Long-Term Care Home System Strained but Not Broken

Co-authored by Nareh Ghalustians

The Report on the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System (the “Report”) was released on July 31, 2019, with 91 recommendations (the “Recommendations”) for improving the safety and security of residents in Ontario’s long-term care system, and for Ontarians receiving home care services. The Report was released following the Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System (the “Inquiry”). The commission to spearhead this Inquiry was established on August 1, 2017, after Elizabeth Wettlaufer pleaded guilty to and was convicted of eight counts of first-degree murder, four counts of attempted murder, and two counts of aggravated assault offences that she committed while working as a registered nurse in various long-term care homes in southwestern Ontario and as a nurse providing home care services in private homes. She has been sentenced to life imprisonment with no parole eligibility for 25 years.

This article reviews Volume 1 of the Report and identifies the mandate of the Inquiry and its key findings and summarizes the Recommendations affecting long-term care homes in Ontario. We anticipate that there will be broader implications across the entire health sector arising from these Recommendations.

Background

The Report was dedicated to the victims and their loved ones. It notes that the regulatory regime that governs the system is not broken and imposes clear standards for long-term care homes, and a rigorous inspection regime to enforce those standards that can be built upon and improved. In that vein, the Report requires the Ministry of Health and Long-Term Care (the “Ministry”)[1] to issue a report by July 31, 2020, describing the steps it has taken to implement the Recommendations coming out of the Report, and to table that report in the Ontario Legislature. In a recent news release, the Ministry stated its intention to meet this deadline.

Mandate

The Report notes that the mandate of the Inquiry was to inquire into the events that led to the offences, circumstances, and contributing factors, and to make recommendations on how to avoid similar tragedies in the long-term care system. The mandate was not to conduct a general review of the long-term care system.

Key Findings

The Report highlights three main findings:

  1. The offences would not have been discovered if Elizabeth Wettlaufer had not confessed.
  2. The offences resulted from systemic vulnerabilities.
  3. The long-term care system is strained, but not broken.

Recommendations

The Report was clear that change is required on a systemic level.

Training

The Report recommends that long-term care home licensees must provide training to administrators and directors of nursing on hiring and discipline of staff, conducting workplace investigations, and on reporting obligations to the Ministry and the College of Nurses of Ontario (the “College”). Recommendation #3 suggests that this training be provided by the Ministry, the College, and the Office of the Chief Coroner/Ontario Forensic Pathology Service.

The Report also recommended that medical directors, attending physicians, and nurse practitioners of long-term care homes receive comprehensive, ongoing training on preventing resident abuse and neglect, a requirement from which they are currently exempted, unlike other staff such as registered nurses.

The Report also adds a specific Recommendation that Medical Directors complete the Ontario Long-Term Care Clinician’s Medical Director course within two years of assuming the role of Medical Director in a long-term care home.

Furthermore, the Report recommends additional training for staff, visitors, and residents about their obligations to report to the Ministry (not just to the long-term care home) regarding suspected abuse and neglect of residents that results in a risk of harm to the resident (see s. 24(1) of the Long-Term Care Homes Act, 2007 (the “Act”)).

Summary of Other Key Recommendations

  • Handling of Medication. Recommendations were made for improving the long-term care home’s medication administration and medication incident reporting systems, and how to use the recommended redesigned institutional Patient Death Record, once it is created.

 

    • Improved medication management in long-term care homes is recommended through a three-pronged approach directed at the Ministry creating new policies, improving the annual quality inspection process, and by long-term care homes modifying and improving the security of rooms in which medications are stored and using technology to support medication management.

 

    • Recommendations are made to the Ministry to permit long-term care homes to use the additional nursing and personal care funding to purchase or upgrade integrated automated medication dispensing cabinets and install cameras and/or glass doors in medication rooms.

 

    • It is recommended that long-term care homes improve their medication incident analyses (required by the Act) and treat the use of glucagon as a medication incident. Medication incidents, under the Act, would have to be reported and reviewed at least quarterly by the long-term care home’s medication management interdisciplinary team, composed of the Medical Director, administrator, director of nursing and personal care, and the pharmacy service provider. More details regarding medication management can be found in Recommendations #74-84 of the Report.

