Health, Seniors and Active Living Personal Care Home Standards Review Tool #1 Regional Health Authority: Facility: Number of Beds: Winnipeg RHA Parkview Place Care Centre 261 Review Team: Sabine Bures (Manitoba Health, Seniors and Active Living) (MHSAL), Bonnie Lounsbury (MHSAL), Michael Haip (Winnipeg Regional Health Authority) (WRHA), Kristine Schellenberg (WRHA) Review Date (yyyy/mm/dd): Report Date (yyyy/mm/dd): 2020/03/9-10 2020/04/21 Page 2 of 78 Summary of Results Standard 01 03 07 08 09 11 12 17 19 20 24 26 Regulation Bill of Rights Eligibility for Admission Integrated Care Plan Freedom from Abuse/Neglect Use of Restraints Nursing Services Pharmacy Services Therapeutic Recreation Safety and Security Disaster Management Staff Education Critical Incidents and Critical Occurrences Review Team Rating Met Met Met Met Met Met Met Met Met Met Met Met Summary Met Partially Met Not Met 12 General Comments: The standards review team appreciates the work of management and staff of Parkview Place Care Centre in preparing for the standards review. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 3 of 78 Monitoring Tool #1 was randomly selected for this facility review and ratings for the standards included in this tool are summarized in the table above. Findings: All of the standards assessed were assigned a rating of met. The facility is, however, required to address any performance measures in core standards rated as other than met. While there were no concerns noted with respect to resident care provided directly by staff, significant issues were identified with respect to the facility's state of repair, cleanliness, and sanitation practices. These concerns are summarized under Standard 19 Safety and Security and further detailed in a separate attachment to the standards review report. Action must be taken to mitigate these issues. Standard 1: Bill of rights Reference: Personal Care Homes Standards Regulation sections 2, 3, and 4 The operator of a personal care home shall ensure that a residents’ bill of rights is developed for the home in consultation with the residents and their designates. The bill of rights must be reviewed and approved annually by the residents and their designates (at minimum, the members of the resident council). What the bill of rights must contain The bill of rights must be consistent with the Act and this regulation and must, at a minimum, clearly reflect the following principles: 1. Residents are to be treated with courtesy and respect, and in a way that promotes their dignity and individuality. 2. Residents are to be sheltered, fed, dressed, groomed and cared for in a manner consistent with their needs. 3. Residents or their legal representatives have the right to give or refuse consent to treatment, including medication, in accordance with the law. 4. Subject to safety requirements and the privacy rights of other residents, residents are to be encouraged to exercise their freedom of choice whenever possible, including the freedom to do the following: a) exercise their choice of religion, culture and language; b) communicate with, and have contact with and visits to and from friends, family and others in private if desired; c) choose recreational activities; d) choose the personal items to be kept in their rooms, when space permits; and e) select the clothing to be worn each day. 5. Residents are to be afforded reasonable privacy while being treated and cared for. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 4 of 78 6. Residents are to be provided with a safe and clean environment. 7. Residents may communicate and meet with their legal representative as often as necessary and in private if desired. Bill of rights to be respected and promoted The operator shall ensure that the bill of rights is respected and promoted in the personal care home. The bill of rights must be posted in standard CNIB print (Arial 14 font or larger) in locations that are prominent and easily accessible to residents, family, designates and staff. Expected outcome: The resident’s right to privacy, dignity and confidentiality is recognized, respected and promoted. Performance measures # Measure Facility Rating 1.01 The PCH has a resident bill of rights. Met 1.02 The bill of rights is reviewed and approved by residents and/or their designates annually. Met The bill of rights is posted:  In minimum standard CNIB 1.03 print (Arial font 14 or larger), and; Met Comments See Resident Council binder for 1.01-1.17. Several reviewed, discussed and approved monthly at Resident Council meetings. Sticker indicating date of final yearly approval on posted Bill of Rights. Posted in Arial font 14 Review Team Rating Comments Met Met Met One at the main entrance and one across from the 1.04 Met Met second floor elevator. Approval dates affixed. The bill of rights is consistent with the requirements of the Personal Care Homes Standards Regulation and reflects that: 1.05  residents are treated with Met Please see the bill of rights Met  In locations that are prominent and easily accessible by residents, families and staff. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 5 of 78 # Measure Facility Rating Comments Review Team Rating Comments courtesy and in a way that promotes their dignity and individuality  residents are sheltered, fed, dressed, groomed and cared for 1.06 Met Please see the bill of rights Met in a manner consistent with their needs  residents or their legal representative have the right to 1.07 Met Please see the bill of rights Met give or refuse consent to treatment, including medication, in accordance with the law Subject to safety requirements and the privacy rights of other residents, the facility’s bill of rights outlines that each resident has the right to:  exercise their freedom of choice 1.08 Met Please see the bill of rights Met of religion, culture and language This right to contact and communicate with others should be more explicitly stated. With the exception of the following statement,  communicate with, have contact the current bill makes no with and have visits to and from 1.09 Met Please see the bill of rights Partially Met reference to contact with friends, family and others, in others. private if desired "…participate and remain in contact with life outside our home; let us to be usefull to our community."  choose their recreational 1.10 Met Same as above Met activities Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 6 of 78 # Measure Facility Rating Comments  choose the personal items to be Met Same as above kept in their rooms, when space permits  select the clothing to be worn 1.12 Met Same as above each day  be provided reasonable privacy 1.13 Met Same as above while being treated and cared for  be provided with a safe and clean 1.14 Met Same as above environment  communicate and meet with their legal representative as often as 1.15 Met Same as above necessary and in private, if desired There is evidence that the PCH respects and promotes the bill of rights, as follows: Policies are compatible with the Resident Bill of Rights, for example: ADMIN9-P10-LTCLeadership and Management Practices.pdf ADMIN9-010.01-LTCWalkabouts.pdf  The facility policies are 1.16 Met CARE15-010.02-LTCcompatible with the bill of rights. Residents Bill of Rights.pdf ADMIN1-P10-ENT Resident Non-Abuse Program.pdf ADMIN1-010.01-E2-LTCNon-Abuse Variations in Provincial Legislation.pdf 1.11 Review Team Rating Comments Met Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 7 of 78 # Measure Review Team Rating Comments Met Audits are conducted by the Recreational Director Met Reminder to audit staff and resident interaction through direct observation, not only through resident surveys. Met Audits are communicated at resident council and also morning report with the management team Met Facility Rating Comments Care15-P10-LTCPromoting Quality of Life.pdf Care1-P10-Resident Assessment and Plan of Care.pdf Care4-010.02-MB-LTCACP Goals of Care.pdf Care1-010.06-LTC-Care Conferences.docx Care15-010.01-LTCPerson Centred Care Approach.pdf Care16-P30-LTC-Resident Council.pdf Care15-010.04-LTCSupporting Spiritual and Religious.pdf  Audits of how staff incorporate the bill of rights into their daily interactions with residents are 1.17 completed at least annually as part of the facility’s continuous quality improvement/risk management activities. The audit results: 1.18  are reported Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 8 of 78 # 1.19 1.20 Measure  are reviewed and analyzed  recommendations are made, as required, from the audit analysis Facility Rating Met Met Comments Same as above Same as above Review Team Rating Comments Met Although the majority of audits were scored at 100% there were some measures Partially Met rated as less than 100%. There were no recommendations made to address these.  recommendations are Met Same as above Partially Met As in above statement. implemented and followed up Scoring methodology:  The bolded measures (1.01, 1.02, 1.03 & 1.04) are pass/fail performance measures. If they are not met, the standard is not met. If they are met, the other measures are considered before assigning an overall rating to the standard.  Of the 17 other measures: o If ≥14 measures are met, the standard is met. o If ≥10 and <14 measures are met, the standard is partially met. o If <10 measures are met, standard is not met. Result: All bolded measures were met and 14 of 17 other measures were met. The standard is: Met Comments: 1.21 Standard 3: Eligibility for Admission Reference: Personal Care Homes Standards Regulation section 7 Eligibility for admission If a bed is available in a personal care home, any person who meets the eligibility requirements described in sections 3(a) and (b) of the Personal Care Services Insurance and Administration Regulation is entitled to be admitted, unless it can be demonstrated that safe and adequate care cannot be provided to the person in the home. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 9 of 78 When determining whether safe and adequate care can be provided, the needs of the person must be considered, as well as the staffing and physical facilities of the personal care home. The person’s needs are those described in the completed Application and Assessment Form and as determined by any contact between the staff of the personal care home and a) the person and his or her designate or legal representative; and b) any other person or entity that has provided health care to the person. A bed designated for short-term respite care is not available under regulation subsection 7(1). Expected outcome: Residents are assessed and placed in the most appropriate setting according to their needs. Performance measures # Measure Facility Rating 3.01 There is evidence in the resident’s health record that eligibility for admission has been determined by an assessment panel independent of the PCH. Met 3.02 The admission process is guided by specific documented criteria developed by the facility/regional health authority (RHA) to determine its ability to meet the Met Comments See admissions binder for 3.01 - 3.03. Application for Admission (A/A), Part 1 is evidence of the independent assessment panel and contains the panel date. The A/A is filed in the Admission section of the chart, and a copy of Part 1 is kept in the Resident file by both the Office Manager and the S.W. Admission process guided by ADMIN8-010.01Movein, Discharge and LTC Transfer; ADMIN8-P10 Management of Resident Review Team Rating Comments Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 10 of 78 # Measure Facility Rating needs of the prospective resident. 