, on how 
the first stage of the comprehensive inspection 
process (see Appendix 4) could be improved 
to identify key risk areas to investigate further 
in the second stage. The first stage includes 
five mandatory protocols, and the second stage 
Discontinuing comprehensive inspections also 
meant that the extent of the Ministry’s oversight 
of IPAC in homes decreased significantly. Specif￾ically, unless the Ministry received a complaint 
about them or a critical incident report relating to 
an infection outbreak, inspectors were no longer 
required to proactively inspect homes’ IPAC 
practices and programs and assess whether homes 
were evaluating their IPAC programs annually, as 
required by the Act. 
From 2015 to 2017, comprehensive inspections 
resulted in inspectors identifying, on average, 179 
instances of IPAC non-compliance each year. Even 
in 2018, the last year of comprehensive inspections, 
when the Ministry conducted 40% fewer of them 
compared with the preceding three-year average 
(370 versus 624), inspectors still identified 95 
instances of IPAC non-compliance. In contrast, in 
2019, the Ministry identified only 52 instances of 
IPAC non-compliance from conducting primarily 
complaint and critical incident system inspections—
less than one-third of what it was identifying when 
Figure 24: Instances of Infection Prevention and Control Non-Compliance Identified by Inspection Type,
2015–2019*
Source of data: Ministry of Long-Term Care
* Based on the number of written notifications issued under section 86 of the Long-Term Care Homes Act, 2007 and section 229 of Ontario Regulation 79/10.
A non-compliance identified through a comprehensive inspection may be related to a critical incident or complaint that was investigated during the 
comprehensive inspection.
0
50
100
150
200
250
300
2015 2016 2017 2018 2019
 Other
Follow up
 Critical Incident System
 Complaint
 Comprehensive Inspection 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 71
on factors such as complaints, critical incidents 
and compliance history. We also recommended 
that the Ministry determine the frequency at which 
it would conduct comprehensive inspections in 
the future. Prioritizing inspection resources was 
important because our review found that complaints 
and critical incidents requiring inspections had 
increased and were not being addressed in a timely 
manner. The Ministry did not have sufficient 
resources to conduct annual comprehensive inspec￾tions of all long-term-care homes and address 
all complaints and critical incidents within the 
required time frames. The Ministry’s policy is to 
conduct inspections of homes with complaints and 
critical incidents in accordance with their risk level: 
high-risk cases should be inspected immediately 
and medium-risk cases within 30 days. 
In August 2016, the Ministry began conducting 
what it called risk-focused comprehensive inspections. 
Compared to full comprehensive inspections, risk￾focused ones were shorter in duration, required 
fewer inspectors, and looked at fewer areas of the 
home’s operation (Figure 25). At the time, the Min￾istry’s goal was to still conduct full comprehensive 
inspections of medium- to high-risk homes at least 
once every three years and up to two risk-focused 
inspections every three years for low-risk homes. 
Based on this information, we assessed the status of 
our 2015 recommendations to be fully implemented 
at the time of our 2017 follow-up. These shorter, 
risk-focused inspections comprised 68% of the 
over 1,300 comprehensive inspections conducted 
between August 2016 and fall 2018.
 According to the Ministry, the approach it 
adopted in fall 2018 (Figure 25) prioritized the 
highest-risk issues as identified exclusively through 
complaints and critical incident reports. Solely 
relying on complaints and critical incident reports 
to base inspections on cannot be considered an 
effective risk-based approach.
We agree that complaints and critical incidents 
are factors that could indicate a risk of non-compli￾ance. However, certain types of non-compliance, 
such as those related to IPAC, are not evident when 
includes protocols that are triggered based on 
results of the first stage.
During our 2018 audit of Health Quality Ontario 
(HQO, now part of Ontario Health), we noted that 
every year, HQO identified priority performance 
indicators—for example, percentage of residents 
who had a fall in the last 30 days and percentage of 
residents who were given antipsychotic medication 
without a psychosis diagnosis—that long-term￾care homes could include in their annual quality 
improvement plans. The intent of providing this 
information was to highlight areas for improvement 
both at the home-level and at the physician-level 
(through individualized reports). However, we 
noted in that audit that the use of these indicators by 
long-term-care homes, and physicians who worked 
in them, were optional. In 2017/18, only 57% of 
long-term-care homes included all of HQO’s per￾formance indicators in their quality improvement 
plans. As of March 2019, only 55% of physicians 
working in long-term-care homes had signed up to 
receive an individualized report.
We recommended that the then Ministry of 
Health and Long-Term Care, in conjunction with 
HQO, should look at requiring physicians to receive 
individualized reports and use such information to 
improve quality of care. We also recommended that 
health-care organizations that were performing 
below the provincial average of a performance 
indicator identified by Health Quality Ontario be 
required to include the indicator in their quality 
improvement plan. This information would also 
benefit the Ministry’s inspection process.
4.5.2 Discontinuation of Comprehensive
Inspections Contrary to Previous
Recommendation by Our Office
The Ministry’s decision to discontinue comprehen￾sive inspections is contrary to Recommendation 3
of our 2015 report on the Long-Term-Care Home 
Quality Inspection Program. We recommended that 
the Ministry prioritize comprehensive inspections 
of higher-risk homes over lower-risk homes, based  

72
Figure 25: Differences Between Inspection Approaches, 2011—2020
Prepared by the Office of the Auditor General of Ontario
Full Comprehensive Inspections Risk-Focused Comprehensive inspections Complaint and Critical Incident Inspections 
Started 2011 2016 2011
Ended 2018 2018 Ongoing and expanded in 2018
Proactive or 
Reactive 
Proactive Proactive Reactive 
Trigger for 
inspection 
Scheduled based on several factors, including 
risk level of the home, inspector experience 
and availability, and geographic considerations. 
Regional office managers review this information 
quarterly and assign/reassign comprehensive 
inspections based on the above factors.
Scheduled for homes that were deemed 
substantially compliant in their most recent risk 
and performance assessment, and based on 
several factors, including number of findings of 
non-compliance; incidence of worsening pain of 
residents; and information from banks, suppliers, 
or other creditors that raises concerns about the 
home’s operations.
Complaints or critical Incidents.
Overview Objective is to assess residents’ satisfaction and 
homes’ compliance with the Long-Term Care 
Homes Act, 2007. 
A random sample of 40 residents is taken for 
whom the Quality of Care and Quality of Life 
indicators mentioned in Appendix 4 are compared. 
Usually involves three to four inspectors examining 
a home over the course of an eight-day period. 
This inspection must be conducted at least once 
every three years for each home.
A random sample of 20 residents is taken for 
whom the Quality of Care and Quality of Life 
indicators mentioned in Appendix 4 are compared. 
Usually involves two inspectors examining a home 
over the course of a three-to-five-day period. This 
inspection is conducted a maximum of twice in 
three calendar years for any given home with the 
third year being a comprehensive inspection.
See Figure 13, footnotes 2 and 4.
Areas inspected Required components include: dining observation, 
a family council interview, infection prevention 
and control, medication, and a residents’ council 
interview.
Information from resident surveys may prompt 
inspections to include other protocols included in 
Appendix 4.
Required components include: a family council 
interview, infection prevention and control, 
medication, and a residents’ council interview.
Information from resident surveys may prompt 
inspections to include other protocols included in 
Appendix 4.
The subject of the complaint and/or areas 
mentioned in the critical incident report. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 73
statistics—such as confirmed cases, hospitaliza￾tions, and deaths—at the end of the outbreak. As 
a result, homes may not be consistently reporting 
this information to the Ministry. In addition, the 
form does not allow homes to report the number 
of affected residents separately from affected staff. 
This information would provide an additional basis 
for determining whether an inspection is warranted 
than simply checking whether three outbreaks have 
occurred in a six-month period.
RECOMMENDATION 14 
So that risks, systemic issues and instances of 
non-compliance at long-term-care homes are 
identified and addressed before they result in 
even more significant negative outcomes for 
residents, we recommend that the Ministry of 
Long-Term Care (Ministry): 
• determine the level of inspection staff 
needed to conduct proactive comprehensive 
inspections while also effectively address￾ing complaints and incident reports in the 
required timelines in accordance with legis￾lation and Ministry policies;
• conduct annual comprehensive inspections 
of all homes including specific issues of care 
that are the subject of ongoing complaints, 
incidents and previous issues of non-compli￾ance with legislation and regulations;
• develop an inspection protocol focused 
on directly inspecting residents’ plans of 
care; and
• review and improve its triaging policy so that 
outbreaks reported by long-term-care homes 
are properly investigated.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry agrees with the goal of identifying 
and addressing issues of non-compliance before 
they result in more significant outcome for resi￾dents. To support this, the Ministry is:
an inspector is focused solely on a complaint or 
critical incident. 
As well, our review of information about acute 
respiratory infections reported by homes identified 
that the majority of outbreaks have not historically 
been investigated by the Ministry. From 2016 to 2019, 
there were an average of 1,150 acute respiratory 
infection outbreaks per year at homes across the 
province. The Ministry responded to only 10% 
of these outbreaks: 271 or 6% were deemed to 
require an inspection, while 161 or 4%, required an 
inspector to follow up by phoning the home. The 
remaining 90% of reported outbreaks were deemed 
to require no further action because they did not 
meet the definition of a “trend” under the Ministry’s 
triaging policy. Under the Ministry’s triaging policy, 
an inspection is deemed necessary where a “trend” 
has been identified. A trend is identified when 
there is a pattern or repetition of the same type of 
incident/issue that has occurred three times in a 
six- month period, for example, if a home reports 
three outbreaks within six months. So, under this 
triaging policy, a home that reports an outbreak in 
January and February and then again in November 
will not be inspected. 
During this same period, 264 or 42% of homes 
averaged two or more outbreaks of acute respiratory 
infection per year. Also, during this same period, 
there were 32 outbreaks that were deemed to 
require no further action despite the fact that the 
outbreaks involved multiple resident deaths or one 
resident death plus over 10 suspected or confirmed 
cases. For example, one outbreak (in Extendicare 
Falconbridge in Sudbury) resulted in the deaths 
of seven residents, and another outbreak (in 
Cassellholme in North Bay) that lasted for 48 days 
included 41 suspected or confirmed cases of acute 
respiratory infections. 
Infection outbreaks vary in severity depending 
on the type of infection, how contagious the disease 
is, the duration of the outbreak, and how many 
residents contract the infection. We noted that the 
current form used by homes to report outbreaks to 
the Ministry lacks a separate area to report outbreak  