 

    • Recommendation #19 recommends that the Ministry expand the nursing and personal care funding envelope and permit long-term care homes to use these funds to pay for a broader spectrum of staff including porters, pharmacists, and pharmacy technicians.

 

    • Recommendation #76 goes further to recommend that long-term care homes use this funding to engage a staff pharmacist and/or pharmacy technician. The Report also recommends that the licensees use this new funding for training, education, and professional development of all staff, including the backfilling of positions for staff attending training. Further, the Report recommends that licensees be permitted to use the expanded or new funds for annual membership fees in AdvantageOntario and the Ontario Long-Term Care Association.

 

  • Agency Nurses, Service Providers, and the Role of the Ministry. Specific Recommendations are made regarding long-term care homes’ use of agency nurses (Recommendations #11-13); home care service provider obligations (Recommendations #14-18); and the role of the Ministry (Recommendations #19-31).

 

  • LHINS/Ontario Health, College, Coroner, and Ministry Recommendations. Recommendations #32-39 are directed toward Local Health Integration Networks (“LHINs”) and providers and coordinators of home care services, and thereby to Ontario Health, once it takes over this role. One of the Recommendations is for the LHINs to adopt a common electronic events reporting system and to train staff and service providers on its use. Recommendations #40-49 are directed to the College and Recommendations #50-61 to the Office of the Chief Coroner/Ontario Forensic Pathology Service. Recommendations #62-63 suggest an expanded leadership role for the Ministry and improved communication with the LHINs/Ontario Health.

 

  • Health Care Serial Killer Phenomenon. Building awareness of the “healthcare serial killer” phenomenon is addressed in Recommendations #64-73 (a phenomenon used to describe murders committed by individuals working as health care professionals). The Inquiry heard evidence that 90 healthcare serial killers have been convicted in the USA, Canada, and Western Europe since 1970, but the phenomenon has been documented since the 1800s.

 

  • Number of Registered Staff. It is recommended that the Ministry conduct a study to determine the adequate levels of registered staff in the long-term care homes on each of the day, evening, and night shifts, table the study in the legislature by July 31, 2020, and increase funding accordingly (Recommendation #85).

 

  • Detecting Deaths. Suggestions for improving the detection of intentionally caused resident deaths are covered in Recommendations #86-91.

Conclusion

The Report highlights the dedication and commitment of individuals working in the long-term care system under pressure and with limited resources. The Report highlights improvements that were implemented by stakeholders during the Inquiry and prior to the release of this Report, including the formation of a working group on medication management systems in long-term care homes, and the increase in the amount of information available from the College about nurses’ employment history, and stakeholder-led initiatives that predated the Inquiry, such as a medication safety pilot project and the clinical support tools program.

The Report expresses hope that the Inquiry and the Report can rebuild Ontarians’ shattered trust in the long-term care system.

[1] The Government of Ontario recently divided this Ministry into two, appointing a separate Minister of Long-Term Care in addition to what is now called the Ministry of Health. This blog post uses the language of the Report, which references both Ministries jointly.

Sexual abuse of patients by health care providers

Physicians and other regulated health professionals have a duty to act in the best interests of their patients, an obligation that has always been viewed as being generally incompatible with any sort of sexual relationship between health care providers and patients. Under the Regulated Health Professions Act, Ontario takes a zero tolerance approach to sexual activity between patients and health care providers, and it’s no defence to argue that a sexual relationship between a patient and a provider is consensual. All sexual acts, including “behaviour and remarks of a sexual nature” come within the definition of “sexual abuse”, though the concept “of a sexual nature” excludes touching, behaviour, or remarks of a clinical nature appropriate to the service provided.

The Health Professions Procedural Code provides for mandatory revocation of a regulated health professional’s certificate of registration for certain instances of sexual abuse – if the abuse comes within a defined list of sexual acts, revocation must result. For sexual abuse that does not involve these acts, the penalty is at the discretion of the Discipline Committee. If a provider’s certificate of registration has been revoked, the provider can’t apply for re-instatement for 5 years.

The mandatory revocation provisions have been challenged in the Court of Appeal several times since they took effect in December of 1993. This month the Divisional Court affirmed the legislative scheme, and specifically the mandatory revocation sections, as being constitutional[1].  The Court affirmed that there is no constitutional right to practise a profession; that a revocation of a professional license is not a deprivation of an individual’s liberty (and therefore not contrary to section 7 of the Charter) and that the ordeal of undergoing disciplinary proceedings (and the related media storm) is not a violation of a provider’s security interests (also protected under section 7 of the Charter).