3.03 There is documented evidence on the resident’s health record of pre-admission contact between staff of the facility and the prospective resident, the resident’s representative and/or any other person or entity that has provided health care to the prospective resident. Met Comments Move-in, Discharge and Transfer. The WRHA Admission Review and Outcome Form may also be part of the admission process. If it is an Inability to Admit, a completed form is faxed to LTC and a copy filed by the S.W. ADMIN8-010.01-T1-MBLTC Pre-Move-In Assessment and Screening Tool records visit date if relevant as well as information gleaned from the Admission Application, family/SDM and/or other health care facility. The IPN indicates any visits, communication and contact relating to that admission. Review Team Rating Comments Met Scoring methodology:  Each of the performance measures is bolded (3.01, 3.02, 3.03) and are therefore pass/fail performance measures. If any one of the performance measures is not met, the standard is not met. Result: All performance measures were rated as met. The standard is: Met Comments: Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 11 of 78 Standard 7: Integrated Care Plan Reference: Personal Care Homes Standards Regulation sections 11, 12, 13 and 14 Initial care plan Within 24 hours of admission, the operator shall ensure that the following basic care requirements for the resident are documented: a) medication, treatment and diet orders; b) the type of assistance required for activities of daily living; and c) any safety or security risks. Integrated Care Plan Within eight weeks after admission, the operator shall ensure that each member of the interdisciplinary team assesses the resident’s needs and that a written integrated care plan is developed to address the resident’s care needs. Integrated care plan Within eight weeks after admission, the operator shall ensure that each member of the interdisciplinary team assesses the resident’s needs and that a written integrated care plan is developed to address the resident’s care needs. The integrated care plan must include the following information: a) the type of assistance required with bathing, dressing, mouth and denture care, skin care, hair and nail care, foot care, eating, exercise, mobility, transferring, positioning, being lifted, and bladder and bowel function, including any incontinence care product required; b) mental and emotional status, including personality and behavioural characteristics; c) available social network of family and friends, and community supports; d) hearing and visual abilities and required aids; e) rest periods and bedtime habits, including sleep patterns; f) safety and security risks and any measures required to address them; g) language and speech, including any loss of speech capability and any alternate communication method used; h) rehabilitation needs; i) preference for participating in recreational activities; j) religious and spiritual preference; k) treatments; l) food preferences and diet orders; m) any special housekeeping considerations for the resident’s personal belongings; Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 12 of 78 n) whether the resident has made a Health Care Directive; and o) any other need identified by a member of the interdisciplinary team. Where appropriate, the integrated care plan must also state care goals and interventions that may be taken to achieve these care goals. Review of the integrated care plan As often as necessary to meet the resident’s needs, but at least once every three months, the operator shall ensure that appropriate interdisciplinary team members review the integrated care plan and amend it, if required. The operator shall ensure that each team member reviews each integrated care plan annually and that any amendments required to meet the resident’s needs are made. Staff to be made aware of current care plan The operator shall ensure that the staff who provide direct care and services to the resident are aware of the resident’s current care plan. If the method of communicating the plan includes preparing a summary for staff to refer to, the operator shall ensure that the summary accurately reflects the current plan. Expected outcome: Beginning at admission, residents consistently receive care that meets their needs, recognizing that residents’ care needs may change over time. Performance measures # 7.01 Measure Integrated care plans are maintained as part of the permanent resident health record. Facility Rating Comments Met All components of the integrated Care Plan are completed and maintained as part of the permanent Resident health record. As sections of the care plan are reviewed/changed a new copy of the MDS care plan is printed and replaces Review Team Rating Met Comments Eight integrated care plans were examined during the course of the standards review. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 13 of 78 # Measure Facility Rating Comments Review Team Rating Comments the outdated version. Previous care plans are retained in the Resident's health record thinned file. Within 24 hours of admission, basic care requirements for the resident are documented, including: Medication Reconciliations are completed for all new admissions. Orders are verified by the physician and communicated to the pharmacy by the nurse. Orders are documented in the health record, with current medication orders and their administration 7.02  medications and treatments Met Met documented on the Mediation Administration Record and Treatment Administraton Record. These records are kept in a binder accessible to the assigned nurse to support administration of medication, and filed in the health record monthly. Diet orders are verified from transfer sheet from hospital or pre admission visit 7.03  diet orders Met Met assessment from community. Diet is communicated to Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 14 of 78 # Measure Facility Rating 7.04  assistance required with activities of daily living Met 7.05  safety and security risks Met Comments Pharmacy, Dietitian and Food Services Manager. A Meal Observation Screening Form is completed at the first meal to verify thar the diet texture is tolerated by the resident. Swallowing concerns are assessed by a Speech Language Pathologist through consultation. Diet orders are verified from transfer sheet from hospital or pre admission visit assessment from community. Diet is communicated to Pharmacy, Dietitian and Food Services Manager. A Meal Observation Screening Form is completed at the first meal to verify thar the diet texture is tolerated by the resident. Swallowing concerns are assessed by a Speech Language Pathologist through consultation. Information obtained through the admission and transfer process is used as Review Team Rating Comments Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 15 of 78 # Measure Facility Rating 7.06  allergies Met 7.07 There is evidence that within the first eight weeks of admission, the resident’s needs have been assessed by the interdisciplinary team and a written integrated care plan has been developed. Met Comments a starting point for nursing assessment of safety issues, including falls risk, exit-seeking and wandering risks and swallowing concerns. Allergies are verified from transfer sheet or community assessment and documented in the medical record and Medication Administration Record and in the MDS care plan. Allergies are communicated to pharmacy and food allergies are communicated to Dietary Services. Residents with allergies have this noted on their chart cover and on their identification band. The integrated care plan is completed within 8 weeks, after a full week of assessment of the resident after admission, replacing the admission care plan. Interdisciplinary Assessments are completed within 8 weeks of admission, which is Review Team Rating Comments Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 16 of 78 # Measure Facility Rating Comments Review Team Rating Comments included in the Integrated Care Plan and presented for discussion at the 8 week post-admission care conference. The active integrated care plan contains detailed and current information on all aspects of each resident’s care needs, to ensure all appropriate and proper care is provided, including information on and requirements for: Performance Measures #7.08 to #7.21 are contained in the MDS integrated care plan, and at 7.08  bathing Met Met the bedside on the ADL Sheet, with care completion documented on the Resident Flow Sheet 7.09  dressing Met See 7.08 Met 7.10  oral care Met See 7.08 Met 7.11  skin care Met See 7.08 Met 7.12  hair care Met See 7.08 Met 7.13  fingernail care Met See 7.08 Met 7.14  foot care Met See 7.08 Met 7.15  exercise Met See 7.08 Met 7.16  mobility Met See 7.08 Met In one care plan, under the "safety" focus it indicated that supervision is required 7.17  transferring Met See 7.08 Met with transfers but under the "transfer" focus it indicated that no supervision is required. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 17 of 78 # Measure Facility Rating 7.18  positioning Met 7.19  bladder function Met 7.20  bowel function Met 7.21  any required incontinence care product Met 7.22  cognitive and mental health status Met 7.23  emotional status, and personality and behavioural characteristics Met Comments See 7.08. Mobility Logo posted at bedside andturning clocks support turning in bed when required. See 7.08 In addition, residents have toileting/continence care plans and document toileting See 7.08. In addition, residents have toileting/continence care plans and document toileting See 7.0 8. Toileting care plan and required product information documented on ADL sheet. All incontinent residents receive routine skin care of washing, drying and application of barrier cream, and staff receive education to this annually. Care Plan Section 7.1 &7.2 address these needs. CPS scores are generated from MDS assessment. See 7.22 Review Team Rating Comments Met Met Met Met Met Met In one resident health record, there were numerous references made Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 18 of 78 # Measure Facility Rating Comments Review Team Rating Comments to mental health issues but this information was not transferred to the care plan. The care plan should serve as the central source of information required by staff to provide appropriate care. 7.24  available family, social network, friends and/or community supports Met 7.25  hearing ability and required aids Met Available family and community supports are identified in the following sections of the Care Plan: -Momentum software in Care Organizer in Demographics under "Contact" -Care Plan 7.0 Available Family & community Supports. Sensory aids are documented in the Care Plan sections as follows: - Care Plan SectionSensory aids are documented in the Care Plan sections as follows: -Resident Care plans documents use of aidesin section 3.1 Hearing -ADL Sheet provides required information Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 19 of 78 # Measure Facility Rating 7.26  visual ability and required aids Met 7.27  rest periods, bedtime habits, and sleep patterns Met 7.28  safety and security risks and any measures required to address them Met Comments -Resident Care Flow Sheet documents use of aides - Hearing aides are often managed by nursing and documented on the TAR for residents who are not able to manage them independently. Sensory aids are documented in the Care Plan sections as follows: -Care Plan Section 3.2 Vision -ADL Sheet provides required information -Resident Care Flow Sheet documents use of aides Rest periods and bedtime habits are identified in the following sections of the Care Plan: - Care Plan Section 7.5 Sleep Patterns and Bed Time Routines - ADL Sheet provides information at the bedside Safety and security risks and intervention strategies are identified in the Review Team Rating Comments Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 20 of 78 # 7.29 Measure  language and speech, including any loss of speech capability and any alternate communication method used Facility Rating Met Comments following sections of the Care Plan: -Section 6.5 Safety - Risk for elopement book (Wander guard if applicable) -Falls Protocol -Safety Check Sheets -Behaviour Mapping -ADL Sheet provides direction on risks and management strategies -High Risk Tracking Tool -Restraint Documentation and Monitoring Language and speech needs are identified in the following components of the Care Plan: -Section 3.0 Communication Ability, -Consults to SLP and any specific recommendations/interventi ons based on assessment will be integrated into the care plan -ADL Sheet provides staff direction on issues and care activities to address. Review Team Rating Not Met Comments In four of eight care plans, there was no reference to the resident's ability to communicate. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 21 of 78 # 7.30 Measure  rehabilitation needs Facility Rating Met 7.31  therapeutic recreation requirements Met 7.32  preferences for participating in recreational activities Met 7.33  religious and spiritual preferences Met 7.34  food allergies Met Comments Resident Rehabilitation needs are identified in the sections of the Care Plan as follows: -Section 6.6 and 6.7 Rehabilitation Needs. Walking, standing and rehab activities are documented in the resident's health record Resident preferences for participating in recreational activities are identified in section 7.3 Recreational Activity Preferences Resident preferences for participating in recreational activities are identified in section 7.3 Recreational Activity Preferences Religious and Spiritual preference is identified in section 7.4 Religious and Spiritual Preferences, and in Care Organizer in the Demographics section under History. (if known) Allergies are identified in the Review Team Rating Met Comments This focus area was well done with a good level of detail provided. Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 22 of 78 # Measure Facility Rating Comments Care Plan in section 8.0 Allergies and will be communicated to Food Services and entered into Synnergy so information appears on diet and snack lists, available for reference at meals and snack passes. Diet orders including snacks and nutritional supplements are documented in the Care Plan as follows: Care Plan Section 4.0 Meal Management and Section 4.1 Identification of Preferences, -ADL Sheet -Resident Care Flow Sheet -SYNERGY system managed by Food Services Review Team Rating 7.35  diet orders Met 7.36  type of assistance required with eating Met See 7.35 Met Met Health Care Directives and WRHA Advance Care Plan/Goals of Care is documented in - Care Organizer in Demographics, under Demographics, and Met 7.37  whether or not the resident has made a health care directive Comments Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 23 of 78 # Measure Facility Rating 7.38  special housekeeping considerations Met 7.39  other needs identified by the interdisciplinary team Met 7.40 The integrated care plan outlines care goals and interventions that Met Comments - Care Plan Section 7.7 Advance Care Planning with documents maintained in Resident health record under "Health Care Directive" tab. Discussed with Resident/ POA/SDM at time of admission, annual Care Conference, and if change in health. Information on ACP is included in the admission package. If not otherwise defined would be a "R" for resuscitation Special housekeeping considerations are documented in the care plan and communicated to the housekeeper and Manager of Environmental Services Additional needs are identfied in the care plan and communicated to staff through both the care plan and the ADL sheet Care plans are developed on admission and revised Review Team Rating Comments Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 24 of 78 # Measure Facility Rating will be taken to achieve those care goals. Comments Review Team Rating Comments and updated at or before 8 weeks post admission, and then minimally every 3 months with the MDS assessment and with changes in care provision. Care plan review and update of ADL sheets is monitored when care plans are signed off and submitted to CIHI. There is evidence that the integrated care plan is reviewed: 7.41  at least once every three months by the interdisciplinary team 7.42  at least annually by all staff who provide direct care and services to the resident, as well as the resident and his/her representative(s), if possible Met Met Interdisciplinary team members, specifically nursing, recreation, dietary and OT are responsible for quarterly resident assessment and care plan review, including assessment at 8 week post admission and annual care conference, addressing issues arising that impact care plan Interdisciplinary team members, specifically nursing, recreation, dietary and OT are responsible for quarterly resident assessment and care plan review, including Met Met This measure was applicable for three of the eight resident records reveiwed. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 25 of 78 # Measure Facility Rating Comments Review Team Rating Comments assessment at 8 week post admission and annual care conference, addressing issues arising that impact care plan As part of the facility’s continuous quality improvement/risk management activities, there is evidence that care plans audits: Care plans are reviewed with quarterly MDS 7.43  occur at least annually Met Met completion and audited quarterly. Audits are reviewed and analyzed with action plans 7.44  are reviewed and analyzed Met Met developed to address issues Audit concerns are identified and drawn to the  result in recommendations for attention of staff with improvement being made as 7.45 Met Met education and required, based on the audit communicated analysis recommendations. Recommendations are supported and followed up,  result in recommendations being 7.46 Met Met re-audited to ensure implemented and followed up implementation. Scoring methodology:  Bolded performance measures (7.01, 7.07, 7.41 & 7.42) are pass/fail performance measures. If any of the bolded measures is not met, the standard is not met. If all bolded performance measures are met, the other performance measures are considered before assigning a rating to the standard.  Of the 42 other measures: o If ≥34 measures are met, the standard is met. o If ≥25 and <34 measures are met, the standard is partially met. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 26 of 78 # Measure Facility Rating Comments Review Team Rating Comments o If <25 measures are met, the standard is not met. Result: The bolded measures were rated as met and 41 of 42 other measures were rated as met. The standard is: Met Integrated care plans were generally well done. Interventions were resident specific and provided a good Comments: level of detail. Standard 8: Freedom from Abuse/Neglect Reference: Personal Care Homes Standards Regulation section 15 Freedom from Abuse/Neglect The operator shall establish safeguards to prevent residents from being abused. The operator shall establish a written policy that sets out: a) the safeguards established to prevent residents from being abused/neglected; and b) the appropriate action to be taken when abuse/neglect is alleged. In this section, “abuse” means mistreatment – whether physical, sexual, mental, emotional, financial or a combination of any of these behaviours that is reasonably likely to cause physical or psychological harm or death to a resident, or loss of property belonging to the resident. In this section ‘neglect’ means an act or omission that (a) is mistreatment that deprives a patient of adequate care, adequate medical attention or other necessaries of life, or a combination of any of them; and (b) causes or is reasonably likely to cause (i) death of a patient, or (ii) serious physical or psychological harm to a patient. Expected outcome: Residents will be safeguarded and free from abuse or neglect. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 27 of 78 Performance measures # Measure Facility Rating Comments Review Team Rating Comments The PCH has a policy in place regarding freedom from abuse and neglect that includes: ADMIN-010.01-T1-LTC Definitions of Abuse and Neglect. 8.01  a definition of abuse and neglect Met 8.02  the appropriate action to be taken when abuse or neglect is alleged Met 8.03  circumstances for notification of the resident’s designate or legal representative Met The Resident Bill of Rights also states: As a Resident of Parkview Place, I have the right to be free from abuse, including physical, emotional, financial, verbal and sexual. Admin 1-P10-ENT Resident Non-Abuse Program. ADMIN-010.01 Mandatory Reporting of Resident Abuse or Neglect. Families are notified of all unusual incidents per Revera Adverse Event policy and WRHA occurrence reporting policy. ADMIN1-010.02-E2-LTC Tips for Handling Third Party Investigation. See 8.02 Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 28 of 78 # Measure Facility Rating Comments Review Team Rating Met 8.04  a description of available local resources to assist an abused resident Met ADMIN1-010.04-E1-LTC Elder Abuse: Reporting, Assistance and Resources. See Heritage Lodge Handbook, page 13 (admission package). ADMIN1-010.04-LTC Interventions for Victims of Abuse or Neglect. 8.05  mandatory reporting to the Protection for Persons in Care Office (PPCO) Met See 8.02 and policy Admin 1-010.01 Met Met Several posted on each floor. Pamphlets available at reception desk. ADMIN1-010.01-E1-MBLTC - PPCO Slide Presentation; Staff receive education on PPCO at orientation and at least annually thereafter. Met Met All reports of abuse are faxed to PPCO, supported by occurrence reporting in RL6. Faxed PPCO forms and Revera Adverse Event forms are maintained in a binder in the RCM office Met 8.06 The Protection for Persons in Care Act information is posted in locations that are prominent and easily accessible by residents, families and staff. Comments There is documented evidence of: 8.07  all facility reports made to PPCO Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 29 of 78 # 8.08 Measure  facility follow up on all allegations of abuse and/or neglect Facility Rating Comments Review Team Rating Met Occurrences and adverse events are investigated and the PPCO follows up on events they feel are of concern. Met Comments Scoring methodology:  The bolded performance measure (8.06) is pass/fail performance measures. If the bolded performance measure is not met, the standard is not met. If it is met, the other measures are considered before assigning a rating to the standard.  Of the 7 other measures: o If ≥6 measures are met, the standard is met. o If 4 or 5 measures are met, the standard is partially met. o If <4 measures are met, the standard is not met. Result: All performance measures were rated as met. The standard is: Met Comments: Standard 9: Use of Restraints Reference: Personal Care Homes Standards Regulation sections 16, 17 and 18, and the Manitoba Provincial Ministerial Guidelines for the Safe Use of Restraints in Personal Care Homes. Written restraint policy The operator shall establish a written least restraint policy in accordance with guidelines approved by the minister. A statement describing the personal care home policy on restraints shall be included in the resident handbook given to the resident and/or their substitute decision-maker on or before admission to the facility. The minister maintains that all persons receiving care in personal care homes in Manitoba can expect to live in an environment with minimal use of restraint. Where care factors require limitation(s) to a resident’s liberty, this guideline mandates the inter-disciplinary process of:  assessment;  informed consent; Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 30 of 78       decision making; care planning; proper application; regular monitoring and removal; reassessments completed minimally every 3 months; and discontinuance of the restraint as soon as possible. Restraint may be used only if risk of serious harm Except in accordance with the regulation subsection 17(1) and section 18, no operator shall permit a restraint to be used to restrain a resident without the consent of the resident or his or her legal representative. If a resident’s behaviour may result in serious bodily harm to himself or herself, or to another person, the operator shall a) do an interdisciplinary assessment to determine the underlying cause of the behaviour; and b) explore positive methods of preventing the harm. If positive methods of preventing harm have been explored and determined to be ineffective by an interdisciplinary team assessment, then a physician, physician assistant, a nurse practitioner (RN-EP or RN-NP), a registered nurse (RN), a registered psychiatric nurse (RPN) or a licensed practical nurse (LPN) may order a restraint to be used, except in the case of medication (chemical restraint) which must be ordered by a physician, nurse practitioner or physician assistant. Requirements for use of physical restraints Every physical restraint must meet the following requirements: a) be the minimum physical restraint necessary to prevent serious bodily harm; b) be designed and used so as to i. not cause physical injury ii. cause the least possible discomfort iii. permit staff to release the resident quickly; and c) be examined as often as required by the restraint policy referred to in regulation section 16. Requirements for use of chemical restraints When a psychotropic medication is being used in the absence of a diagnosis of a mental illness, it is to be considered a chemical restraint. Also any medication given for the specific and sole purpose of inhibiting a behaviour or movement (e.g. pacing, wandering, restlessness, agitation, aggression or uncooperative behaviour) and is not required to treat the resident’s medical or psychiatric Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 31 of 78 symptom is considered a chemical restraint. If the medications are used specifically to restrain a resident, the minimal dose should be used and the resident assessed and closely monitored to ensure his/her safety. Documentation in resident health record If any restraint is used, the operator shall ensure that the following information is recorded in the resident’s health record: a) a description of the interdisciplinary assessment done to determine the potential for serious bodily harm to the resident or another person; b) a description of the alternatives to restraint that were tried and that were determined to be ineffective by the interdisciplinary team, signed by the person who directed the restraint to be used; c) the specific type of restraint to be used and the frequency of checks on the resident while the restraint is in place; d) each time the resident and the restraint is checked while it is in place; and e) the time and date when use of the restraint is discontinued and the reason why. Restraint review and discontinuance The operator shall ensure that the use of each and every restraint is regularly reviewed. At a minimum, reviews must occur every three months, whenever there is a significant change in the resident’s condition, and whenever the resident’s care plan is reviewed. The operator shall ensure that the use of any restraint is discontinued as soon as the reason for its use no longer exists. Expected outcome: Residents are restrained only to prevent harm to self or others. When a restraint is necessary it is correctly applied and the resident in restraint is checked on a regular basis. Performance measures # 9.01 Measure The PCH’s policy on the use of restraints is consistent with guidelines approved by the minister. Facility Rating Comments Met Revera Policy Care-10010.01complies with the the WRHA policy 110.130.050 Safe Use of Restraints and ministerial Guidelines for Safe Use of Restraints in PCH Care policy # Care 10-010-01- Review Team Rating Comments Met Two of eight resident records reviewed included restraints (one physical and one chemical). Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 32 of 78 # Measure Facility Rating Comments Review Team Rating Comments T1 MB-LTC WRHA and Care 10-010.