74
August 31, 2020, Ministry inspectors issued 4,920 
compliance orders to 565 homes to take immediate 
action, immediately cease inappropriate actions or 
prepare a plan to comply with the Act and Regula￾tion 79/10 by a specified deadline. 
In the five full calendar years from 2015 to 2019, 
Ministry inspectors issued an average of 931 com￾pliance orders per year. In comparison, Ministry 
inspectors issued an average of 783 compliance 
orders per year from 2012 to 2014. We found that, 
despite the increase in compliance orders since 
2016, the Ministry still had not implemented the 
recommendations from our 2015 report aimed at 
addressing the issue of repeated non-compliance by 
long-term-care home operators.
Those recommendations were (1) that the 
Ministry strengthen its enforcement processes 
to promptly address repeated non-compliance, 
including determining when to escalate to stronger 
levels of enforcement actions and (2) that the 
Ministry evaluate the use of other enforcement 
measures, such as issuing fines or penalties to 
homes. In 2018, the province passed amendments 
to the Long-Term Care Homes Act, 2007 and Regu￾lation 79/10 to allow fines and penalties. However, 
at the time of our 2020 continuous follow-up, the 
amendments had not yet been proclaimed. 
The Ministry told us during our 2020 con￾tinuous follow-up work that it had decided to not 
implement any fines or penalties; instead, it will 
be taking a “supportive” rather than a punitive 
approach to overseeing homes. We have significant 
concerns about this decision: 
• The Ministry could not explain what its sup￾portive approach entailed or how it intends to 
implement it. 
• In our view, the sustained levels of and trends 
in non-compliance suggest that there are 
underlying issues that need to be addressed. 
While some issues may be better addressed 
using a supportive approach that, for example, 
determines what additional funding, staff￾ing, training and guidance the Ministry could 
provide to long-term-care homes, other issues 
• developing a Quality Framework that will 
articulate a common understanding of 
quality of care and quality of life, as well as 
performance measures to assess progress 
and support continuous improvement;
• evaluating the inspection program, includ￾ing the triaging of complaints and critical 
incident reports, with the goal to develop an 
improved, standardized inspection process 
that aligns with addressing risk in reactive 
and proactive inspections. This evaluation 
will include what factors require annual 
inspections or reviews; and
• evaluating the appropriate use of and balance 
between supportive and compliance-focused 
mechanisms and tools to both provide 
quality assurance and support quality 
improvement.
The Ministry will evaluate the elements of 
this recommendation and any relevant recom￾mendations from the Long-Term Care COVID-19
Commission in this work, including: 
• evaluating the staffing needs to appropriately 
support compliance, enforcement and con￾tinuous quality improvement on an ongoing 
basis (the hiring of qualified staff for 32 
new inspector positions is in progress with a 
projected target for completion by the end of 
April 2021); and 
• evaluating the other recommendations in 
this report regarding issues that should 
be the subject of regular and ongoing 
inspection.
4.5.3 Non-compliance Still an Issue;
Ministry Still Chooses Not to Implement
Fines or Penalties
Our follow-up work in 2020 found that homes have 
continued to be non-compliant with legislative 
requirements since our 2015 audit of the Ministry’s 
inspection program. From January 1, 2015 to  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 75
compliance orders issued since 2015, this recom￾mendation continues to be relevant. During our 
continuous follow-up work, the Ministry told us 
that it was planning to address repeated non￾compliance through strategies for the sharing of 
best practices among homes. By the end of our 
work for this review, no such strategies had been 
developed.
RECOMMENDATION 15 
So that long-term-care home operators who 
repeatedly do not comply with legislative 
requirements to provide residents with a home 
where they may live with dignity and in secur￾ity, safety and comfort, and have their needs 
met are appropriately held accountable, we 
recommend that the Ministry of Long-Term 
Care (Ministry): 
• analyze the nature and extent of the instan￾ces of non-compliance it has identified, 
including determining the root cause of the 
instances; 
• determine, based on the results of this 
analysis, when a supportive approach can be 
taken, including the reasons why it would be 
better than taking firm enforcement action; 
• develop a strategy for providing the necessary 
supports where a supportive approach is 
necessary and appropriate; 
• monitor the extent to which better outcomes 
result from a supportive approach (in 
other words, establish using clear evidence 
whether or not a supportive approach 
demonstrably improves residents’ quality 
of life and decreases the incidence of con￾ditions and events that diminish quality 
of life); 
• take stronger enforcement actions where 
monitoring shows that a supportive 
approach has not led to better outcomes; 
• revisit proclaiming the 2018 amendments 
to the Long-Term Care Homes Act, 2007
may require the firmer hand of enforcement to 
ensure that homes are places where residents 
live with dignity and in security, safety and 
comfort, and where residents’ needs are met, 
as envisioned in the Act. For example, our 2015 
audit of the Long-Term-Care Home Quality 
Inspection Program highlighted instances of 
sexual harassment and verbal and physical 
abuse of residents not being resolved for four to 
eight months after the Ministry issued the initial 
compliance order, with the Ministry having to 
subsequently issue another compliance order.
• Given the significant issues in the long-term￾care sector (as described in previous sections) 
and the issues we previously raised in our 2015 
audit about the Ministry’s weak enforcement 
approach, we question the Ministry’s decision 
to not fully implement, nor utilize, its existing 
and potentially new enforcement powers. The 
current Act’s enforcement powers include 
issuing a Director’s order, which can withhold a 
home’s funding or request it be returned; having 
another party take over a home’s management; 
and revoking a home’s licence. Between 2011 
and 2014, only six homes’ repeated non-com￾pliance, taking place over a year or more, were 
brought to the Program Director’s attention, and 
issues continued to be identified in some of the 
homes’ 2015 comprehensive inspections. Since 
2010, the Ministry has revoked only two homes’ 
licences and took action to recover monies from 
one of those homes because it failed to address 
serious fire and safety concerns. In its testimony 
at the Long-Term Care COVID-19 Commission, 
the Advocacy Centre For The Elderly high￾lighted the Ministry’s “overuse” of written 
notices and voluntary plans of correction, as 
well as the Ministry’s lack of follow up to ensure 
that a home has complied with the plan. 
We also recommended in our 2015 audit that 
the Ministry help homes comply with the Act by 
providing additional information and support on 
how to rectify issues, and by sharing best practices 
with homes. Based on the significant number of  

76
Directors Referrals, Mandatory Management 
Orders and Cease of Admissions.
4.5.4 No On-Site Home Inspections
Conducted forTwo Months During
COVID-19 Pandemic
We found that for almost two months, from 
March 14 to May 8, 2020, Ministry inspectors did 
not conduct on-site inspections of long-term-care
homes. Instead, beginning on March 21, the 
Ministry redeployed its inspectors to conduct 
“monitoring calls” to homes, during which inspect￾ors asked about the status of outbreaks, staffing 
levels and personal protective equipment (PPE); 
and the types of support that homes needed, if any. 
Inspectors were also assigned to answer calls from 
residents’ families that came through the Family 
Support Line. Residents’ families can call the Family 
Support Line if they have questions or concerns 
about the care that their family members (who are 
residents of long-term-care homes) are receiving.
We noted the following issues with the way the 
Ministry used inspectors during this period:
• Homes were not clearly told that the inspectors’ 
role in asking questions during the calls was 
not to perform an enforcement function but, 
on a temporary basis, to offer support by gather￾ing information about challenges faced by the 
homes (for example, PPE and staffing shortages) 
and relaying such information to Ministry senior 
management. Representatives from the Ontario 
Long Term Care Association told us that some of 
its members were initially wary of the inspectors 
in this new temporary role, and so did not want 
to openly communicate issues to inspectors 
for fear of being found not in compliance with 
the Act. 
• Prior to the pandemic, inspectors’ responsibilities 
did not include making routine phone calls to 
homes and answering questions from residents’ 
families. In addition, because inspectors were 
not physically at the homes, they had to first 
call the homes to gather information about a 
that would allow the Ministry to issue 
penalties; and
• establish the criteria and circumstances 
when home operators must pay penalties 
with the proclamation of the outstanding 
2018 legislative amendments.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry agrees with the goal of improving 
accountability in instances of repeated non￾compliance. To support this the Ministry is:
• developing a Quality Framework that will 
articulate a common understanding of 
quality of care and quality of life, as well as 
performance measures to assess progress 
and support continuous improvement;
• evaluating the inspection program, includ￾ing the triaging of complaints and critical 
incident reports, with the goal to develop an 
improved, standardized inspection process 
that aligns with addressing risk in reactive 
and proactive inspections. This evaluation 
will include what factors require annual 
inspections or reviews; and 
• evaluating the appropriate use of and balance 
between supportive and compliance-focused 
mechanisms and tools to both provide 
quality assurance and support quality 
improvement.
The Ministry will evaluate the elements of 
this recommendation and any relevant recom￾mendations from the Long-Term Care COVID-19
Commission in this work in order to enhance 
the accountability of long-term-care home 
operators’ compliance with the legislation and 
regulations.
While this work is under way, the Ministry 
will use all available tools to increase compli￾ance with the Long-Term Care Homes Act, 2007
including, but not limited to, Director Orders,  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 77
outlined the inspection approach, including when 
inspections could be conducted off-site, during the 
COVID-19 pandemic. The policy leaves the decision 
of when an inspection can be conducted off site up 
to the inspectors and their managers and does not 
outline criteria to be considered. 
RECOMMENDATION 16 
So that the Ministry of Long-Term Care 
(Ministry) can better utilize its inspection 
function in cases of infectious disease outbreaks 
and other types of emergencies, we recommend 
that the Ministry: 
• immediately establish the criteria for when 
inspectors will be required to do their work 
on site during an emergency such as a pan￾demic and what type of work they will be 
required to do; 
• immediately prioritize and conduct required 
on-site inspections of long-term-care homes, 
such as those related to infection prevention 
and control and repeated non-compliance, 
based on assessed risks; and
• in cases of infectious disease outbreaks, 
have available a reliable supply of personal 
protective equipment and provide it to 
inspectors, along with the safety training 
required for them to conduct effective on-site 
home inspections.
MINISTRY OF LONG-TERM CARE 
RESPONSE
The Ministry accepts this recommendation. 
Inspectors are now required to primarily do 
inspections on-site, including during emergen￾cies with inspector safety measures in place. 
The reasons for doing inspections off-site 
or partially off-site are very specific to each 
individual situation and require consultation 
between the inspector and manager.
 The Ministry currently uses a risk-based 
approach for all intakes to prioritize the timing 
particular resident before they could give 
families any information. 
The inspectors we interviewed told us that not 
being able to conduct on-site inspections during the 
first months of the pandemic made it very difficult 
to address complaints received from residents and 
family members. Inspectors were instructed to call 
long-term-care homes only to determine whether 
there was non-compliance, and they could not 
adequately verify whether homes had addressed 
the issues that were a part of the complaints. They 
also could not verify whether the information being 
provided to them by the homes regarding any issues, 
including whether they were addressed, was com￾plete and accurate.
According to the Ministry, sending inspectors 
without appropriate preparation into homes that 
had COVID-19 outbreaks would have put inspectors, 
residents and staff at risk. This concern was raised 
by the Ontario Public Service Employees Union in 
April 2020. We noted that inspectors were not fully 
trained and equipped with PPE to safely conduct 
inspections until May 1, 2020. Specifically: 
• The Ministry sent IPAC training materials to 
inspectors on April 21, 2020. 
• Inspectors received PPE, such as masks, gowns, 
face shields, gloves, sanitizers and wipes, the 
week of April 27, 2020.
• On May 1, 2020, the Ministry sent a check￾list for inspectors to sign to confirm they had 
completed the online IPAC training that was 
provided by Public Health Ontario. 
The first on-site inspection began on 
May 8, 2020—51 days after the first case of 
COVID-19 involving a long-term-care home resident 
was recorded on March 18, 2020. We reviewed the 
reports for all 30 inspections conducted from May 
8 to May 31, 2020 and noted that half were still 
conducted remotely from inspectors’ homes and not 
on site. In one-third of cases, inspectors performed 
a portion of their inspections on site and others 
remotely or off site. In summer 2020, the Ministry 
updated its inspection policy and guideline that  