Over the years, some providers have argued in court that the zero tolerance provisions are too broad because they include spouses, and sexual relationships that pre-date the professional relationship, and certain exemptions with respect to spousal relationships have been added to the Act. A spousal exemption enacted in 2013, to permit treatment of spouses where the profession makes a regulation to that effect, gave rise to a novel  defence in a recent abuse case.

In Sliwin v CPSO, the provider argued that his multi-year extra-marital relationship, conducted clandestinely in his office, in exchange for free (and major) cosmetic surgery, was tantamount to a spousal relationship, even though they did not cohabit. The court rejected this argument, holding that the exemption is specific, unambiguous and narrowly drafted to include only spouses, as defined in the Family Law Act (which includes married and common law spouses), and only sexual relationships that occur when the provider is not engaged in the practice of the profession.

Zero tolerance for sexual abuse is now an entrenched principle, and in some ways is becoming even more strict. The Ontario government has recently proposed changes to expand the list of defined sexual acts which, once proven, will require mandatory revocation; the proposed changes will also require suspension of a professional’s privilege to practise where outright revocation is not mandatory. Debates about these changes, embodied in Bill 87, the Protecting Patients Act, began on March 27, 2017.  As of April 13, 2017, the Bill is at second reading and has been referred to the Standing Committee of the Legislative Assembly of Ontario.

While the Bill expands the grounds for mandatory revocation, and increases fines for failures to report instances of sexual abuse of patients, the proposed amendments would introduce temporal parameters around the meaning of “patient”. In Bill 87, a patient remains a patient for one year after the end of the patient-provider relationship. Additional criteria for defining “patient” may be set out in a government regulation. This introduces some flexibility into the zero tolerance approach and reflects some of the arguments previously advanced by unsuccessful litigant health care professionals.

To see Bill 87, click here http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=4477&detailPage=bills_detail_the_bill

To see the decision of the Divisional Court in Sliwin v. CPSO (2017), click here. http://www.canlii.org/en/on/onscdc/doc/2017/2017onsc1947/2017onsc1947.html?searchUrlHash=AAAAAQAGc2xpd2luAAAAAAE&resultIndex=7

To see a list of the 26 professions regulated under the RHPA, click here https://www.ontario.ca/laws/statute/91r18#BK52   and then click on Schedule 1.

Simmie Palter is senior health law counsel at Dykeman & O’Brien LLP. Professional regulation is one of Simmie’s main areas of interests, but she provides advice in many other aspects of health law. The views expressed herein do not constitute legal advice. For more information email spalter@ddohealthlaw.com.

[1] Sliwin v. College of Physicians and Surgeons of Ontario 2017 ONSC 1947 (CanLII, Div Ct).

What Colleges, members, advocacy associations and health care institutions need to know about Bill 87

Bill 87, the Protecting Patients Act, 2016, was introduced by Ontario’s Minister of Health and Long-Term Care on December 8th.  Proposed amendments to the Regulated Health Professions Act will give the Minister more control over the composition of colleges’ statutory committees, increase the colleges’ power to suspend members as an interim measure, implement changes regarding sexual abuse that aim to protect the public, and increase reporting obligations of members. Fines for a facility’s failure to report sexual abuse are also increased.

Regulators should be vigilant to ensure that their needs are communicated to the government and request consultation prior to the government making regulations that will affect selection of panel members and quorum for the Registration, Discipline, Fitness to Practice and Inquiry, Complaints and Reports committees, among other matters. Members of regulated health profession colleges, as well as advocacy associations, should be concerned about increased reporting obligations for members and collection of members’ personal information and personal health information to aid the Minister in deciding whether or not a college is fulfilling its duties under the Act.  Health care institutions should be aware of the increased monetary fines for failures to report sexual abuse.

A detailed exploration of the Bill’s impact on the Regulated Health Professions Act follows.

Bill 87’s impact on the Regulated Health Professions Act:  a detailed review

Bill 87, the Protecting Patients Act, 2016, amends a number of pieces of health care legislation.  This blog focuses on the proposed amendments to the Regulated Health Professions Act.