-01-E7-MBLTC 9.02 9.03 9.04 There is documented evidence that the resident, if capable, has given written consent to the use of the restraint. Where the resident is not capable, the consent of the resident’s legal representative is documented. If written consent is not available, verbal consent must be obtained from the resident or their legal representative. Verbal consent must be documented, dated and signed by two staff members, one of which must be a nurse. There is documented evidence that a comprehensive assessment of the resident is completed by an interdisciplinary Met When a restraint is initiated as a last resort, written or verbal consent is obtained from the Resident/ family member/advocate (as applicable per the Resident's capability). The consent form becomes part of the Resident's permanent Health Record. Acquisition of informed consent is also documented on the Basic Restraint Documentation Tool. Met Met Same as above. Verbal consent is documented on the Consent form and the Nurse and witness signed the consent form Met Met The High Risk TeamTeam comprised of members of the interdisciplinary team reviews the application/ Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 33 of 78 # Measure team, prior to application (or reapplication) of any restraint. Facility Rating Comments Review Team Rating Comments reapplication of restraints. Team involvement in the review process is documented on the Basic Restraint Documentation Tool. Reviewed and reassessed quarterly. Restraint use and documentation is audited quarterly to ensure compliance and correct any issues The assessment includes documentation of each of the following: The description of  description of the resident’s behavior and environment behaviour and the environment in 9.05 Met in which it occurs is which it occurs (including time of recorded in Restraint day) Documentation Tool The Resident's physical, emotional, psychological, 9.06  the resident’s physical status Met nutritional state is recorded in the Restraint Documentation Tool 9.07  the resident’s emotional status Met See 9.06 9.08  the resident’s mental status Met See 9.06 9.09  the resident’s nutritional status Met See 9.06 The alternatives tried and exhausted are recorded in  all alternatives tried and 9.10 Met the Restraint exhausted Documentation Tool. Met Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 34 of 78 # Measure Facility Rating Comments Review of current medications are recorded 9.11  review of current medications Met in the Restraint Documentation Tool. The benefits and burdens of restraint use to the  actual and potential benefits to 9.12 Met Resident are recorded in the resident if the restraint is the Restraint applied Documentation Tool The benefits and burdens of restraint use to the  actual and potential burdens to 9.13 Met Resident are recorded in the resident if the restraint is the Restraint applied Documentation Tool. Ethical considerations are  any other additional ethical 9.14 Met recorded in the Restraint considerations Documentation Tool There is a written order for the restraint in the resident’s health record that indicates: Revera and WRHA policy specifies that the type of 9.15  the kind of restraint to be used Met restraint in use must be indicated in the order. Revera and WRHA policy specifies the frequency of  the frequency of checks on the checks that must be 9.16 Met resident while the restraint is in included in the written use order, which can be written by a physocian or nurse. As per policy, a written  the signature of the person giving 9.17 Met order is required for the order (where a chemical restraint use (in the case restraint is used it must be Review Team Rating Comments Met Met Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 35 of 78 # Measure Facility Rating Comments Review Team Rating Comments ordered by a doctor, nurse practitioner or physician assistant) of a chemical restraint, the order must be written by a physician). As per policy, a written Reminder to include order is required for professional designation in restraint use (in the case the order section of the  the professional designation of 9.18 Met Met of a chemical restraint, the basic restraint assessment, the person giving the order order must be written by a even if it is referenced on a physician). physician's order. As per policy, the physician's written  for a chemical restraint, the time medication order is time 9.19 Met Met limit for its use (the limitedfor review at discontinuation date) quarterly medication reviews. There is evidence of a care plan for every restraint in use, that outlines the resident’s unique and specific needs, including: Number of application; Individual Resident needs related to the use of restraints is included in the following components of the care plan: a.In MDS Physical  the type of restraint and method 9.20 Met Met Restraints will be triggered of application and also addressed under 6.5 Safety in WRHA Base Care Plan. b.The ADL sheet indicates the type of restraint in use and Resident specific Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 36 of 78 # Measure Facility Rating Comments Review Team Rating Comments needs related to restraint use (additional needs). c.The Safety Checks completed by the HCA and checked by the nurse each shift indicates the type of restraint(s) in use and the Resident's needs that are assessed/attended to with the monitoring checks. d.The care plan is regularly reviewed through the MDS Quarterly Assessment process, which includes a reevaluation of the alternatives to restraint use as documented in the Restraint Documentation Tool and the IPN. e.Resident Care Team meets quarterly to review and evaluate continuation of restraints and all new restraints. f. Interim Restraints from time of admission are reviewed after 8 weeks. 9.21  the length of time the restraint is to be used for each application Met See 9.20 Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 37 of 78 # Measure Facility Rating Comments  the frequency of the checks on Met See 9.20 the resident while the restraint is in use  when regular removal of 9.23 Met See 9.20 restraints is to occur There is documented evidence that the continued use of any restraint is 9.24 Met See 9.20 reviewed at least once every three months. There is documented evidence within the health record of efforts to 9.25 Met See 9.20 resolve the issue for which the restraint was initiated. Where a restraint is used in an emergency situation there is documented evidence of: Revera and WRHA Restraint Policy describes the procedure for emergency restraint application. The policy indicates that the following information must be  the events leading up to the use 9.26 Met included in the IPN of the restraint documentation for emergency restraint use: a) a full description of the reason for the restraint and the events leading up to the need for a restraint. b) the name and  the name of the person ordering 9.27 Met designation of the person the restraint 9.22 Review Team Rating Comments Met Met Met Met Met One resident record reviewed, included two emergency restraints. Both were completed as required. Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 38 of 78 # Measure Facility Rating Comments Review Team Rating Comments ordering the restraint. 9.28  the designation of the person ordering the restraint Met 9.29  the time the restraint was applied Met 9.30  the frequency of checks Met 9.31  notification of the resident’s legal representative or next of kin Met 9.32  care provided to and response of the resident in restraint Met 9.33  when the resident’s reassessment is to occur Met The name and designation of the person ordering the restraint. c) the time the restraint was applied and the frequency of monitoring checks to be done. The time the restraint was applied and the frequency of monitoring checks to be done. d) notification of the Resident's family/substitute decision maker e) the care provided during the course of the use of the restraint. f) when the reassessment of restraint use is to occur. Met Met Met Met Met Met As part of the facility’s continuous quality improvement/risk management activities, there is evidence that audits of the use of restraints: Audits are being 9.34  occur at least annually Met completed, reviewed and Met analyzed Quarterly 9.35  are reviewed and analyzed Met See 9.34 Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 39 of 78 # Measure Facility Rating Comments Review Team Rating Comments  demonstrate that recommendations for 9.36 Met See 9.34 Met improvement were made, if required, based on the analysis  demonstrate that 9.37 Met See 9.34 Met recommendations were implemented and followed up Scoring methodology:  Bolded measures (9.01, 9.04) are pass/fail performance measures. If any one of the bolded performance measures is not met, the standard is not met. If the bolded performance measures are all met, the other performance measures are considered before assigning a rating to the standard.  Of the 35 other measures: o If ≥28 measures are met, the standard is met. o If ≥21 and <28 measures are met, the standard is partially met. o If <21 measures are met, the standard is not met. Result: All measures were rated as met. The standard is: Met Reviewers noted that significant efforts were made to regularly assess and limit the use of chemical Comments: restraints wherever possible. Standard 11: Nursing Services Reference: Personal Care Homes Standards Regulation sections 21, 22 and 23; Nursing Services Guideline, the Manitoba Health Policy HCS 205.3 and the Nursing Services Guideline Plan/Template. Nursing services for residents The operator shall ensure that nursing services are organized and available to meet residents’ nursing care needs, in accordance with guidelines approved by the Minister and consistent with professional standards of practice. Nurse in charge of care Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 40 of 78 The operator shall designate a registered nurse or a registered psychiatric nurse to be in charge of administering nursing services in the personal care home. If a personal care home has 60 beds or more, the operator may require the nurse designated under regulation subsection 22(1) of the Personal Care Homes Standards Regulation to also be in charge of administering other services at the personal care home. But the operator shall not require that nurse to supervise nursing care in the home or, except in an emergency, provide clinical services to residents. If a personal care home has fewer than 60 beds, the operator may assign additional responsibilities to the nurse designated under regulation subsection 22 (3). General nursing requirements The operator shall establish written nursing policies and procedures relating to the care needs of the residents. The operator shall ensure that space, equipment and supplies are available to facilitate the professional, educational and administrative activities of the home’s nursing services. Expected outcome: Residents receive nursing care that meets their needs and in a manner that enhances their quality of life. Performance measures # Measure Facility Rating There is an organization chart for the nursing department that clearly 11.01 delineates the lines of Met responsibility, authority and communication. Policies and procedures for the nursing department are: 11.02  reviewed minimally every three years Met Comments Review Team Rating The organizational chart and the lines of communication chart are posted at each Nursing Station Met There is an integrated Long Term Care Service Manual available on MYREVERA. Specific nursing procedures are Met Comments Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 41 of 78 # Measure Facility Rating 11.03  readily available to nursing staff Met There is space, equipment and supplies available to the nursing 11.04 department for professional development, education and administrative activities. Met A registered nurse or registered 11.05 psychiatric nurse is in charge of nursing services for the facility. Met Comments located in the Perry and Potter textbook. See 11.02 There is a Nursing Station on each unit, which provides space for nursing personnel to carry out administrative activities. Pertinent resource materials and manuals are available and maintained electronically at each Nursing Station. Pharmacy materials are posted in the medication rooms. J.W. Crane Memorial Library is accessed as needed. Articles pertinent to the nursing department are circulated to the individual floors for posting. The Director of Care Lowell Friesen is a RN who is the individual designated to be in charge of administering nursing services within the Home. The Director of Care must be a RN or RPN who is in good standing with current Review Team Rating Comments Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 42 of 78 # Measure Facility Rating Comments Review Team Rating Comments licensure with the applicable registering body. The Director of Care manages all aspects of care/service delivery within the Home in order to If the home has 60 or more beds, ensure that quality 11.06 the nurse in charge of the facility Met Met care/service is delivered, does not provide direct care. but is not responsible to provide clinical services except in the event of an