78
of inspections and inquiries. The risk assess￾ment is completed as the intakes are triaged and 
are also reviewed and reprioritized as needed at 
the Service Area Office level by the inspection 
managers.
Inspectors are currently supplied with appro￾priate personal protective equipment and this 
supply will continue to be made available as 
needed. Inspectors have now been provided 
safety training developed by both Public Health 
Ontario and the Long-Term Care Consultant/
Environmental Inspectors. This mandatory 
training requirement will continue as part of 
on-boarding of all new inspectors and re-training 
as needed for current inspectors. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 79
Appendix 1: Select Key Provisions in Legislation and Regulations Relating to 
Long-Term-Care Homes and COVID-19
Prepared by the Office of the Auditor General of Ontario
Legislative Requirement Report Sections
Long-Term Care Homes Act, 2007 (LTCHA)
Section 1. Home: the fundamental principle
“… a long-term-care home is primarily the home of its residents and is to be operated so that it is a place 
where they may live with dignity and in security, safety and comfort and have their physical, psychological, 
social, spiritual and cultural needs adequately met.”
All
Section 5. Home to be safe,secure environment
“Every licensee of a long-term-care home shall ensure that the home is a safe and secure environment for 
its residents.”
All
Section 8(3). 24-hour nursing care
“Every licensee of a long-term care home shall ensure that at least one registered nurse who is both an 
employee and a member of the regular nursing staff of the home is on duty and present in the home at all 
times, except as provided for in the regulations (see O. Reg. 79/10 below).”
2.1.3
O Reg. 79/10. Exemptionsto 24-hour nursing care
3. For all homes, in the case of a pandemic that prevents a registered nurse from getting to the home, 
and where the back-up plan referred to in clause 31 (3) (d) of this Regulation fails to ensure that the 
requirement under subsection 8 (3) of the Act is met,
i. a registered nurse who works at the home pursuant to a contract or agreement with the licensee or 
who works at the home pursuant to a contract or agreement between the licensee and an employment 
agency or other third party may be used,
ii. a registered practical nurse who is an employee of the licensee or who works at the home pursuant to a 
contract or agreement with the licensee or who works at the home pursuant to a contract or agreement 
between the licensee and an employment agency or other third party may be used if the Director of 
Nursing and Personal Care or a registered nurse is available for consultation, or
iii. a member of a regulated health profession who is a staff member of the home and who has a set of 
skills that, in the reasonable opinion of the licensee, would allow them to provide care to a resident, may 
be used if the Director of Nursing and Personal Care or a registered nurse is available for consultation. O. 
Reg. 79/10, s. 45 (1); O. Reg. 72/20, s. 1.
2.1.3
Section 24(1), 25. Reporting certain mattersto Director
Anyone who has reasonable grounds to suspect any of the following has occurred or may occur must 
immediately report their suspicion, and information upon which it is based, to the Ministry:
• improper or incompetent treatment or care, or abuse or neglect, of a resident that resulted in harm or a 
risk of harm to the resident;
• unlawful conduct that resulted in harm or a risk of harm to a resident; and
• misuse or misappropriation of a resident’s money or funding provided to a licensee under the LTCHA, the 
Local Health System Integration Act, 2006 or the Connecting Care Act, 2019.
Upon receipt of the above information, an inspector must conduct an inspection or make inquiries to 
ensure compliance with the requirements under the LTCHA. The inspector must immediately visit the home 
concerned if the information indicates that anything described in the first two bullets resulted in serious 
harm or a significant risk of serious harm to a resident.
4.5 

80
Legislative Requirement Report Sections
Section 86(1). Infection prevention and control program
Each long-term-care home must have an infection prevention and control program that includes the 
following (as prescribed in Regulation 79/10 under the LTCHA):
• daily monitoring, recording and analysis of symptoms to detect the presence of infection and measures 
to prevent transmission of infection;
• an outbreak management system, including a written plan, for detecting, managing, and controlling 
infectious disease outbreaks, including defined staff responsibilities, reporting protocols based on 
requirements under the Health Protection and Promotion Act, communication plans, and protocols for 
receiving and responding to health alerts; 
• a hand hygiene program; and
• an immunization and screening program for various infectious diseases for residents and staff. 
Each home must have an interdisciplinary team to implement the program and a designated staff member 
to co-ordinate the program who has education and experience in infection prevention and control practices, 
including: infectious diseases, cleaning and disinfection, data collection and trend analysis, reporting 
protocols, and outbreak management. The interdisciplinary team must have quarterly meetings to which the 
local medical officer of health is invited. 
The program must be evaluated and updated every year, the results of which must be documented. The 
licensee must ensure that all staff participate in the implementation of the program.
4.1.3, 4.2.2
Section 87(1). Emergency plans
“Every licensee of a long-term care home shall ensure that there are emergency plans in place for the home 
that comply with the regulations, including,
a) measures for dealing with emergencies; and 
b) procedures for evacuating and relocating the residents, and evacuating staff and others in case of an 
emergency.”
4.2.1
Sections 142 to 144, 146(1), 147(1), 149(1), (3). Inspections
An inspector may conduct inspections for the purpose of ensuring compliance with requirements under the 
LTCHA. In conducting an inspection, the inspector may inspect the home or a place operated in connection 
with the home and providing services to it, review records, question individuals, conduct tests, and call 
upon experts for assistance.
Every long-term-care home must be inspected at least once a year without notice.
After completing an inspection, an inspector must prepare an inspection report and give a copy of the 
report to the licensee and to the Residents’ Council and the Family Council, if any. The inspector must 
document all identified non-compliances with the LTCHA in the inspection report.
4.5
Section 152(1). Actions byinspector if non-compliance found
If an inspector finds that a licensee has not complied with a requirement under the LTCHA, the inspector 
must issue at least one of the following as the inspector considers appropriate:
• a written notification of the non-compliance to the licensee;
• a written request to the licensee to prepare a written plan to achieve compliance to be implemented 
voluntarily;
• a compliance order requiring the licensee to either do, or refrain from doing, anything, or submit and 
implement a plan, to achieve compliance with the LTCHA’s requirement;
• a work and activity order for the licensee to allow, and pay for, employees, agents or contractors acting 
under the authority of the Ministry, to perform any work or activity at the home that is necessary to 
achieve compliance with a requirement under the LTCHA; and
• a written notification to the licensee and referral to the Director for further action by the Director.
On December 12, 2017, the LTCHA was amended to give inspectors authority to issue a notice of 
administrative penalty. This amendment is not yet in force. 
4.5.3
Section 155(1). Order that funding be returned or withheld
The Director may order that a specified amount of funding provided or to be provided to the licensee be 
returned by or withheld from the licensee. This includes funding provided under the LTCHA, the Local Health 
Integration Act, 2006 or the Connecting Care Act, 2019.
4.5.3 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 81
Legislative Requirement Report Sections
Section 156(1). Mandatory management orders
The Director may order a licensee to retain, at the licensee’s expense, one or more persons acceptable to 
the Director to manage or assist in managing the home if the licensee has not complied with a requirement 
under the LTCHA and there are reasonable grounds to believe that the licensee cannot or will not properly 
manage the home, or cannot do so without assistance.
4.5.3
Section 157(1), (2). Revocation of licence
The Director may make an order revoking a licence if, for example, the licensee has not complied with a 
requirement under the LTCHA, the home is being operated in a manner that is harmful to the health, safety 
or welfare or its residents, or the licensee, officers or directors of the home are not competent to operate the 
home in a responsible manner.
If the Director has made an order revoking a licence, the Director may also make an order providing for the 
home to be operated by an interim manager until the revocation of the licence becomes effective and the 
residents of the home are relocated.
4.5.3
Ontario Regulation 79/10 under the LTCHA
Section 107. Reportsre critical incidents
Every licensee of a long-term-care home must immediately inform the Director, in as much detail as is 
possible in the circumstances, of: emergencies such as fires, unexpected or sudden death, residents 
missing for three hours or more, residents returning to the home with an injury or adverse change in 
condition, outbreak of a disease of public health significance or communicable disease, and contamination 
of drinking water supply.
4.4
Health Protection and Promotion Act
Section 10(1). Duty to inspect
Every medical officer of health shall inspect or cause the inspection of the health unit served by him or her 
for the purpose of preventing, eliminating and decreasing the effects of health hazards in the health unit.
2.2.5
Section 13(1).Order by Medical Officer of Health or public health inspector re health hazard
A medical officer of health or a public health inspector, by a written order, may require a person to take 
or refrain from taking specific actions in respect of a health hazard in order to decrease the effect of or 
eliminate the health hazard.
2.2.5, 4.4
Section 29.2(1), (2). Ordersto deal with communicable disease outbreaks
A medical officer of health may make an order requiring a public hospital or an institution (long-term 
care home) to take any actions specified in the order for the purposes of monitoring, investigating and 
responding to an outbreak of communicable disease at the hospital or institution. A medical officer of 
health may make an order if he or she is of the opinion, upon reasonable and probable grounds, that an 
outbreak of a communicable disease exists or may exist at the public hospital or institution, and that the 
communicable disease presents a risk to the health of persons in the public hospital or institution, and 
that the measures specified in the order are necessary in order to decrease or eliminate the risks to health 
associated with the outbreak.
2.2.5, 4.4
Section 62(1), 67(1). Medical Officer of Health
Every board of health must appoint a full-time medical officer of health and may appoint one or more 
associate medical officers of health. The medical officer of health reports directly to the board of health on 
issues relating to public health concerns and to public health programs and services under this or any other 
act within the health unit served by the board.
2.2.5
Section 77.1(1). Chief Medical Officer of Health may act where risk to health
If the Chief Medical Officer of Health is of the opinion that a situation exists anywhere in Ontario that 
constitutes or may constitute a risk to the health of any persons, he or she may investigate the situation and 
take such action as he or she considers appropriate to prevent, eliminate or decrease the risk.
2.2.5 