Under the proposed amendments to section 5, the Minister may require reports from a regulated health profession college Council that may contain personal information or personal health information of its members, to the extent necessary to allow the Minister to determine whether:

  • the college is carrying out its objects and fulfilling its duties; and
  • whether the Minister should exercise his powers under the Act or under a health profession Act, the Drug and Pharmacies Regulation Act or the Drug Interchangeability and Dispensing Fee Act

Although the Bill limits the collection of personal information and personal health information to no more than is necessary for the intended purpose, and indicates that collection of this information should not occur if other information will suffice, we have some concern about this ability of the Minister to require the production of personal information and personal health information of members where the Minister reviews the Council’s activities and requires the provision of reports and information.  The Minister’s review of a Council’s activities ,and decision about whether to take action, should not hinge on personal information or personal health information of members. Why would de-identified information or information in aggregate form only not suffice?

Under the proposed amendments, the Minister may request that a college collect personal information directly from its members not only for the purposes of health human resources planning but also for health human resources  research.

New regulation-making powers that are proposed will increase the oversight powers of the government by allowing it to make regulations:

  • governing the composition of committees of the Executive, Registration, Quality Assurance, Patient Relations, Discipline, Fitness to Practise and Inquiry Complaints and Reports Committees; qualifications for sitting on these committees; and reasons for disqualification from them;
  • setting out rules for the selection of panels of the Registration, Discipline, Fitness to Practice and Inquiry, Complaints and Reports Committees and quorum for these panels;
  • clarifying how a college is required to perform its inquiry, complaints, reports, discipline and incapacity functions in respect of allegations of misconduct of a sexual nature and providing for further functions and duties not inconsistent with those functions; and
  • expanding the purposes for which funding for therapy or counselling may be available from a college.

These new regulation-making powers will give the government more control over the kinds of qualifications necessary for members who sit on statutory committees. Any rules set out in these government-made regulations will prevail over rules about committee composition that are currently set out in college by-laws. The degree of input by the colleges into these regulations will depend on the amount of consultation the government undertakes, if any, and the degree to which colleges notify the government of their needs. There is no requirement for consultation with members or the colleges prior to the government making such regulations.  Colleges will want to be proactive in communicating their needs to government.

Additional proposed amendments will enhance the colleges’ power to protect the public from members about whom a complaint or report has been made by permitting an interim suspension order if the Committee is of the opinion that the member’s conduct or the member’s physical or mental state exposes, or is likely to expose, the member’s patients to harm or injury.  Any such interim suspension order, however, is not permitted to contain gender-based restrictions on the member’s certificate of registration. Registrars are also given power to withdraw a complaint or report before the Inquiry, Complaints and Reports Committees takes any action, if the complainant requests the withdrawal of the complaint or report.

The proposed changes also place more obligations on members to report:

  • their membership in another regulatory body that governs a profession inside or outside of Ontario;
  • findings of professional misconduct or incompetence from other regulatory bodies, inside or outside Ontario; and
  • if he or she has been charged with an offence and bail conditions, if any; the results of any appeal must also be reported.

The proposed changes in respect of sexual abuse aim to enhance protection of the public. These amendments:

  • prescribe offences that can trigger the application of the mandatory revocation provisions, via a government-made regulation (not a college regulation);
  • expand the list of grounds for mandatory revocation of a member’s certificate of registration;
  • require suspension where the professional misconduct involving sexual abuse does not fit within the expanded list of acts triggering mandatory revocation;
  • increase the amount of information available from the public register;
  • define “patient” to include an individual who was a member’s patient within the last year or within such longer period of time as may be set out in a government-made regulation;
  • define “patient” by criteria (other than time) set out in a government-made regulation;
  • increase monetary penalties for a facility’s failure to report suspected sexual abuse of a patient by a member, from $25,000 for individuals to not more than $50,000 (upon conviction) and from $50,000 for corporations to $200,000; and
  • allow patients who make complaints or reports involving sexual abuse allegations to access funding for patient therapy and counselling immediately, instead of waiting until after a finding of professional misconduct is made.

Advocacy associations, health care facilities and regulators are encouraged to voice any concerns they may have about this bill to the government without delay. For more information or assistance please contact spalter@ddohealthlaw.com.