emergency. There are Resident Care Managers (RCM) who are A registered nurse or registered RN's/BN's that are on site psychiatric nurse is on-site at the at the home to supervise 11.07 home to supervise the nursing care Met nursing care. In the event Met 24 hours per day, seven days per that a RN is unable to fill, a week. LPN is appointed to be the Nurse in charge. A RN is on call if needed. If a registered nurse or registered psychiatric nurse cannot be secured to supervise nursing care, as an interim measure only: See policy ADMIN2-O10.04 LTC Professional Practice  a licensed practical nurse is on 11.08 Met Met Standards. site at the PCH The DOC or RCM is on call Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 43 of 78 # Measure Facility Rating Comments Review Team Rating Comments  a registered nurse or registered Met See 11.08 Met psychiatric nurse is accessible (on call) There is documented evidence that records are kept of any/all period(s) of time when the facility 11.10 is unable to secure a registered Met See 11.08 Met psychiatric nurse or registered nurse to supervise nursing care on site. There is an advance plan to ensure safe and effective care of residents during any periods where the facility is unable to secure a registered nurse or registered psychiatric nurse to supervise nursing care. The plan includes: The Home tries to ensure that there is a RN on site to supervise nursing care to the residents. The DOC  evidence of ongoing efforts to or RCM is on call when recruit registered psychiatric 11.11 Met there is a shift that there is Met nurse(s)/registered nurse(s) to fill no RN scheduled or due to such vacant positions as may a sick call, vacation, exist unexpected event and all possible avenues have been explored. Same as above. The  description of the role of the facility has an in charge accessible registered nurse or 11.12 Met role in the event that an Met registered psychiatric nurse on RN is not available. call ADMIN 2-010.04  description of the role of the 11.13 Met See 11.12 Met licensed practical nurse on-site 11.09 Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 44 of 78 # Measure Facility Rating Comments Review Team Rating Comments  evidence of on-site preparation of Met See 11.12 Met the licensed practical nurse(s) to undertake this role  criteria to support the licensed 11.15 Met See 11.12 Met practical nurse in decisionmaking for resident care There is documented evidence that records are kept of compliance with The facility's master the minimum required hours of care schedule outlines the 11.16 Met Met per resident per day (HPRD), staffing mix. Compliance is according to the PCH Staffing reviewed quarterly. Guidelines. Scoring methodology:  The bolded performance measures (11.05, 11.10) are pass/fail performance measures. If either of the bolded performance measures are not met, the standard is not met. If the bolded performance measures are met, the other performance measures are considered before assigning a rating to the standard.  If the facility has over 60 beds:  of the remaining 14 measures. o if ≥11 measures are met, the standard is met. o if ≥8 and <11 measures are met, the standard is partially met. o if <8 measures are met, the standard is not met.  If the facility has under 60 beds:  of the remaining 13 measures: o if ≥10 measures are met, the standard is met. o if ≥8 and <10 measures are met, the standard is partially met. o if <8 measures are met, the standard is not met. Result: All measures were rated as met. The standard is: Met Comments: 11.14 Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 45 of 78 Standard 12: Pharmacy Services Reference: Personal Care Homes Standards Regulation sections 24, 25 and 26 Pharmacy services and medications In regulation subsections 24 (1) (a) and (b) states that a pharmacist includes a corporation or other legal entity that: a) contracts with an operator to direct and be accountable for pharmacy services in a personal care home; and b) designates one or more individual pharmacists to provide pharmacy services for the personal care home. The operator shall: a) appoint or contract with a pharmacist to direct and be accountable for pharmacy services for the personal care home; b) ensure that the pharmacist maintains a medication profile of each resident; c) ensure that the pharmacist and other relevant members of the interdisciplinary team review the medications and treatments ordered by a physician for each resident at least every three months; d) ensure that the pharmacy services for the personal care home are consistent with residents' needs and the scope and complexity of the care offered at the home; e) ensure that emergency and after-hours pharmacy services are available for residents; f) ensure that accurate and comprehensive drug information is available to medical, nursing and other staff of the personal care home as required; g) establish written policies and procedures for pharmacy services for the personal care home that provide for the following: i) transmitting medication orders to the pharmacy, ii) handling medication from the point it is procured until it is administered, including delivery, automatic stop orders, recommended times of administration and self-administration by residents, iii) reporting, documenting, and follow-up of medication incidents, adverse reactions and refusal of medication, iv) providing medications for residents who are on planned social leave and for persons who are receiving respite care in the personal care home, v) security of all medications, including appropriate security measures for narcotic and controlled drugs and medications kept at a resident’s bedside; h) by using a current photograph, ensure that each resident’s identity is confirmed before staff administers medication; i) ensure that the overall medication use in the personal care home is monitored; and j) ensure that the need for education programs about medications, including education for nursing staff and residents, is assessed and that appropriate programs are developed. Administering medications The operator shall ensure that when staff administers medications to a resident, such medications are administered: Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 46 of 78 a) only on a physician's, physician assistant’s or nurse practitioner’s order, or the order of a pharmacist, made in accordance with The Pharmaceutical Act and its regulations, or registered nurse made in accordance with The Registered Nurses Act and its regulations; b) only by a physician, physician assistant, nurse practitioner, registered nurse, registered psychiatric nurse or licensed practical nurse, in accordance with their respective standards of practice; and c) only after the resident's identity has been confirmed using minimally two identifiers. When a physician, physician assistant, nurse practitioner or registered nurse who is not on-site at the personal care home gives a medication order by telephone, the operator shall take reasonable steps to ensure that it is confirmed in writing on the next visit to the home by the physician, physician assistant, nurse practitioner or registered nurse. The operator shall: a) take reasonable steps to ensure that all medication orders are legible and up-to-date; and b) ensure that the person who administers any medication records it immediately after in the resident's medication administration record. Limited medication supplies The operator shall ensure that: a) a monitored dosage or unit dosage system for drug distribution is adopted and implemented in the personal care home; b) the personal care home has a supply of medications for emergency use; c) there is at least one designated, locked, properly equipped medication storage and preparation area that it is clean, wellorganized and maintained; d) medications are stored in a locked medication storage and preparation area in a manner that protects them from heat, light and other environmental conditions that may adversely affect the efficacy and safety; e) medications requiring refrigeration are kept in a refrigeration unit used only for medication storage; f) the responsible pharmacist ensures regular audits are conducted of medication kept at the personal care home and that any expired, unused and discontinued medications are removed and properly disposed of; and g) the responsible pharmacist ensures regular audits of medication storage areas are conducted and takes any action necessary to ensure that medications are properly stored in accordance with this section. Expected outcome: Residents receive prescribed treatments and medications in accordance, with their needs and their treatments/medications are correctly administered and documented. Performance measures Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 47 of 78 # 12.01 12.02 12.03 12.04 Measure There is a current contract with a licensed pharmacist. The contract defines the scope of service. The contract includes provision for emergency and after hour services. The pharmacist conducts medication and treatment reviews on a quarterly basis (once every 3 months) with the interdisciplinary team (pharmacist, nurse, physician/ nurse practitioner/physician assistant and other members as needed) and this is documented in the health record. Facility Rating Review Team Rating Met A current contract for Pharmacy Services is in place. The contract defines the scope of service and provisions for emergency or after hour services. Met Met See 12.01 Met Met See 12.01 Met Met Policies and procedures for pharmacy services are available, 12.05 Met complete and reviewed minimally every three years. There are designated medication storage areas that are: 12.06  clean Comments Met The Pharmacist, Nurse, and Physician complete medication reviews on a quarterly basis. Completion of the quarterly medication review is documented in the IPN and a copy of the medication review is maintained in the Physician's Orders section of the current health record. Current Pharmacy Services Policy & Procedures are located at each Nursing Station. There is a Medication Room located on each Comments Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 48 of 78 # Measure Facility Rating 12.07  well organized Met 12.08  well equipped Met 12.09  well maintained Met 12.10  secure Met All controlled substances are 12.11 securely stored under a double lock. Met Comments unit. The Night Charge Nurse is responsible for ensuring that the Medication Room is clean weekly and monthly cleaning schedules are assigned to a nurse. There is 1 medication cart in the medication room on the 1st floor and 2 medication carts in the medication room on the 2nd floor. Home stock shelves are labeled and organized on a weekly basis. Medication supplies are evaluated on a weekly basis during reordering. See 12.08 Access to the Medication Room is limited to the RCM's, RN's and LPN's working on the specific unit. Narcotic medications are stored in a locked compartment in the Medication Cart, which is kept in the locked Review Team Rating Comments Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 49 of 78 # Measure All controlled substances are 12.12 counted and signed by two nurses at least once every seven days. Facility Rating Met Comments Medication Room when not in use. As per facility policy, narcotic medications are counted q shift and signed for by two nurses between the day, evening, and night shifts. Review Team Rating Comments Met Nursing staff have access to: Nursing staff is able to access emergency drugs in the emergency drug box that is located on the 2nd Floor Medication Room.  a supply of medications for 12.13 Met In-house medications are Met emergency use (emergency drug located on each Floor. box) Emergency Drug Box and In-House Medication Lists are posted in each medicatoin room. The 2nd floor has an in house drug box which  medications that should be allows them to administer administered without undue delay 12.14 Met medication without undue Met (in-house drug box for antibiotics, delay. These are analgesics, etc.) organized and checked on a weekly basis. Withdrawals from the emergency drug box, in-house drug box and controlled substance storage are documented, including: Policies outlines the 12.15  date Met procedure for documenting Met the withdrawals from the Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 50 of 78 # 12.16 Measure  the name and strength of the drug being withdrawn 12.17  quantity taken Facility Rating Met Met 12.18  the name of the resident being given the drug Met 12.19  the name of the nurse making the withdrawal Met There is a process in place whereby the medications ordered for a resident on admission, and for any transfer between health care 12.20 facilities, is confirmed by the physician/nurse practitioner, the pharmacist and the nursing staff at the receiving facility (i.e. medication reconciliation). The pharmacist ensures that:  audits of the medication storage 12.21 room, emergency drug box, inhouse drug box, and controlled Comments emergency drug box or inhouse medications. The policy specifies that the following must be documented when a withdrawal is made from the emergency / in-house drug supply: a) date, b) name and strength of drug, c) the number of doses withdrawn, d) the Resident being given the drug, and e) the