82
Legislative Requirement Report Sections
Section 77.7(1) to (5). Directivesto health-care providers
Where the Chief Medical Officer of Health is of the opinion that there exists or there may exist an immediate 
risk to the health of persons anywhere in Ontario, he or she may issue a directive to any health-care provider 
or health-care entity regarding precautions and procedures to be followed to protect the health of persons 
anywhere in Ontario. Long-term-care homes are considered health-care providers or health-care entities.
In issuing a directive, the Chief Medical Officer of Health must consider the precautionary principle where,
(a) in the opinion of the Chief Medical Officer of Health there exists or may exist an outbreak of an 
infectious or communicable disease; and
(b) the proposed directive relates to worker health and safety in the use of any protective clothing, 
equipment or device.
A health-care provider or health-care entity that is served with a directive shall comply with it. However, 
the directive may not be used to compel regulated health professionals to provide services without their 
consent. Regulated health professionals are health practitioners whose profession is regulated under the 
Regulated Health Professions Act, 1991 or the Drugless Practitioners Act. In the event of a conflict between 
this section and the Occupational Health and Safety Act or a regulation made under it, the Occupational 
Health and Safety Act or the regulation made under it prevails.
2.2.5, 4.4
Section 80(2). Inspections
An inspector shall make inspections of health units to ascertain the extent of compliance with this Act and 
the regulations and the carrying out of the purpose of this Act.
2.2.5
Emergency Management and Civil Protection Act
Section 7.0.1, 7.0.7. Declaration of emergency
The Lieutenant Governor in Council (LGIC) or the Premier, if in the Premier’s opinion the urgency of the 
situation requires that an order be made immediately, may declare that an emergency exists throughout 
Ontario or in any part of Ontario if the following criteria are satisfied:
• There is an emergency that requires immediate action to prevent, reduce or mitigate a danger of major 
proportions that could result in serious harm to persons or substantial damage to property.
• The resources normally available to a ministry of the government of Ontario or an agency, board or 
commission or other branch of the government, including existing legislation: cannot be relied upon 
without the risk of serious delay, or may be insufficiently effective to address the emergency.
Unless terminated sooner or extended by the LGIC, emergency declarations are terminated 14 days after 
they are made. The LGIC may extend an emergency before it is terminated for one further period of no more 
than 14 days. The Assembly, on the recommendation of the Premier, may by resolution extend the period of 
an emergency for additional periods of no more than 28 days.
2.2.1
Section 7.0.2, 7.0.8. Emergency orders
During a declared emergency, the LGIC may make orders that the LGIC believes are necessary and essential 
in the circumstances to prevent, reduce or mitigate serious harm to persons or substantial damage to 
property, if in the opinion of the LGIC it is reasonable to believe that the order will alleviate the harm or 
damage and is a reasonable alternative to other measures that might be taken to address the emergency.
Such orders include, for example: regulating travel; establishing facilities for the care, welfare, safety and 
shelter of individuals; closing any public or private establishments or institutions; and requiring any person 
to collect, use or disclose information that may be necessary to prevent, respond to or alleviate the effects 
of the emergency.
Unless revoked sooner or extended, emergency orders are revoked 14 days after they are made. The LGIC 
or a Minister to whom the power has been delegated may extend the effective period of an emergency order 
for periods of no more than 14 days.
2.2.1
Reopening Ontario (A Flexible Response to COVID-19) Act, 2020
Section 2(1). Emergency orders
Orders made under the Emergency Management and Civil Protection Act that have not been revoked as 
of the day this subsection comes into force are continued as valid and effective orders under this Act and 
cease to be orders under the Emergency Management and Civil Protection Act.
2.2.1 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 83
Legislative Requirement Report Sections
Section 3(1).Time limit on application of orders
An order continued under section 2 ceases to apply 30 days after it is continued under section 2, subject to 
extension under subsection.
2.2.1
Section 3(2). Extension of orders
The Lieutenant Governor in Council may by order, before it ceases to apply, extend the effective period of an 
order for periods of no more than 30 days.
2.2.1
Section 4(1). Power to amend orders
The Lieutenant Governor in Council may, by order,
(a) subject to subsections (2) and (5), amend a continued section 7.0.2 order in a way that would have 
been authorized under section 7.0.2 of the Emergency Management and Civil Protection Act if the 
COVID-19 declared emergency were still in effect and references in that section to the emergency were 
references to the COVID-19 pandemic and its effects;
(b) amend an order continued under section 2 to address transitional matters relating to the termination 
of the COVID-19 declared emergency, the enactment of this Act or the continuation of orders under 
section 2.
2.2.1
Section 5. Power to revoke orders
The Lieutenant Governor in Council may by order revoke an order continued under section 2.
2.2.1
Section 10(1). Offences
Every person who fails to comply with a continued section 7.0.2 order or who interferes with or obstructs 
any person in the exercise of a power or the performance of a duty conferred by such an order is guilty of an 
offence and is liable on conviction,
(a) in the case of an individual, subject to clause (b), to a fine of not more than $100,000 and for a term of 
imprisonment of not more than one year;
(b) in the case of an individual who is a director or officer of a corporation, to a fine of not more than 
$500,000 and for a term of imprisonment of not more than one year; and
(c) in the case of a corporation, to a fine of not more than $10,000,000.
2.2.1
Section 17.Termination of COVID-19 declared emergency
Unless it has been terminated before this section comes into force, the COVID-19 declared emergency is 
terminated and Ontario Regulation 50/20 (Declaration of Emergency) is revoked.
2.2.1 

84
Appendix 2: Overview of Ontario’s Health-Care System Related to the Long￾Term-Care Sector
Prepared by the Office of the Auditor General of Ontario
1. As a part of the ongoing health-sector reorganization, the administrative functions of the 14 LHINs were transferred to Ontario Health on April 1, 2021. 
Effective April 1, 2021, the remaining operational functions of the LHINs became known as Home and Community Care Support Services. The responsibilities 
of current LHINs with respect to long-term-care homes will be moved to the Ministry of Long-Term Care. 
2. Includes single-tier municipalities (e.g., City of Toronto) and upper-tier municipalities (e.g., Region of Peel, Halton Region).
3. Local boards of health operate under different governance models, some within the municipal structure, while others are separate.
4. Local public health units receive funding from the Ministry of Health and reports to the Ministry only regarding funded programs. 
5. The Chief Medical Officer of Health has the authority to direct local jurisdictions in Ontario to implement public health actions in response to a public health 
risk or emergency. 
• Administers Ontario’s health-care system. • Regulates, licenses and inspects long-term-care homes. 
• Provides funding to long-term-care homes.
• Led by a local medical officer of health.
• Deliver programs focused on preventing and controlling 
communicable diseases.
• An Assistant Deputy Minister, who reports to the Deputy 
Minister of Health.
• Provides advice on public health matters to the health 
sector and the province.
• Co-ordinates and oversees delivery of health care in 
the province.
• Looks into complaints about health-care services, 
including those provided in long-term-care homes.
Limited reporting relationship. See footnotes.
• Conducts surveillance of reportable disease and provides 
scientific and technical advice to the public health and 
health-care systems. 
• Provides advice and operational support in emergency or 
outbreak situations with public health implications.
• Composed of healthcare service providers who 
would receive funding from Ontario Health to 
deliver coordinated services.
• Determine eligibility for admission, prioritize and 
manage the admission process to long-term-care 
facilities.
• Distribute Ministry funding to long-term-care 
homes.
Ministry of Health
Minister of Health Minister of Long-Term Care
Ministry of Long-Term Care
Long-Term-Care Homes
Municipalities2
Government of Ontario
Dr. David Williams, Chief Medical Officer of Health
Public Health Ontario
Ontario Health
Patient Ombudsman
Hospitals
Ontario Health Teams
14 Local Health Integration Networks1
Local Boards of Health3
34 Local Public Health Units4,5 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 85
Appendix 3: Ministry of Long-Term Care: Long-Term Care Inspections Branch, 
December 2020
Prepared by the Office of the Auditor General of Ontario
1. Approximately 20 inspectors are not currently active due to secondment, long-term disability, or another absence.
2. Nine Assessment and Triage Officers are located in Hamilton; one is located in Sudbury.
Regional Offices
1 Director, 3 Senior Managers, 4 Service Area Office Managers, 
12 Inspection Managers, 143 Inspectors,1
 11 Administrative Staff
• Conduct complaint, critical-incident, comprehensive and follow-up inspections at 
long-term-care homes
• Take necessary enforcement actions to ensure homes comply with the Act
Ministry of Long-Term Care
• Regulates, inspects and sets out accommodation fees for all long-term-care homes
Long-Term Care Operations Division
• Oversees compliance of Long-Term Care Homes with applicable legislation and Ministry policy
• Leads the design, development and implementation of legislation, regulations and policy
Long-Term Care Inspections Branch
• Enforces the legislative and regulatory requirements governing long-term-care residents' rights, 
safety and quality of care
• Manages incoming complaints, triages high-risk issues and establishes communication with 
homes
Intake, Assessment and Triage
1 Manager, 10 Assessment and Triage Officers,2 1 Administrative Assistant
• Receives and assesses each complaint and critical incident reported and determines 
whether an inspection is required
• Assigns a risk level for each case that requires an inspection and forwards cases to 
regional offices
Training, Development and Recruitment
1 Manager, 4 Regional Training Managers, 2 LQIP Clinicial Consultants, 
3 Environmental Consultants, 1 Learning and Development Specialist
• Develops and maintains internal policies for the inspections branch
• Manages a referral process for the regional offices to get subject matter expertise on 
a variety of environmental and public health topics
Strategic Planning and Program Development
1 Manager, 1 Project Manager, 2 Quality Leads, 
1 Administrative Co-ordinator (1 contract), 1 Appeals Specialist
• Supports the development of a branch-level performance management framework to 
ensure continuous quality improvement and consistent application of program policy 