Emergency Preparedness Program for Health Care Organizations

At DDO Health Law, we understand your organization’s need to put in place a robust emergency management plan (including for some organizations, by September 30, 2015). We have developed a 12-step program to help you meet that deadline and then continue to prepare your organization in case of emergency such as fire, flood, or pandemic.  Our program reflects current best practices, including materials provided by at least one local health integration network to its health services providers. We have read all of these materials and pulled from them and other resources to determine current best practices — so that you do not need to.

DDO Health Law’s Emergency Preparedness Program offers your organization the comfort and assurance of:

  • Understanding the pillars of emergency management, including Prevention and Mitigation, Preparedness, Response, Recovery
  • Creating organization-specific emergency management plans to establish simultaneous response to fires and other emergencies
  • Effectively participating in system level preparedness and coordinating emergency response with other health service providers
  • Properly training team members in case of emergency
  • Identifying key gaps, including hazard identification and risk analysis
  • How to best communicate with your clients, their families, the public and the media

The DDO Health Law Emergency Preparedness Program provides you with:

  •  Dial-in series. You will be invited to take part in 5 phone sessions, scheduled in September. We will provide you ahead of the calls a template plan, the 12 steps you need to take to be ready, and other templates and materials. Noon sessions are:
    • Thursday, September 3
    • Friday, September 11
    • Thursday, September 17
    • Thursday, September 24
    • Final session with open Q&A on Monday, September 28
  • Training materials. You will be provided template training materials for team members, including a training slide deck you can circulate before your Board signs off, even before you schedule an in-person session to walk your team through the training.
  • Admin on call workbook. DDO Health Law previously wrote an administrator on call workbook to help health care staff deal with various kinds of crises. It is the bedrock of emergency management. We will provide you a copy of this workbook, and a draft chapter specifically on emergency preparedness. We will also provide you a copy of the updated workbook once available, for your future reference.
  • Mutual aid/assistance agreement. This template agreement is ready to be used in the event that an emergency strikes your organization, and you need to quickly put into place legal arrangements to backfill services.
  • Briefing note for your senior leadership and Board. Written by DDO Health Law, it will state that you have signed up for and participated in the DDO Health Law program, have been provided with the materials described here, and that you have undertaken that you have “filled in the blanks” and taken the steps we’ll discuss in the dial-ins. As long you have done this, we are prepared to say that your organization is compliant and that your Board should feel assured that it can sign the M-SAA by September 30, 2015 as requested by at least one LHIN. For others who do not need a September 30 signoff, the materials and briefing note still serves as a baseline for your Board and shows a measure of your due diligence.
  • Board resolution. Template Board resolutions will be provided, both for those organizations that must meet the September 30 deadline, and a more generic one for those that do not.
  • Feel free to include whomever you wish on the dial-in. The flat fee covers any team members you want to have at your table to listen in and ask questions as you work through and finalize your plan and program.

Registration is $1,000.00 plus HST ($1,130). We accept Visa or cheques.

Fax to Franca Latino at (416) 967-7120; or call her at (416) 967.7100 ext. 242 to say you will register and how you will pay.

DDO HEALTH LAW

Mary Jane Dykeman and Kate Dewhirst are partners at DDO Health Law, a boutique health law firm in Toronto. They frequently advise on risk management issues relating to health care organizations premises, reputational risk, staff issues and other crises. Mary Jane was recently part of a fire safety emergency preparedness panel at the 2015 OANHSS annual convention. Mary Jane and Kate work extensively with community providers, large and small hospitals, community support services providers, disease associations, long-term care homes, family health teams, community health centres, retirement homes and other housing and health service providers.

Feel free to email or call Mary Jane Dykeman at (416) 967-7100 ext. 225 with any questions

Recommendations from the QCIPA Review Committee

In 2014 the Ministry of Health and Long-term Care called for the formation of a committee to look at current practices in the interpretation and implementation of the Quality of Care Information Protection Act and to make recommendations for improvement. The resulting QCIPA Review Committee, which submitted its report to the Ministry in December 2014, issued 12 recommendations. These recommendations include among other things propositions related to: (i) changes in the legislation; (ii) an increased emphasis on patient involvement in investigations; and (iii) mechanisms to better utilize the lessons learned through investigations. Michael Gleeson was recently interviewed on the topic. See:

http://www.advocatedaily.com/recommendations-for-qcipa-a-good-step-forward.html