signature of the nurse making the withdrawal. Review Team Rating Comments Met Met Met Met Met Medications are reviewed by the nurse and physician on admission and prior to transfers to a different facility. Met Met The medication storage on each unit is audited monthly. The Pharmacist Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 51 of 78 # Measure Facility Rating Comments Review Team Rating Comments substance storage are conducted and documented at three month intervals audits the following on a weekly basis: -emergency drug box contents, -in-house medication supply, and -the contents of the narcotic drawers. In addition, the pharmacist audits the Medication Rooms on a quarterly basis. A copy of the audits is forwarded to the DOC and then given to the appropriate RCM so that  the audit results are shared with 12.22 Met Met the information may be nursing staff shared with nursing personnel and deficits may be addressed. Parkview Place utilizes the Pac Med dose system A monitored dose or unit dose supplied by Geri-Aid 12.23 system is used for medication Met Services as per Pharmacy Met distribution in the facility. Standards. Pharmacy audit med rooms regularly. There are processes in place to ensure staff administering medications are trained and follow the appropriate procedures for the monitored dose system, including: a.) A Department Specific 12.24  an orientation for new staff Met Met Orientation is provided Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 52 of 78 # 12.25 Measure  periodic audits of a medication pass for each nurse Facility Rating Met The resident’s identity is confirmed prior to administration of 12.26 medications by use of minimally two identifiers. Met The medication administration 12.27 record identifies allergies and diagnoses. Met Comments which incorporates a review of the monitored dose system b.) The RCM's complete a medication pass audit on each nurse on a annual basis and followed as required. Resident's identity is confirmed by a current photo on the MAR Identification sheet and pouch porters and arm band with their name and room number. Photos are reviewed on an as needed basis in order to ensure that likeness in the picture is current. Photos are updated as required. Resident allergies and diagnoses are noted on each MAR and TAR sheet. In addition, allergies are also noted on the MAR Identification Sheet and pouch porter, and in Care Organizer under "History" Drug allergies are noted on every care plan. Review Team Rating Comments Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 53 of 78 # 12.28 Measure A pharmacist is available to provide drug information as required. Facility Rating Comments Review Team Rating Met The pharmacist provides information as requested in written form and is available if requested at the Resident Care Conference to discuss medications with Residents/ families/advocates . A written report is provided for care conferences. Phone consultation is available and pharmacy inservices are provided to staff. Met Met Our Medical advisory Committee stands as our Pharmacy & Therapeutics (RA/P&T) Committee meets quarterly and completes the functions as listed below (12.30 to 12.33). Met Met See 12.29 Met Met See 12.29 Met Comments A committee has been established: 12.29 12.30 12.31  that includes representation from pharmacy, medicine, nursing and administration  that meets at least once every three months  to review and make recommendations on drug utilization and costs Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 54 of 78 # Measure Facility Rating Comments Review Team Rating Comments  to review and follow up on See 12.29 and at nursing Met Met medication incidents and adverse council meetings reactions  to review and make recommendations on all policies 12.33 Met See 12.29 Met for the procurement and administration of medication within the home Scoring methodology:  The bolded performance measures (12.01, 12.04, 12.23, 12.28, 12.29, 12.30,) are pass/fail performance measures. If any of the bolded performance measures are not met, the standard is not met. If all the bolded performance measures are met, the other performance measures are considered before assigning an overall rating to the standard.  Of the 27 other measures: o If ≥22 measures are met, the standard is met. o If ≥16 and <22 measures are met, the standard is partially met. o If <16 measures are met, the standard is not met. Result: All measures were rated as met. The standard is: Met During medication passes observed on one unit, the nurse repeatedly addressed residents as "honeybun", "sweetie", "dear". This practice should be discouraged as it may be perceived by residents Comments: as disrespectful. Otherwise, interactions between residents and nurses was observed to be positive and appropriate. 12.32 Standard 17: Therapeutic Recreation Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 55 of 78 Reference: Personal Care Homes Standards Regulation section 31 The operator shall ensure that: a) recreational programming, for both individuals and groups, are available to meet residents' physical, emotional, cultural and social needs; b) recreational programming is available to residents who are unable to leave their rooms; c) recreational programming is available during some evenings and weekends; d) recreational areas with suitable equipment and materials to enhance residents' quality of life are available to residents; and e) information about the current recreational programs available is posted in large print in a prominent and easily accessible location in the personal care home. Subject to safety requirements and the privacy rights of other residents, the operator shall ensure that residents are assisted to participate in the recreational programs referred to in regulation subsection 31(1). Expected outcome: Residents participate in therapeutic recreational programming that enhances their quality of life. Performance measures # Measure Facility Rating Comments There is evidence in the resident’s permanent health record of: Recreation assessment is  a recreation assessment that completed within 8 weeks 17.01 Met identifies the resident’s individual of admission and filed in therapeutic recreation needs the Resident chart. Recreation staff completes  recreation staff participation in a care plan review each 17.02 Met each resident’s quarterly quarter, according to the interdisciplinary care plan review MDS schedule. Completion of a care conference assessment by  recreation staff participation in the 17.03 Met Recreation staff and/or annual interdisciplinary care documentation of their conference participation in the care Review Team Rating Comments Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 56 of 78 # Measure Facility Rating Comments conference meetings is in the health record. Individual Resident flowsheets document program attendance and  the resident’s participation in 17.04 Met participation. Completed recreation programs flowsheets from previous months are filed in the Resident health record. There is an individual recreation plan, that is part of the resident’s integrated care plan: The recreation specific portion of the Resident's  that is based on the resident’s 17.05 Met integrated care plan is assessed recreation needs section 7.3 The recreation specific portion of the Resident's  that identifies the resident’s 17.06 Met integrated care plan is specific recreation goals section 7.3 The recreation specific portion of the Resident's  that identifies the resident’s 17.07 Met integrated care plan is specific recreation interventions section 7.3 Each month’s recreation programming includes: A monthly recreation programs calendar is  a variety of planned programs to posted prominently around meet all residents’ physical, 17.08 Met the Home. A copy is also emotional, cultural and social placed in each Resident's needs (including large and small room. A variety of group activities) programs are planned. Review Team Rating Comments Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 57 of 78 # Measure Facility Rating 17.09  some evening and weekend activities Met 17.10  options for residents who cannot/do not prefer to participate in group programs Met Comments Evening and weekend programming is noted on the recreational programs calendar. Weekend programs are offered during the day One to one programs are provided for these Residents if the prefer not to participate in group activities. Review Team Rating Comments Met Met Information about recreation programs: Recreational program calendars are posted on each floor and in each  is posted in prominent, residentResident Room. Daily 17.11 Met Met accessible locations throughout program boards that are the home located on each care floor and the main floor are updated each morning. Calendars are provided in Arial 14 font or larger. Based on Resident's  is clear and easy for residents to 17.12 Met needs calendars are Met read formatted to ensure ease of use when Resident's request it. As part of the facility’s continuous quality improvement/ risk management activities, a variety of recreation audits, including program/services audits and audits related to meeting individual resident’s recreation goals (as they were determined by the resident and from their recreation assessment): Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 58 of 78 # Measure  are conducted at least every 17.13 three months 17.14 17.15  are reviewed, analyzed and reported  recommendations are made from the audit analysis, as required Facility Rating Met Met Met Comments Documentation audits are completed quarterly, program audits are completed monthly. See above. Documentation audit results are reviewed with Recreation staff at department meetings and followed up with individual staff members on an as needed basis. Program audits are completed by and reviewed with Recreation staff at department meetings See 17.03  recommendations are Met See 17.03 implemented and followed up Scoring methodology:  There are no pass/fail performance measures.  Of the 16 measures: o If ≥ 13 measures are met, the standard is met. o If ≥ 10 and < 13 measures are met, the standard is partially met. 17.16 Review Team Rating Met Comments Very good audit templates for individual program evaluation. Met The audit forms have an area for suggested ideas and improvements. Some are left blank. If there are Partially Met "none" this should be noted as such. Partially Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 59 of 78 # Measure Facility Rating Comments Review Team Rating Comments o If < 10 measures are met, the standard is not met. Result: Fourteen of 16 measures were rated as met. The standard is: Met Comments: Standard 19: Safety and Security Reference: Personal Care Homes Standards Regulation sections 33 and 34 Temperature The operator shall take reasonable steps to ensure that the temperature in residential areas of the personal care home is kept at a minimum of 22 degrees Celsius (C). Safety and Security The operator shall ensure that the environment of the personal care home is maintained so as to minimize safety and security risks to residents and to protect them from potentially hazardous substances, conditions and equipment. Without limiting the generality of the above subsection, the operator shall ensure that: a) nurse call systems are installed and maintained in proper working order within resident rooms, resident washrooms, and bathing facilities; b) open stairwells are safeguarded in a manner which prevents resident access; c) all outside doors and doors to stairwells accessible to residents are equipped with an alarm or a locking device approved by the fire authority under the Manitoba Fire Code; d) windows cannot be used to exit the personal care home; e) handrails are properly installed and maintained in all corridors, and grab bars are properly installed and maintained in all bathrooms and bathing facilities; f) all potentially dangerous substances are labelled and stored in a location that is not accessible to residents; g) all equipment is safe and it is used, stored and maintained in a manner which protects residents; h) domestic hot water temperature in resident care areas is not less than 43°C and not more than 48°C; i) the personal care home is kept clean and combustible materials are stored separately and safely; j) exits are clearly marked and kept unobstructed at all times; Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 60 of 78 k) facility grounds and exterior furniture are safe for resident use; and l) a system is in place whereby all residents who may wander are identified and all staff are informed. To ensure compliance with this section, the operator shall establish an ongoing safety and accident prevention program that includes the following: a) maintenance programs for resident safety devices, ventilation, heating, electrical equipment and all other equipment used by staff and residents; b) protocols relating to hazardous areas; and c) a policy governing electrical appliances to be used or kept by residents in their rooms. Expected outcome: Residents are provided a safe, secure, and comfortable environment, consistent with their care needs. Performance measures # 19.01 Measure The temperature in residential areas is a minimum of 22˚C. Domestic hot water, at all water sources that are accessible to 19.02 residents, is not less than 43˚C and not more than 48˚C. There is documented evidence of frequent monitoring (minimally once 19.03 per week) of domestic hot water temperatures at locations accessible to residents. There is an easily accessible call 19.04 system in all resident rooms. 