86
Appendix 4: Thirty-One Ministry of Long-Term Care Inspection Protocols Used in 
Comprehensive and Other Inspections 
Source of data: Ministry of Long-Term Care
Note: Inspectors may review residents’ Plans of Care if concerns are identified in any of the protocols that impact resident care.
Mandatory Inspection Protocols1
The following five protocols must be examined in stage one or two in every comprehensive inspection:
1. Dining observation2
2. Family council interview
3. Infection prevention and control
4. Medication
5. Residents’ council interview
Other Inspection Protocols1
Inspectors examine one or more of the following protocols in stage two of a comprehensive inspection if it is called for (i.e., 
triggered by records review, their observations and/or interviews):
Home-Related (Triggered)
6. Housekeeping3
7. Laundry
8. Maintenance
9. Critical incident response
10. Food quality
11. Reporting and complaints
12. Safe and secure home
13. Snack
14. Staffing (whether sufficient)
15. Trust accounts4
Resident-Related (Triggered)
16. Continence care and bowel management3
17. Dignity, choice and privacy3
18. Falls prevention3
19. Hospitalization and change in condition
20. Minimizing of retraining3
21. Nutrition and hydration3
22. Pain3
23. Personal support services
24. Prevention of abuse, neglect and retaliation3
25. Recreation and social activities
26. Responsive behaviours
27. Skin and wound care3
Inspector-Initiated
28. Admission and discharge
29. Quality improvement
30. Resident charges5
31. Training and orientation
1. These inspection protocols can be used during any type of inspection. For complaint and critical incident inspections, inspectors use the inspection 
protocol(s) that best match the nature of the complaint or critical incident. The categorization of inspection protocols as mandatory, triggered, and inspector￾initiated is only relevant for comprehensive inspections.
2. This protocol was not a mandatory inspection protocol for the risk-focused comprehensive inspection (see Figure 25).
3. This protocol was included in the risk-focused comprehensive inspection (see Figure 25).
4. Trust accounts are bank accounts into which the home operator is to deposit all money entrusted to its care on behalf of a resident.
5. Resident charges are charges to residents for goods and services they receive in the homes that are not covered by government funding, such as haircuts, 
cable TV and phone lines. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 87
Appendix 5: Key Requirements Under the Institutional/Facility Outbreak 
Management Protocol, 2018
Source of data: Ministry of Health
Area Protocols
General • Develop and maintain policies and procedures to respond to infectious disease outbreaks in 
institutional settings.
• Assist institutions during outbreak management preparation by establishing ways to collect 
data and providing education on preventing and management an outbreak.
• Communicate disease policies and procedures.
• Assist in the review and revision of infection prevention and control policies and procedures 
and provide health recommendations for outbreak prevention, detection and management. 
• Assist institutions in establishing and reviewing written outbreak response plans at a minimum 
of every two years.
Detection, Investigation, 
and Identification 
• Inform institutions that they should notify the medical officer of health of all infectious diseases. 
• Work with institutions in developing surveillance system that can accurately assess a probable 
or confirmed outbreak. 
• Assist institutions in developing communication to receive notification and outbreak 
information. 
• Provide to institutions current epidemiological information on local occurrences of infectious 
diseases. 
Notification: Reporting 
from Source to Boards 
of Health
• Have an on-call system for receiving and responding to notifications of infectious disease 
outbreaks. 
• Help in infectious disease outbreak assessments within 24 hours of receiving notification of an 
outbreak. 
• Obtain the epidemiological information necessary to assess, evaluate, and control the 
outbreak.
• Assist in ensuring the collection of any environmental, clinical or other samples to assess, 
evaluate, confirm and control an outbreak.
Management • Assist institutions in the management of infectious disease outbreaks however, it is ultimately 
the responsibility of the institution to manage the outbreak
• Assist in confirming the existence of an outbreak and with declaring an outbreak
• Perform the following actions when assisting in the management of outbreaks: 
a) Review and/or establish a case definition in collaboration with the institution; 
b) Determine the population at risk; 
c) Assist in active case finding; 
d) Assess the status of the outbreak daily, or as previously arranged; and 
e) Review and discuss line listings provided by the institution, including populations at risk and 
number of cases.
• Recommend and assist with the implementation of appropriate infection prevention and control 
practices.
• Participate in outbreak management team meetings.
• Assist institutions with developing and implementing a risk communications plan. 
• Declare whether an outbreak is over, in consultation with the institution.
• Review the response to outbreaks with institutions after they have been declared over.
• Evaluate the management and impact of outbreaks and assist in identifying strategies for 
improvement in their management. 
• Inspect institutions for infection outbreaks, infection prevention and control practices, and food 
preparation and handling within the institution.
• Respond to food safety and environmental issues in outbreak settings.  

88
Area Protocols
Data Collection, Reporting, 
and Information Transfer: 
Boards of Health to 
Ministry of Health, Ministry 
of Long-Term Care and 
Other Stakeholders
• Report outbreak data on diseases of public health significance to the Ministry and to Public 
Health Ontario within one business day of receiving notification of an outbreak or of assessing 
that an outbreak is occurring but has not been reported by the institution.
• Update the outbreak file and enter data as required. 
• Communicate as soon as possible with the ministry and PHO about any unusual outbreaks or 
outcomes and/or the possibility of multi-jurisdiction.
• Enter final summary outbreak data no later than 15 business days after the outbreak is 
declared over.
• Assist the institution to summarize the outbreak and highlight areas for improved responses.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 89
Organization Activities to be Performed and Other Information
Federal
Public Health 
Agency of Canada
• Distribute to the provinces information received from the World Health Organization. 
• Collect COVID-19 information from provinces, such as case and death information, for consolidation 
and provision to the World Health Organization.
Canada Border 
Services Agency
• Facilitate flow of international travellers into Canada, including complying with travel restrictions 
imposed by the federal government on who may enter the country.
• Collect information on international travellers to share with the Public Health Agency of Canada for 
ensuring compliance and enforcement of 14-day quarantine or isolation requirement established by 
the government of Canada as per the Minimizing the Risk of Exposure to COVID-19 in Canada Order 
(Mandatory Isolation) No. 4.
Canadian Armed 
Forces
• Deploy, through Operation LASER, medical and support personnel to seven long-term-care homes in 
Ontario from April to July 2020 to help prepare and serve meals, feed residents, assist residents with 
personal hygiene, accompany residents on walks, prepare and distribute medical products, and share 
observations with health-care staff. The Canadian Armed Forces released an interim report on 
May 24, 2020, followed by a final report on July 29, 2020.
Provincial (Health)
Ministry of Health • Lead Ontario’s health-care response to COVID-19.
• Deputy Minister of Health co-chairs the Health Command Table.
Ministry of 
Long-Term Care
• Support the Ministry of Health’s response by participating in the Health Command Table and 
the sub-tables related to long-term-care and retirement homes.
• Develop and implement policy for long-term-care homes.
Chief Medical 
Officer of Health
• Deliver a report annually on the state of public health in Ontario to the Speaker of the Legislative 
Assembly. 
• Issue a directive:
• to any health-care provider or health-care entity identifying precautions and procedures to be 
followed when they are of the opinion that there exists or there may exist an immediate risk to the 
health of persons anywhere in Ontario; and
• to any or all boards of health or local medical officers of health requiring the adoption or 
implementation of policies or measures when there exists or is an immediate risk of a provincial, 
national or international public health event, a pandemic or an emergency with health impacts 
anywhere in Ontario and the policies or measures are necessary to support a co-ordinated 
response to the situation.
• Take on the role of an Assistant Deputy Minister, reporting to the Deputy Minister, Ministry of Health, 
with responsibility over the Ministry of Health’s Public Health group. 
Ontario Health • Lead five regional steering committees.
Public Health 
Ontario
• Monitor infectious disease outbreaks and provides scientific advice to the health-care system and 
government of Ontario.
• Operate 11 public health laboratories, which perform testing of infectious diseases (including seven 
laboratories that perform COVID-19 testing).
Health-care 
Providers
• Hospitals and primary care providers assist with assessing and treating individuals with COVID-19. 
• 13 hospital and three community laboratories perform COVID-19 testing.
• 149 assessment centres (primarily operated by hospitals) collect specimens from individuals seeking 
a COVID-19 laboratory test.
Appendix 6: Key Government Entities Involved in Ontario’s COVID-19 Response
Prepared by the Office of the Auditor General of Ontario 

90
Organization Activities to be Performed and Other Information
Provincial (Non-Health)
Solicitor General • Administer the Emergency Management and Civil Protection Act, which was used on March 17, 2020 
to require a number of public and private businesses to remain closed.
Emergency 
Management 
Ontario
• Report to the Solicitor General with responsibility for overseeing and co-ordinating the province’s 
emergency management program and the emergency management programs of ministries and 
municipalities.
Municipal
Public Health 
Units
• Administer health promotion and disease prevention programs as well as communicable disease 
control, including performing case management and contact tracing activities in relation to COVID-19. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 91
Appendix 7: Chronology of Select Key Events Relating to COVID-19 in Ontario 
Long-Term-Care Homes, January 27, 2020–December 31, 2020 
Prepared by the Office of the Auditor General of Ontario
Date Event
January 27—Canada reports its first confirmed case of COVID-19 in Toronto, Ontario.
Feb 3 Province releases guidance on COVID-19 prevention and screening in long-term-care homes.
Feb 11 Province releases updated guidance on COVID-19 prevention and screening in long-term care.
Feb 28 Ontario’s Ministry of Health (Ministry) establishes a Health Command Table as a source of advice to the Minister of 
Health, Cabinet and the Premier.*
Mar 9 Ministry issues a memo to all long-term-care operators with guidance to actively screen all visitors, residents, re￾admissions and returning residents to long-term-care homes.
Mar 9 Canada’s first COVID-19 death occurred in a long-term care home in British Columbia.
March 11—World Health Organization declares COVID-19 to be a pandemic.
Mar 11 Ministry amends March 9 memo to also include staff and volunteers.
Mar 13 Ontario’s Chief Medical Officer of Health recommends that long-term-care homes allow only essential visitors, such 
as those visiting the very ill or making end-of-life visits.
Mar 14 The Ministry of Long-Term Care halts all on-site including complaint and critical incident inspections of long-term￾care homes. 
March 17—Ontario government declares a state of emergency.
Mar 17 Province announces up to $304 million in funding to help respond to COVID-19, $50 million of which is allocated 
to long-term-care homes to support 24/7 screening, additional staffing and critical supplies.
Mar 17 The first resident cases of COVID-19 are confirmed in the long-term-care sector, in Toronto, Oshawa and Vaughan. 
Mar 20 The first staff cases of COVID-19 are confirmed among long-term-care staff, in Scarborough, Oshawa and 
Bobcaygeon.
Mar 20 Province amends regulations under the Long-Term Care Homes Act, 2007 (O. Reg. 72/20) to allow homes to 
quickly bring in more and new staff to prevent potential staffing shortages, and to allow staff to spend more time 
on direct care to residents.
Mar 22 Ontario’s Chief Medical Officer of Health issues a directive (called Directive #3) to long-term-care homes to 
immediately implement the following: 
• to not permit residents to leave the home for short-stay absences to visit family and friends; and
• to, wherever possible, limit the number of work locations that employees are working at.
Mar 23 Province issues a temporary order (O. Reg. 77/20) for long-term-care homes to support increased staffing flexibility, 
enabling homes to be able to respond to, prevent and alleviate an outbreak of COVID-19.
Province also suspends short stays in long-term-care homes and provides guidance to homes on how to use short￾stay beds to maximize capacity for applicants waiting for admission to a long-stay bed in a long-term-care home.
Mar 24 Province amends regulations to allow for streamlined long-term-care admissions, discharge and re-admissions 
processes.
Mar 25 Province launches Ontario’s Action Plan: Responding to COVID-19, a $17-billion emergency relief package, 
which includes $3.3 billion in additional resources for the health-care system, and specifically $243 million for 
long-term care.
Mar 27 Province issues a second temporary order (O. Reg. 95/20) for long-term-care homes to provide further flexibility for 
long-term-care homes and allow homes to redirect their staffing and financial resources to essential tasks during 
the COVID-19 crisis.
Mar 30 The Chief Medical Officer of Health updates Directive #3 limiting visitors to long-term-care homes to only essential 
visitors—those performing essential support services, such as food delivery, inspection, maintenance, or health-care 
services; or those visiting a very ill or palliative resident.
Mar 30 Also, in Directive #3, the Chief Medical Officer of Health directs that, wherever possible, employers should work with 
employees to limit the number of work locations that employees are working at.  

92
Date Event
Apr 7 The Ministry launches the Ontario Matching Portal to triage and match potential employees and volunteers who 
wish to help with the COVID-10 pandemic.
Apr 8 The Chief Medical Officer of Health updates Directive #3 to:
• implement masking for staff and essential visitors;
• save and securely store used personal protective equipment;
• provide direction for staff and resident cohorting;
• recommend employers to work with staff in limiting the amount of locations staff are working at;
• test for COVID-19; and 
• follow a protocol for outbreak management.
The updated Directive #3 also directs long-term-care homes to immediately begin more aggressive screening—
upgraded to twice daily—of staff, essential visitors and residents.
Apr 11 First meeting of the Provincial Central Co-ordination Table, which was formed for decision-making purposes on the 
advice of a contracted consulting firm. 
Apr 13 The province begins to provide same-day deliveries of supplies and equipment to hospitals, long-term-care and 
retirement homes, and other facilities to support essential workers in all settings and expedites delivery of supplies 
to those most in need.
Apr 14 Province issues a third temporary order (O. Reg. 146/20) to restrict employees of long-term-care homes from 
working in more than one location. This order comes into effect on April 22, 2020.
Apr 15 The province orders hospitals to suspend transfers of alternate-level-of-care patients from hospitals to long-term￾care homes.
Apr 16 Province issues a temporary order (O. Reg. 156/20) that allows Local Health Integration Networks (LHINs) to work 
with their home care service providers to redeploy workers to long-term-care homes. 
Province issues a temporary order (O. Reg. 157/20) that allows municipalities to have flexibility to reassign staff to 
where there is local need, including long-term care.
Apr 22 Province requests the Canadian Armed Forces to help five long-term-care homes with COVID-19 outbreaks. 
Apr 24 Province amends O. Reg. 74/20 to authorize hospitals to redeploy staff to long-term-care settings to provide 
assistance.
Apr 28 Canadian Armed Forces staff are deployed to five long-term-care homes.
May 8 The Ministry of Long-Term Care allows inspectors to resume on-site inspections. However, inspectors are not 
required to go on-site to conduct inspections. 
May 12 Province amends O. Reg. 210/20 to give the Ministry the ability to appoint a person to assume the management of 
a long-term-care home should at least one resident or employee test positive for COVID-19.
May 23 The Ontario Chief Medical Officer of Health (CMOH) updates Directive #3 to include a requirement for homes to 
have a plan for resident cohorting in the event of a COVID-19 outbreak.
May 24 The Canadian Armed Forces releases an interim report on its observations at the five long-term-care homes at which 
they were deployed on April 28.
May 25 The Ministry of Long-Term Care issues mandatory management orders appointing local hospitals to temporarily 
manage two long-term-care homes. Southlake Regional Health Centre temporarily manages River Glen Haven 
Nursing Home in Sutton, and Humber River Hospital temporarily manages Downsview Long Term Care in North York.
May 27 The Ministry announces it is appointing temporary management at five more long-term-care homes—in Brampton, 
Etobicoke, North York, Pickering and Scarborough. At four of those homes, the Canadian Armed Forces reported 
examples of homes not adhering to or not having required policies, inadequately trained staff and shortages of 
medical supplies, deficiencies in facilities, and concerns about standards of care.
Jun 2 Ontario’s Patient Ombudsman launches an investigation into the complaints of long-term-care homes during the 
COVID-19 pandemic.
Jun 2 The Ministry of Long-Term Care issues a mandatory management order appointing a hospital to temporarily manage 
a long-term-care home in Kitchener. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 93
Date Event
Jun 10 Province begins allowing new admissions from community or hospital (including patients designated alternate level 
of care) to long-term-care homes. 
Jun 12 The Ministry appoints a hospital to temporarily manage a long-term-care home in Scarborough.
Jun 17 The Ministry appoints a hospital to temporarily manage a long-term-care home in Vaughan.
Jun 16 The Ministry appoints a hospital to temporarily manage a long-term-care home in North York. 
Jul 29 Province, under the authority of the Health Protection and Promotion Act, launches an independent commission to 
investigate the spread of COVID-19 within long-term-care homes.
Aug 14 The Canadian Armed Forces releases its final report on the Long-Term Care Mission, which states most concerns 
found in long-term-care homes are addressed. However, the report also states outstanding concerns exist, largely 
related to training of new staff and supervision to ensure consistent infection prevention and control measures are 
in place and followed. 
Aug 28 Province announces that long-term-care residents can once again leave their residences for short-stay and 
temporary absences.
Sep 2 Province updates its long-term-care home visitor policy to help operators implement consistent visiting practices 
across the province. This policy includes guidance on safely allowing essential caregivers into homes.
Sep 25 Two new voluntary management agreements are established between The Ottawa Hospital and two long-term-care 
homes: Extendicare West End Villa and Extendicare Laurier Manor.
Oct 5 Province updates its visitor policy to address areas where there is a higher community spread of COVID-19, effective 
October 7, 2020. 
Oct 7 The Ministry of Long-Term Care facilitates a voluntary management agreement between Unity Health Toronto and 
Norwood Nursing Home in Toronto.
Oct 13 The Ministry of Long-Term Care issues a Mandatory Management Order appointing Royal Victoria Regional Health 
Centre to temporarily manage Simcoe Manor Home for the Aged, on behalf of the Corporation of the County of 
Simcoe in Beeton.
Oct 23 Canadian Red Cross teams provide short-term support to the Prescott and Russell Residence long-term-care home 
in Hawkesbury.
Oct 28 The Ministry of Long-Term Care issues a Mandatory Management Order requiring the Millennium Trail Manor long￾term-care home in Niagara Falls to retain the Niagara Health System to temporarily manage the home. 
Nov 6 Province announces a new framework to categorize public health regions into five different levels: Green-Prevent, 
Yellow-Protect, Orange-Restrict, Red-Control and Lockdown.
Nov 9 Province launches The Ontario Workforce Reserve for Senior Support program, which focuses on recruiting, training 
and deploying individuals as Resident Support Aides (RSAs) to work at homes during the COVID-19 pandemic. The 
RSAs will assist residents with daily living activities, including assistance during meal times and nutrition breaks, 
the co-ordination of visits, and support with technology or recreational activities. 
Nov 12 Province announces an additional $761 million investment to build and renovate 74 long-term-care homes across 
the province. This investment supports the commitment made by the government to create 30,000 beds over 10 
years. 
Nov 20 Province commits to 29 projects that would create 1,968 new spaces and 1,015 upgraded spaces in long-term 
care. Twenty-three projects involve constructing new buildings. 
Nov 25 The Ministry of Long-Term Care issues a Mandatory Management Order naming Joseph Brant Hospital to temporarily 
manage Tyndall Nursing Home in Mississauga. 
Nov 28 The Ministry of Long-Term Care approves new voluntary management agreements for two long-term-care homes. 
The agreements are between Scarborough Health Network and Rockcliffe Care Community in Scarborough; and 
Mackenzie Health and Langstaff Square Care Community in Richmond Hill.
Dec 3 The Ministry of Long-Term Care approves a voluntary management agreement between Southlake Regional Health 
Centre and King City Lodge Nursing Home, a long-term-care home in King City.
The Ministry of Long-Term Care also approves a voluntary management agreement between Lakeridge Health to 
support Sunnycrest Nursing Home in Whitby. 

94
Date Event
Dec 14 The Ministry of Long-Term Care issues a Mandatory Management Order between Revera Long Term Care Inc. and 
UniversalCare Canada Inc. to temporarily manage Westside, a long-term-care home in Etobicoke.
Dec 15 The Ministry of Long-Term Care approves a Voluntary Management Agreement between Scarborough Health Network 
and Craiglee Nursing Home, a long-term-care home in Scarborough.
Dec 16 The Ministry of Long-Term Care approves a Voluntary Management Contract between Hamilton Health Sciences and 
Grace Villa Nursing Home, a long-term-care home in Hamilton.
Dec 18 The Ministry of Long-Term Care approves a Voluntary Management Contract between Cambridge Memorial Hospital 
and Cambridge Country Manor, a long-term-care home licensed under Caressant-Care Nursing and Retirement 
Homes Limited.
Dec 21 The Ministry of Long-Term Care approves a Voluntary Management Contract between Markham Stouffville Hospital 
and Faith Manor Nursing Home, a Brampton long-term-care home licensed under Holland Christian Homes Inc.
Dec 23 Canadian Red Cross teams begin providing short-term support to an additional 20 long-term-care and retirement 
homes in Ontario. 
Dec 29 The Ministry of Long-Term Care approves a Voluntary Management Contract between North York General Hospital 
and Tendercare Living Centre, a Scarborough-based long-term-care home licensed under Tendercare Nursing Homes 
Limited.
The Ministry of Long-Term Care also approves a Voluntary Management Contract between St. Joseph’s Healthcare 
Hamilton and Shalom Village Nursing Home in Hamilton.
Dec 30 Province releases the Ethical Framework for COVID-19 vaccine distribution, which was developed in partnership 
with the COVID-19 Vaccine Distribution Task Force to guide further vaccine prioritization and distribution across the 
province. 
Dec 31 The Ministry of Long-Term Care approves a Voluntary Management Contract between Niagara Health System and 
Oakwood Park Lodge, a Niagara Falls-based long-term-care home licensed under Maryban Holdings Ltd.
* See the Office of the Auditor General’s 2020 Special Report COVID-19 Preparedness and Management, Chapter 2: Outbreak Planning and Decision-Making, 
Appendix 9 for a listing of sub-tables formed under the Health Command Table. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 95
Appendix 8: Observations from the Canadian Armed Forces and Patient Ombudsman 
Prepared by the Office of the Auditor General of Ontario based on data from reports by the Canadian Armed Forces1 and Patient Ombudsman2
Observations
Canadian Armed Forces
Patient 
Ombudsman2
Altamont 
Care 
Community
Downsview 
Long-Term￾Care Centre3 Eatonville Care Center
Hawthorne 
Woods Care 
Community
Holland 
Christian 
Homes
Orchard 
Villa
Woodbridge 
Vista Care 
Poor infection control practices such as allowing COVID-19 
positive residents to wander, putting staff, other residents and 
visitors at risk of exposure. (Section 4.1.3)
4,5 4,5 4 4,5 4,5 
Quality of care concerns such as forceful feeding, causing 
audible choking/aspiration, observed by staff. (Section 4.1.2) 5 4,5 4,5 4,5 4,5 5 
Discontinuance of Resident Quality Inspections that would 
have ensured an infection prevention and control (IPAC) 
protocol review and assessment. (Sections 4.5.1 and 4.5.2)
Shortage of proper supplies and personal protective 
equipment, such as expired medication. (Section 4.1.3) 4 4 4 4 
Ambiguity with local practices such as cohorting residents. 
Ministry requirements were cited as a reason why COVID￾19-negative residents were rooming with infected residents. 
(Section 4.4.2)
4 4 4 4
Poor communication such as lack of handover during shift 
change, leading to instances of residents not receiving proper 
care. (Section 4.1.2) 
4 4 4
Staffing shortages such as facilities being severely 
understaffed during the day. (Section 4.1.2) 4 4,5 4,5 4 
Family caregivers being denied access to their loved ones in 
long-term-care homes and patients dying alone without their 
families. (Section 4.3.3)