19.05 There is an easily accessible call system in all resident washrooms. Facility Rating Comments Review Team Rating Met Audits are conducted daily to ensure home meets the requirements Met Met Logs are kept and audits are completed to ensure we meet the temps daily Met Met See audit binder Met Met Yes Met Met Yes Met Comments Thirty-eight of 44 temperature readings taken were within required range. Cord in one resident room on 4th floor very difficult to pull. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 61 of 78 # Measure There is a call system in all bathing 19.06 facilities that is easily accessible from all areas around the tub. All open stairwells are safeguarded 19.07 in a manner which prevents resident access. All outside doors and stairwell doors accessible to residents are equipped with an alarm or locking 19.08 device approved by the Fire Authority under the Manitoba Fire Code. All windows are equipped with a mechanism or are appropriately 19.09 designed so they cannot be used as exits. 19.10 Handrails are properly installed and maintained in all corridors. Grab bars are properly installed 19.11 and maintained in all bathrooms and bathing facilities. All potentially dangerous substances are labeled and stored 19.12 in a location not accessible to residents. Combustible materials are stored 19.13 separately and safely in a container that does not support combustion. Facility Rating Comments Review Team Rating Comments Call bells in all tub rooms need to be centred over the tub for easy access by staff. Met Yes Met Met Yes, Key pad system with code Met Met Yes. Wander guard in place to reduce the risk of elopement Met Met All windows are set to open 6'' Met Partially Met Not Met Met Met Two areas Identified that need repair to ensure the rails are secure to the wall Many missing, and need to be in place asap, An audit was conducted and we have a plan to ensure all bathrooms and a grab bar All are stored in a metal cabinet located in the basement in the maintenance shop See 19.12 Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 62 of 78 # Measure Facility Rating Comments Review Team Rating Comments Upon inspection/observation, all equipment is: 19.14  safe for use Met Met 19.15  safely stored Met Met  used in a manner that protects 19.16 Met Met residents There is documented evidence for all equipment, including building systems, that demonstrates the completion of: Hippo, Arjo inspection report, Lowe Mechanical 19.17  as needed repairs Met Not Met See comments below. Quarterly inspection reports 19.18  preventive maintenance Met Hippo, Lowe Mechanical Not Met See comments below. The facility has a current policy governing the use of personal Applicance log kept at 19.19 Met Met electric appliances kept by the reception resident. In facilities where smoking is permitted, it takes place in designated areas only, and the N/A. No smoking in the 19.20 Met Not Applicable ventilation system prevents home exposure to second hand smoke within the facility. All exits are: 19.21  clearly marked Met Yes Met 19.22  unobstructed Met Yes Met The exterior of the building is 19.23 maintained in a manner which Met Yes Met protects the residents. The grounds and exterior furniture 19.24 are maintained in a manner which Met N/A Met protects the residents. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 63 of 78 # Measure A system is in place to identify, and inform all staff of any resident who 19.25 may wander and/or is at risk for elopement. Facility Rating Comments Review Team Rating Met Yes - High risk elopement binder kept at reception and identified on the care plans. Those who are high risk are provided a wander guard braclet that will sound the alarm when they get close to the doors Met Comments Scoring methodology:  The bolded performance measure (19.02) is a pass fail measure. If the bolded measures is not met, the standard is not met. If it is met, the other performance measures are considered before assigning an overall rating to the standard.  Where smoking is permitted, of the 24 other measures: o If ≥19 measures are met, the standard is met. o If ≥14 and <19 measures are met, the standard is partially met. o If <14 measures are met, the standard is not met.  Where smoking is not permitted, of the 23 other applicable measures: o If ≥18 measures are met, the standard is met. o If ≥14 and <18 measures are met, the standard is partially met. o If <14 measures are met, the standard is not met. Twenty-three of 25 measures were rated as met (19.17 Repairs as needed and 19.18 preventative Result: maintenance not met). The standard is: Met While the standard overall was met, there are numerous locations throughout the facility in need of repair to mitigate infection control and safety risks. Examples include: - Numerous cracks, gaps and missing baseboards noted along wall/floor providing collection point for dirt. - Numerous instances of damaged drywall observed. Comments: - Two call bells found in need of repair (facility has since replaced). Routing of call bell string in one bathroom on 4th floor has been routed along walls - resulting friction on cord makes it difficult to trigger the call bell. Call bells in multiple tub rooms need to be relocated to the centre of the tub. - Numerous resident room washrooms are in need of attention - flooring, undersized toilets and strong odour of urine. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 64 of 78 # Review Team Comments Rating - Some furniture and bedside tables found to have missing pieces of laminate and/or worn surfaces. - Tops of radiators in some rooms are being used as a shelf to hold personal items, cable cords and plush stuffed animals, - Review of exterminator invoices suggest cockroach issue existed prior to Jan. 2018. Critical recommendations were made by the company to plug and repair wall holes and replace missing baseboards to prevent insect access to the kitchen. Monthly work summaries received from the same company indicate repairs are still outstanding. - Greater attention to high level cleaning is required. Significant dust found on shelves, toilet room light fixtures and vents. Multiple high surfaces in kitchen including top of range hood over cook stoves found to have very heavy grease laden dust. -Basement floor (sections sinking) needs to be jack hammered and build up. Asbestos determined to be in wall. Remediation and work is currently underway to address this. Measure Facility Rating Comments Facility related concerns are further detailed in an addendum to this report. Standard 20: Disaster Management Program Reference: Personal Care Home Standards Regulation section 35 and Manitoba Fire Code, section 2.8.3 The operator shall establish a disaster management program that at a minimum consists of a) processes and procedures for the facility, its residents, and staff to identify, manage and prepare for risks and vulnerabilities from hazards; and b) a disaster response plan to ensure staff are able to protect and care for the residents during an emergency. The disaster response plan must be developed in consultation with appropriate authorities and community agencies, and must a) provide direction and outline the procedures to be followed in response to internal and external threats to the personal care home, including but not limited to, i) severe weather, floods and other natural events, ii) failure of the heating, water or electrical supply, and other equipment or technological problems, and iii) bomb threats or other threats of violence or harm arising from the actions of persons; b) outline specific operational roles, responsibilities and lines of authority for personal care home staff; Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 65 of 78 c) d) e) f) outline procedures to be followed in evacuating and relocating residents to a safe temporary or long-term location; outline procedures to be followed in searching for a missing resident; include procedures to alert staff and residents of disasters; include procedures to locate, acquire, distribute and account for services, personnel, resources, materials and facilities required during a disaster response; g) outline procedures for returning evacuated residents to the personal care home or for placing them in safe temporary or long term accommodations; and h) identify a program for the restoration of services, programs and infrastructure at the facility following a disaster. The disaster management program established under regulation subsection 35(1) of the Personal Care Homes Standards Regulation must: a) document the objectives, requirements and schedule to ensure appropriate training is provided to staff; b) ensure training for all staff on methods to lift and transfer residents to safety; c) ensure instruction on staff roles and responsibilities under the personal care home’s disaster response plan; d) ensure records are maintained that document the training conducted; and e) include a process to exercise, test and evaluate all components of the disaster management program, at specified periodic intervals, and to implement improvements as required. Expected outcome: Residents are provided with a safe environment. Threats/risks that threaten the safety of the environment are proactively identified, hazards minimized and steps taken to respond when disasters occur. Performance measures # Measure Facility Rating Comments Review Team Rating Comments The home has documented The Home completes the evidence of having identified 20.01 Met WRHA Hazard and Met potential risks and vulnerabilities Vulnerability Assessment. from hazards. The home has taken steps to manage and prepare for the identified risks and vulnerabilities by developing disaster response plans, specific to the PCH, that provides direction and outlines the procedures to be followed in response to: 20.02  severe weather Met Refer to policy EPM-J-100 Met 20.03  floods (internal and external) Met Refer to policy EPM-J-20 Met 20.04  failure of heating Met Refer to policy EPM-J-90 Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 66 of 78 # Measure Facility Rating Comments Review Team Rating Met 20.05  failure of water  failure of electrical supply, 20.06 including generator, if applicable Met Refer to policy EPM-J-60 Met Refere to policy, EPM-J-80 Met 20.07  bomb threats Met Refer to policy EPM-I-10, EPM-I-05, EPM-I-40, EPMI-50. Met Met Refer to policy EPM-J-50 Met Met Refer to policy EPM-E-10 Met Met Refer to policy EPM-G-1520 Met Met Refer to policy EPM-G-1555, and EPM-G-15-50 Met Met Refer to policy EPM-F-10 Met Met Refer to policy EPM-G-1510 Met Met Refer to policy EPM-G-1550 Met Met Refer to policy EPM-G-1575 Met Met Refer to EPM-G policies Met  technological failures, such as data loss and computer failures 20.09  other threats of violence or harm The disaster management plan includes:  procedures for evacuating and 20.10 relocating to a temporary or long term location  operational roles, responsibilities 20.11 and lines of authority  procedures to be followed in 20.12 searching for a missing resident  procedures for alerting staff and 20.13 residents of disasters  procedures to locate, acquire, distribute, and account for 20.14 personnel, resources, equipment and supplies and facilities  procedures for returning evacuated residents to the home, 20.15 or moving them to short/long term accommodations  a program for the restoration of 20.16 infrastructure, services, and programs following a disaster 20.08 Comments Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 67 of 78 # Measure Facility Rating Comments Training is provided for all staff on All staff are trained on safe methods to lift and transfer lifting and transfers in an 20.17 residents to safety in an Met emergency and every three emergency, at least every three years. years. A record of attendance at all 20.18 disaster management training is Met See attendance record maintained. There is documented evidence of exercising, testing and evaluation of all components of the disaster See debriefing binder with 20.19 Met management program, over a reports period of three years, based on the level of risk. There is documented evidence of implementing improvements as See debriefing binder with 20.20 Met identified in the review/evaluation of reports exercises/tests. There is documented evidence that 20.21 fire drills are conducted at least Met See Fire Drill Report binder. once a month. Staff participation in fire drills is 20.22 recorded and reviewed annually to Met See attendance record ensure staff competency. Scoring methodology:  There are no pass/fail performance measures.  Of the 22 measures: o If ≥18 measures are met, the standard is met. o If ≥13 and <18 measures are met, the standard is partially met. o If <13 measures are met, the standard is not met. Result: All measures were rated as met. Review Team Rating Comments Met Met Met Reminder that a debrief after actual incidents does not take the place of education activities, mock exercises and drills. Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 68 of 78 # Measure The standard is: Comments: Facility Rating Comments Review Team Rating Comments Met Standard 24: Staff Education Reference: Personal Care Homes Standards Regulation section 39 The operator shall provide an organized orientation and in-service education program for all staff of the personal care home. The operator shall ensure that each new employee signs an acknowledgement of the information received in the orientation. The operator shall ensure that the orientation and in-service education programs are evaluated at least annually and revised as necessary to ensure that they are current and meet the learning needs of the staff. The operator shall make available health related resources, including books, journals and audio-visual materials, to staff and volunteers at the personal care home. Expected outcome: The appropriate knowledge, skills and abilities for each position in the personal care home have been identified, documented and training is available to staff to enable them to perform their roles effectively. Performance measures # Measure There is documented evidence 24.01 that all new staff participate in an orientation program. Facility Rating Comments Review Team Rating Met The Employee Orientation Record is completed for each individual to document the completion of the general orientation. The new employee and mentor complete a Met Comments Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 69 of 78 # Measure Facility Rating Comments Review Team Rating Comments Department Specific Orientation Record in order to document completion of the job specific portion of the orientation Orientation includes: 24.02  a general orientation 24.03  a job specific orientation Met Met See 24.01 See 24.01 The Employee Orientation Record and Department Specific Orientation Each staff signs an Record include the staff acknowledgement of the signature in 24.04 Met information received at general and acknowledgement of the job specific orientation. information provided. The completed records are retained in the personnel file. The orientation program includes, at a minimum, the following components: The Resident Bill of Rights is a component of the 24.05  residents’ bill of rights Met General Orientation and is discussed at the general orientation session The Mission, Vision and Values Statements are 24.06  mission statement Met included in the General Orientation and are discussed at the session. Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 70 of 78 # Measure Facility Rating 24.07  organization chart Met 24.08  disaster management including the fire plan Met 24.09  Workplace Hazardous Materials Information System (WHMIS) Met 24.10  infection control Met 24.11  proper use of all equipment specific to job function Met 24.12  personnel policies Met Comments Reviewed in General Home specific Orientation. The Emergency Response system (i.e. codes) is reviewed at the home specific orientation. Each employee is given a copy of the WHMIS selflearning module, which is reviewed with the orientation group. Each employee is required to complete a quiz as part of the general orientation session Infection Control (i.e. Routine Practices) is discussed during general orientation. Infection Control practices are also reviewed during the home specific orientation. Proper use of all relevant equipment is demonstrated to new employees during the job specific portion of the orientation process Personnel policies reviewed at general Review Team Rating Comments Met Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 71 of 78 # Measure Facility Rating 24.13  The Personal Health Information Act Met 24.14  The Protection for Persons in Care Act Met 24.15  the facility policy on freedom from abuse Met 24.16  signing an oath of confidentiality Met 24.17  job description Met Comments orientation include: Attendance Management, Dress Code, and the Standards of Employee Conduct. A copy of the Resident Non Abuse (Protection for Persons in Care Act) are discussed with new employees at General Orientation. A copy of the Resident Non Abuse (Protection for Persons in Care Act) are discussed with new employees at General Orientation. Freedom From Abuse policies and the STOP program are part of the General Orientation As per facility policy all new employees are required to sign a Pledge of Confidentiality at the time of orientation. A copy of the job description is forwarded to the employee with the acceptance letter/package. Review Team Rating Comments Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 72 of 78 # Measure Facility Rating Comments The job descriptions include a list of 24.18  expected skills and routines Met responsibilities for the particular position. Lowell DOC, and Rose Resident Care Manager is There is an organized staff on site in order to organize 24.19 Met education program for all staff. and direct the annual facility educational program. The staff education program annually includes at least the following: Fire prevention/safety and the fire plan in-service  fire drill participation or fire sessions are included in prevention education for every 24.20 Met the annual educational staff member, including program in addition to permanent, term and casual monitoring of participation employees in fire drills. An annual review of Freedom From Abuse policies and the STOP  review of the freedom from abuse 24.21 Met program are part of the policy annual educational program. The Resident Bill of Rights is reviewed and included  review of the residents’ bill of 24.22 Met in the overall educational rights plan. The Resident Bill of Rights  review of the use of restraints 24.23 Met is reviewed and included policy Review Team Rating Comments Met Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 73 of 78 # 24.24 24.25 24.26 Measure  Workplace Hazardous Materials Information Sheets (WHMIS)  education about Alzheimer’s disease and related dementias, and other geriatric care information  education opportunities that match the special considerations/needs of the facility’s current resident population Facility Rating Met Met Met Comments in the overall educational plan. WHMIS is reviewed every three years with staff through in-servicing. A variety of topics related to geriatric care are included in the annual educational plan A variety of topics related to geriatric care are included in the annual educational plan. The manufacturer/supplier or trained facility staff Education on the proper use of provides education related new, job-specific equipment is 24.27 Met to equipment specific to provided whenever new equipment job function prior to the is acquired. introduction of new equipment. The staff education program also includes the following, minimally once every 3 years: Offered to nursing staff 24.28  oral health care Met every 3 years or as necessary. A review of lift and transfer  proper resident transferring 24.29 Met techniques is a component techniques of the educational plan.  education opportunities to ensure Spiritual and religious 24.30 Met staff have a basic understanding training provided to staff. of the value of spiritual and Review Team Rating Comments Met Met Met Met Met Met Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 74 of 78 # Measure Facility Rating Comments Review Team Rating Comments religious care as an integral part of holistic care A Master Attendance Record is maintained for all in-service sessions. In An attendance record is maintained addition, individual 24.31 for every in-service education Met employee attendance is Met program provided. recorded on a Individual Employee Attendance Record that becomes part of the personnel file. Changes to facility policy are distributed to There is a process to ensure that all appropriate departments 24.32 staff are made aware of all new or Met Met for review. New Policies revised policies. are brought forth at Department meetings. As part of the facility’s continuous quality improvement/ risk management activities, there is evidence of an education services audit process which includes: In-service evaluations are provided at educational sessions in order to evaluate the effectiveness of the program. Results of  annual evaluation of all education 24.33 Met evaluations are compiled Met programs in order to identify components of the plan/presentation that are effective or that require adjustment. Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 75 of 78 # Measure Facility Rating Comments Review Team Rating Comments  review and analysis of the Met See 24.33 Met program evaluations  recommendations for 24.35 Met See 24.33 Met improvement resulting from the analysis, as required  implementation and follow-up of 24.36 Met See 24.33 Met those recommendations Scoring methodology:  The bolded performance measures (24.01, 24.14, 24.20) are pass/fail performance measures. If any one of the bolded performance measure is not met, the standard is not met. If all the bolded performance measures are met, the other performance measures are considered before assigning a rating to the standard.  Of the 33 other measures: o If ≥26 measures are met, the standard is met. o If ≥20 and <26 measures are met, the standard is partially met. o If < 20 measures are met, the standard is not met. Result: All measures were rated as met. The standard is: Met A very comprehensive education program is in place. Related audit processes are well-established and Comments: consistenty completed. 24.34 Standard 26: Reports about Critical Incidents and Critical Occurrences Reference: Personal Care Homes Standards Regulation section 42; The Regional Health Authorities Act Part 4.1; Patient Safety section 53.2(1); The Regional Health Authorities Amendment Act and The Manitoba Evidence Act. The operator shall provide to the department, via the respective regional health authority, all reports about incidents and occurrences in or related to the personal care that have resulted in a consequence that: a) is serious and undesired, such as death, disability, injury or harm, unplanned admission to hospital or unusual extension of a hospital stay, and does not result from the individual's underlying health condition or from a risk inherent in providing the health services; or b) loss of or damage to property; or Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 76 of 78 c) other harm or risk not described in clause (a) or (b); in accordance with the policy developed based on the guidelines approved by the minister and approved by the regional health authority. Expected outcome: Critical incidents and critical occurrences are reported in accordance with the requirements set out by the minister. Reported incidents and occurrences are reviewed with the goal of preventing a recurrence wherever possible. Performance measures # Measure Facility Rating Comments Review Team Rating Comments The Home utilizes the No CI/CO in 2018 and WRHA/ RL6 Occurrence There is a record of all critical 2019 (i.e. incidents did not Report for documenting all 26.01 incidents and critical occurrences Met Met meet RL6 threshold). occurrences, critical that have taken place in the PCH. Measures are therefore occurrences, and critical based on related policies. clinical occurrences. The PCH has a policy that includes the following information about critical incidents and critical occurrences: Performance Measures #26.2 to #26.5 are included in facility policies LEGAL 3 P10 LEGAL 3P10-E2 LEGAL 3 010.01-T9-LTCMB LEGAL 3-020-01 26.02  definitions Met Met LEGAL 3-010-01T4-LTC which were adapted from the WRHA Occurrence Reporting policies Occurrences Reporting and Management (other than Critical Clinical Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 77 of 78 # Measure Facility Rating Comments Review Team Rating Comments Occurrences), Critical Clinical Occurrences Reporting & Management, and Disclosure of Critical Clinical Occurrences.  procedures for recording incidents 26.04  procedures for reporting incidents 26.05  procedures for follow up There is documented evidence of: 26.03 26.06  timely reviews following a critical incident or critical occurrence  regular evaluation of the outcomes of those reviews  development of recommendations 26.08 from the evaluation of outcomes, as required  implementation and follow-up of 26.09 those recommendations Scoring methodology: 26.07 Met See 26.02 Met Met Met See 26.02 See 26.02 Met Met Met The "Statement about the Occurrence" and the "Recommendations/Plan of Action" sections of the Occurrence Investigation form are completed for all types of occurrences. The remainder of the investigation form is completed in the event of a critical occurrence or a critical clinical occurrence. Met Met See 26.06 Met Met See 26.06 Met Met See 26.06 Met Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living Page 78 of 78 # Measure Facility Rating Comments Review Team Rating Comments   There are no pass/fail (bolded) performance measures. Of the 9 measures: o If ≥7 are met, the standard is met. o If >5 or <7 are met, the standard is partially met. o If <5 are met, the standard is not met. Result: All measures were rated as met. The standard is: Met Comments: Licensing and Compliance Branch Effective: January 1, 2015 Health, Seniors and Active Living