Long-term-care homes having significant COVID-19 outbreaks 
in April when patients were transferred from hospitals to create 
capacity. (Section 4.3.2) 

96
Observations
Canadian Armed Forces
Patient 
Ombudsman2
Altamont 
Care 
Community
Downsview 
Long-Term￾Care Centre3 Eatonville Care Center
Hawthorne 
Woods Care 
Community
Holland 
Christian 
Homes
Orchard 
Villa
Woodbridge 
Vista Care 
At the outset of the pandemic in March, large-scale testing 
for COVID-19 was impossible. (Chapter 3, Laboratory Testing, 
Case Management and ContactTracing)

Long-term-care homes cannot effectively cohort and isolate 
because of physical infrastructure limitations. (Sections 4.1.1
and 4.3.1)
Local public health units should be sent into homes to conduct 
timely, focused inspections to ensure homes are properly 
implementing proactive IPAC measures and are responding 
effectively to their assessment results. (Section 4.2.2)
1. The Canadian Armed Forces released an interim report on its observations at five of the seven homes on May 24, 2020, followed by a final report on all seven homes on July 29, 2020.
2. The Patient Ombudsman released her interim report with preliminary recommendations in October 2020. The Ombudsman report also included findings on inadequate access to home and community care services, 
delays in non-emergency procedures, and whistle-blower protection, which were not in the scope and objective of this report (see Section 3.0 Objective and Scope).
3. None of the issues listed were found in the Downsview home.
4. Observation included in the Canadian Armed Forces’ interim report (Eatonville Care Centre, Hawthorne Place Care Centre, Holland Christian, Orchard Villa and Altamont).
5. Observation included in the Canadian Armed Forces’ final report (which covered the homes included in the interim report along with Downsview Long Term Care and Woodbridge Vista Care Community). 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 97
1. Roles, responsibilities and accountability requirements, including with respect to infectious disease outbreak and 
pandemic management and response, were clearly defined to achieve legislative objectives.
2. Partnerships between the Ministry of Long-Term Care, long-term-care homes and other health-care-sector partners, 
such as local hospitals and public health units, were in place to facilitate provision of staff and expertise with respect
 to infection prevention and control and outbreak management.
3. Relevant and timely information about long-term-care home facilities, residents and staffing were regularly collected, 
analyzed and used to inform the Ministry of Long-Term Care’s ongoing oversight activities as well as decisions made 
during the pandemic.
4. Long-term-care home inspectors are sufficiently trained to assess long-term-care homes’ compliance with legislative and 
regulatory requirements. Inspection staffing levels are sufficient to conduct inspections related to complaints and critical 
incidents within the required time frames as well as proactive comprehensive inspections.
5. Public health measures and restrictions that were intended to contain the spread of COVID-19 in long-term-care homes 
were clearly communicated in a timely manner. The consequences of such restrictions were examined to minimize 
adverse effects on the level and quality of care received by long-term-care home residents.
Appendix 9: Criteria
Prepared by the Office of the Auditor General of Ontario 

98
Stakeholder Name Description
AdvantAge Ontario The provincial association representing not-for-profit providers of long-term care, and 
services and housing for seniors. Members include municipal, charitable and non-profit 
long-term-care homes, seniors’ housing projects, and community service agencies. Member 
organizations serve over 36,000 long-term-care residents per year in Ontario.
Advocacy Centre for the Elderly A specialty community legal clinic established to provide a range of legal services to low￾income seniors in Ontario. Legal services include advice and representation to individual 
and group clients, public legal education, law reform and community development activities.
Canadian Patient Safety Institute Regarded as the authority on patient safety in Canada, the Institute works with partners to 
implement and evaluate measurable and sustainable safety improvement projects aligned 
with pan-Canadian priorities. 
CorHealth Ontario Formed in 2017 after the merger of the Cardiac Care Network of Ontario and the Ontario 
Stroke Network, CorHealth Ontario provides advice to the Ministry of Health, Local Health 
Integration Networks, hospitals and care providers to improve the quality, efficiency, 
accessibility and equity of cardiac, stroke and vascular services for patients across Ontario.
Ontario Long-Term Care 
Association
The largest association of long-term-care providers in Canada, representing nearly 70% of 
Ontario’s long-term-care homes. Focusing on advocacy, the Association works to influence 
legislative, policy and regulatory change, support sector expansion and redevelopment, and 
provide educational opportunities to ensure residents’ needs are being met.
Ontario Nurses’ Association The union representing 68,000 registered nurses and health-care professionals. The 
Association works with members to ensure their front-line nurses working in hospitals, public 
health, community health centres, home care, family health teams, long-term care and 
private clinics can provide quality care to patients.
Ontario Hospital Association 
(OHA)
An association representing hospitals across Ontario. Hospital members would like OHA to 
be a leader in shaping new funding methodologies and in providing thought leadership on 
key ideas that can help build a better health system and ensure that Ontario hospitals have 
a strong voice in reshaping the system in the coming years.
Ontario Personal Support 
Workers Association
An association striving to improve the professional status of personal support workers 
in Ontario through advocacy for excellence and consistency in training, services, working 
conditions and value to personal support workers. 
Ontario Public Sector Employees’ 
Union (OPSEU)
A union representing about 170,000 public-sector employees in the province of Ontario. 
OPSEU has about 3,500 members working in long-term-care and retirement homes, and 
related facilities.
Ontario Society of Occupational 
Therapists
The voluntary provincial professional association representing the interests of the over 
4,500 members, who are occupational therapists and students of occupational therapy. 
Registered Nurses’ Association of 
Ontario
The professional association representing registered nurses, nurse practitioners and nursing 
students in Ontario.
Appendix 10: Stakeholder Associations Our Office Met with for This Special 
Report
Prepared by the Office of the Auditor General of Ontario 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 99
Data Source
Who Enters 
the Data
Who Collects 
the Data Description of the Data
Integrated Public 
Health Information 
System/Case Contact 
Management System 
(iPHIS/CCM)
Local public health 
units
Public Health Ontario • Primary data source for Ontario’s public health 
information.
• Contains personal information on positive COVID-19 
cases (e.g., age, sex and risk factors).
• Captures data on COVID-19 outbreaks at the facility 
level.
Ministry of Long￾Term Care Inspectors 
Dataset
Ministry inspectors; 
long-term-care home 
staff
Ministry of Long-Term 
Care
• Inspectors call long-term-care homes daily and log 
their COVID-19 cases and deaths information into the 
dataset.
• Long-term-care home staff enter facility-level 
information.
• The updated number of cases, deaths and outbreaks 
are rolled up into the LTC Daily Summary Report.
Ontario Laboratories 
Information System 
(OLIS)
Testing facility staff Ontario Health • Ontario’s primary lab test data repository, including 
data for all tests covered by OHIP.
• Contains comprehensive test history for patients 
and can be used to monitor progress of treatments, 
support chronic disease management and monitor 
COVID-19 case growth.
Continuing Care 
Reporting System 
(CCRS)
Nursing staff in
long-term-care
homes
Canadian Institute 
for Health 
Information (CIHI)
• Contains demographic, clinical, functional and 
utilization data about long-term-care homes and their 
residents.
• Allows for detailed analysis of long-term-care 
residents based on clinical characteristics.
• Information is updated quarterly.
Office of the Chief 
Coroner of Ontario
Long-term-care home 
staff
Office of the Chief 
Coroner of Ontario
• Captures personal records of COVID-19 deaths within 
hours of the death being confirmed at the home.* 
• Data is reported within a day and contains details on 
the clinician-informed cause of death.
• Does not track long-term-care staff deaths and 
residents who died in a hospital.
* Long-term-care homes were mandated to submit the COVID-19 status of resident deaths from April 14 to June 23, 2020.
Appendix 11: Sources of Long-Term-Care Data 
Source of data: Ministry of Long-Term Care 

100
Appendix 12: Comparison of Ontario1 and British Columbia’s Health-Care System Organization 
Prepared by the Office of the Auditor General of Ontario
Ministry of Health Office of the Provincial Health Officer
Government of British Columbia
Assisted Living Registry
• Administers the registration of all 
assisted living residences.
• Investigates complaints about 
the health and safety of residents 
in assisted living facilities.
• Provides independent advice to 
the Minister and public officials 
on public health issues.
• Led by Medical Health Officers 
(MHO).
• Carry out ongoing inspection and 
monitoring of community care 
facilities.
5 Regional Health Authorities2
Long-Term-Care Homes
Hospitals
Ministry of Health Ministry of Long-Term Care
Long-Term-Care Homes
Government of Ontario1
Chief Medical Officer of Health Chief Medical Officer / 
Provincial Health Officer
Public Health Ontario
Ontario Health
14 Local Health 
Integration Networks
Ontario Health Teams
Hospitals
Municipalities
Local Boards of Health
34 Local Public Health Units Limited reporting relationship.
1. See Appendix 2 for a description of the different entities in Ontario’s health-care system.
2. Medical Health Officers (MHO) are employed by regional health authorities, and have reporting relationships to the Chief Medical Officer/Provincial Health Officer.  

Chapter 5: Pandemic Readiness and Response in Long-Term Care 101
Appendix 13: Summary of Key Changes in Requirements under COVID-19 
Directive #3 for Long-Term-Care Homes, March 30—December 7, 20201
Source of data: Ministry of Health and Ministry of Long-Term Care
Date 
Issued Requirement
Absences (Short-term, Temporary and Medical)
Mar 30 “Long-term-care homes must not permit residents to leave the home for short-stay absences to visit family and 
friends. Instead, residents who wish to go outside of the home must be told to remain on the home’s property and 
maintain safe physical distancing.”
Jun 10 “Temporary short-stays in hospitals can be considered for residents in the event of an outbreak where residents 
cannot be placed in other areas of the home that are not part of the declared outbreak area, or there are other 
exceptional circumstances (e.g., resident safety, advice from local public health unit).”
Aug 28 “Residents may leave the home’s property for a short-stay absence for health-care, social or other reasons. A short￾stay absence does not include an overnight stay, with the exception of single-night emergency room visits. Upon 
return to the home, residents must be actively screened but are not required to be tested or self-isolate.” 
“Residents may leave the home’s property for a temporary absence (one or more nights) for personal reasons. Upon 
return to the home the resident will be required to self-isolate for 14 days.” 
Oct 14 “The resident or substitute decision-maker must make an absence request to the home. Homes must review and 
approve all non-medical absence requests based on a case-by-case risk assessment considering, but not limited 
to: the home’s ability to support self-isolation for 14 days upon the resident’s return, local disease transmission and 
activity, and risk associated with the planned activities that will be undertaken by the resident while out of the home.”
“If the home denies an absence request, the home must communicate this to the resident/substitute decision￾maker in writing, including the rationale for this decision. Residents whose request for an absence is denied but 
wish to go outside must be told to remain on the home’s property and maintain a physical distance of at least two 
metres from any other resident or staff on the property.”
Admissions, Re-admissions and Transfers
Mar 30 “Long-term-care homes must screen new admissions and re-admissions for symptoms and potential exposure to 
COVID-19. All new residents must be placed in self-isolation for 14 days on arrival at the long-term-care home.”
Apr 8 “If test results are negative, they must remain in isolation for 14 days from arrival. If test results are positive, 
homes must report a confirmed case and follow case management protocol, which includes treating residents with 
compatible illnesses as probable for having COVID-19 pending test results, and cohorting confirmed cases. Patients 
transferred from hospital to a long-term-care home must be tested prior to the transfer.”
Apr 15 “Hospitals are being asked to temporarily stop transfers to long-term-care and retirement homes. However, in 
the unlikely event that a transfer is still required, patients transferred from a hospital to a long-term-care home or 
retirement home must be tested and confirmed negative prior to transfer.” All patients should self-isolate for 14 days 
following transfer.”
Jun 10 New admissions and readmissions to a long-term-care home or retirement home can occur if a home has sufficient 
staffing and can ensure COVID-19 preparedness measures such as self-isolation, and the resident is placed in a 
room with no more than one other resident. 
Aug 28 “In the case that there is any difference of view between a hospital and long-term-care home about the suitability 
of the return of the resident to the long-term-care home,” parties should “contact the local placement coordinator/
office.” If the issue cannot be resolved, it will be “escalated to the Ministry.”
Dec 7 “Individuals who may have challenges with isolation due to a medical condition (e.g., dementia) should not be 
denied admission or transfer on this basis alone.”
Communications
Mar 30 “Long-term-care homes must keep staff, residents and families informed about COVID-19, including frequent and 
ongoing communication during outbreaks.” 

102
Date Event
COVID-19 Preparedness
Mar 30 Long-term-care homes, in consultation with their Joint Health and Safety Committees or Health and Safety 
Representatives, if any, must ensure measures are taken to prepare the home for a COVID-19 outbreak, including: 
• ensuring outbreak swab kits are available;
• ensuring sufficient personal protective equipment (PPE) is available, and staff are trained on the use of PPE;
• reviewing advanced directives for all residents, reviewing communications protocols and reviewing staffing 
schedules;
• reviewing internal activities to ensure social distancing;
• reviewing environmental cleaning protocols; and
• developing polices to manage staff who may have been exposed to COVID-19.
Sep 9 Long-term-care homes must discuss with each resident and their substitute decision-maker an advanced care plan 
for the resident, and document the plan. 
Homes must communicate with local acute care hospitals regarding outbreaks, including number of residents in 
the facility, and number who may potentially be transferred to hospital if ill based on the expressed wishes of the 
residents. 
Homes must develop policies to manage staff who may have been exposed to COVID-19 and must permit an 
organization completing an IPAC assessment to share the report with any or all of the following: public health units, 
local public hospitals, LHINs, and the Ministry of Long-Term Care in the case of long-term-care homes.
Limiting Work Locations
Mar 30 Wherever possible, employers should work with employees to limit the number of work locations that employees are 
working at.
Apr 15 Long-term-care home employers are reminded that they must also comply with Ontario Regulation 146/20 under 
the Emergency Management and Civil Protection Act.
Management of a Single Case in a Resident
Mar 30 The resident must be in isolation under appropriate droplet and contact precautions, which include staff wearing 
a mask and eye protection or face shield within two metres of the resident, wearing a long-sleeved gown for direct 
care when skin or clothing may become contaminated, wearing gloves for direct care, and being in a single room if 
possible.
Management of a Single Case in Staff
Mar 30 Long-term-care homes must immediately implement outbreak control measures for a suspected outbreak. Even 
if the staff exposure was to a specific area of the long-term-care home, consideration must be given to applying 
outbreak control measures to the entire home.
Managing Visitors
Mar 30 Long-term-care homes must be closed to visitors, except for essential visitors. Essential visitors include a person 
performing essential support services (e.g., food delivery, maintenance and other health care) or a person visiting a 
very ill or palliative resident. If an essential visitor is admitted to the home, the visitor must: 
• be screened on entry for symptoms of COVID-19, including temperature checks, and not be admitted if they show 
any symptoms of COVID-19;
• visit only the one resident they are intending to visit and no other resident; and
• wear a mask while visiting a resident who does not have COVID-19. 
For any essential visitor in contact with a resident who has COVID-19, appropriate PPE should be worn in 
accordance with Directive #1.2
May 21 For any essential visitor in contact with a resident who is suspected or confirmed to have COVID-19, appropriate PPE 
should be worn in accordance with Directive #53
 and Directive #1. 

Chapter 5: Pandemic Readiness and Response in Long-Term Care 103
Date Event
Jun 10 At minimum, visitor policies must: 
• Be informed by the ongoing COVID-19 situation in the community and the home and be flexible to be reassessed 
as circumstances change. 
• Be based on principles such as safety, emotional well-being and flexibility, and address concepts such as 
compassion, equity, non-maleficence, proportionality (i.e., be appropriate to the level of risk), transparency and 
reciprocity (i.e., provide resources to those who are disadvantaged by the policy). 
• Include education about physical distancing, respiratory etiquette, hand hygiene, infection prevention and control 
practices (IPAC) and proper use of PPE. 
• Include allowances and limitations regarding indoor and outdoor visiting options. 
• Include criteria for defining the number and types of visitors allowed per resident when the home is not in an 
outbreak, in accordance with Ministry of Long-Term Care and Ministry for Seniors and Accessibility policies. When 
the home is in an outbreak, only essential visitors are permitted in the home. 
• Include visitors confirming they have not been experiencing any of the typical and atypical symptoms of 
COVID-19. 
• Comply with the home’s IPAC protocols. 
• Clearly state that if the home is not able to provide surgical/procedure masks, no family visitors should be 
permitted inside the home. Essential visitors who are provided with appropriate PPE from their employer may 
enter the home. 
• Include a process for communicating with residents and families about policies and procedures, including the 
gradual resumption of family visits.
• State that non-compliance with the home’s policies could result in a discontinuation of visits for the non￾compliant visitor. 
• Include a process for gradual resumption of family visitors that specify essential visitors.
Personal Protective Equipment (PPE)
Mar 30 Long-term-care homes must follow COVID-19 Directive #12
 for Health Care Providers and Health Care Entities.
May 21 Long-term-care homes must follow COVID-19 Directive #53
 for Hospitals within the meaning of the Public Hospitals 
Act and Long-Term Care Homes Act, 2007. 
Required Steps in an Outbreak
Mar 30 When a local public health unit declares an outbreak in a long-term-care home:
• New resident admissions are not allowed. 
• No readmission of residents until the outbreak is over.
• If residents are taken by family out of the home, they may not be readmitted until the outbreak is over.
• For residents who leave the home for an outpatient visit, the home must provide a mask, and the resident, if they 
can tolerate it, must wear a mask while out and be screened upon their return.
• All non-essential activities must be discontinued.
Screening of Residents
Mar 30 All residents must be actively screened and assessed at least twice a day—at the beginning and end of the day—
including temperature checks, to identify if any resident has fever, cough or other symptoms of COVID-19. Residents 
with symptoms, including mild respiratory symptoms, must be isolated and tested for COVID-19.
Jun 10 The home must provide a mask to residents who leave the home for an outpatient visit. The resident must wear a 
mask while out, if they can tolerate it, and be screened upon their return, but does not need to self-isolate.
Screening of Staff and Visitors
Mar 30 Active screening must include symptom screening and temperature checks twice a day (at the beginning and end of 
the day or shift).
Anyone showing symptoms of COVID-19 should not be allowed to enter the home and should go home immediately 
to self-isolate. Staff responsible for occupational health at the home must follow up on all staff who have been 
advised to self-isolate based on exposure risk.
May 21 Should anyone show symptoms, staff members should contact their immediate supervisor/manager or occupational 
health and safety representative in the home. 

104
Date Event
Staff and Resident Cohorting
Mar 30 Resident cohorting may include maintaining physical distancing of two metres, cohorting of the well and unwell, 
utilizing respite and palliative care beds and rooms, or utilizing other rooms as appropriate.
Staff cohorting may include designating staff to work with either ill residents or well residents.
Triggering an Outbreak Assessment
Apr 8 Once at least one resident or staff has presented with new symptoms compatible with COVID-19, the long-term-care 
home should immediately trigger an outbreak assessment.
If the long-term-care home receives negative test results for the initial person who was tested, the long-term-care 
home can immediately end the suspect outbreak assessment-related steps.
If the long-term-care home receives a single, laboratory-confirmed case of COVID-19 in a resident or staff member, 
an outbreak must be declared. Residents, staff and visitors who were in close contact with the infected resident, 
or those within that resident’s unit/hub of care, should be identified. Further testing on those identified should be 
assessed, in collaboration with the local public health unit, using a risk-based approach based on exposures.
Universal Masking
Apr 8 Long-term-care homes should immediately require all staff and essential visitors to wear surgical/procedure masks 
at all times for the duration of full shifts or visits in the home, regardless of whether or not the home is in outbreak 
or not. During breaks, staff may remove their mask but must remain two metres away from other staff to prevent 
staff-to-staff transmission of COVID-19.
Dec 7 When staff are not in contact with residents or in resident areas during their breaks, staff may remove their 
surgical/procedure mask but must remain two metres away from other staff to prevent staff-to-staff transmission of 
COVID-19.
Long-term-care homes are required to have policies regarding masking for residents. It is strongly recommended 
that residents wear masks in common indoor areas in the home as tolerated. Homes are also required to follow any 
additional directions provided by provincial, local public health unit or municipal bylaws.
1. Directive #3 has been revised at least 10 times since March 22, 2020, (see Appendix 7 for details) when it was first issued. As of December 31, 2020, 
the last revision was on December 7, 2020.
2. Directive #1, regarding personal protective equipment (PPE), was first issued on March 12, 2020 and directed the use of droplet and contact precautions 
for the routine care of patients or residents with suspected or confirmed COVID-19.
3. Directive #5 was first issued on March 31, 2020 to public hospitals, and lists the required precautions and procedures for disbursements and storage of PPE. 

Office of the Auditor General of Ontario
20 Dundas Street West, Suite 1530
Toronto, Ontario
M5G 2C2
www.auditor.on.ca
ISBN 978-1-4868-4851-5 (PDF)
Cover photograph credit:
© iStockphoto.com/xavierarnau 