Standards of Care in Retirement and Lodging Homes

The Policy and Finance Committee recommends the adoption of the Recommendation of the Community Services Committee embodied in the following communication (January 13, 2000) from the City Clerk:

Recommendation:

The Community Services Committee on January 13, 2000:

(i) recommended to the Policy and Finance Committee the adoption of the attached report (December 29, 1999) from the Commissioner of Community and Neighbourhood Services respecting standards of care in retirement and lodging homes; and

(ii) directed that a copy of the report be forwarded to the Board of Health for information.

The following persons gave a presentation to the Community Services Committee in connection with the foregoing matter:

- Councillor Case Ootes, Chair, Retirement and Lodging Homes Advisory Committee; and

- Ms. Julie Mathien, Community and Neighbourhood Services Department.

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(Report dated December 29, 1999, addressed to the

Community Services Committee from the

Commissioner of Community and Neighbourhood Services)

Purpose:

This report provides background information on the issue of standards of care in retirement and lodging homes. The report outlines the results to date of the short term measures the City adopted this past fall; and the information received through consultations with key informants, and background research undertaken by staff. As well, the report provides an analysis of the relationship of retirement and lodging homes to the regulated long term care system. Finally, recommendations regarding municipal and provincial roles and activities directed at improving conditions for residents of retirement and lodging homes are proposed for Council's consideration.

Financial Implications and Impact Statement:

If Council approves the report and recommendations, the Commissioner of Community and Neighbourhood Services, in consultation with the Medical Officer of Health, and the Commissioner of Urban Development Services, will report on financial implications and impacts through the year 2000 budget process.

The Chief Financial Officer and Treasurer have reviewed this report and concur with the financial impact statement.

Recommendations:

It is recommended that:

(1) the Provincial Government be strongly urged to develop mandatory Province-wide standards of resident care in retirement and lodging homes;

(2) such standards be enforced by a body at arm's length from both government and the retirement home industry, consisting of representatives from the industry and appointments to represent consumers, advocates and government;

(3) the Provincial Government assume the full costs of the development and enforcement of resident standards of care;

(4) the Provincial Government be requested to respond to the City's recommendations for mandatory, Province-wide standards of care by April 2000;

(5) notwithstanding provincial responsibility for standards of resident care, the City enhance its traditional inspection and enforcement activities in the areas of health, fire and buildings by considering the need for additional inspectors in each department for the purposes of inspecting retirement and lodging homes;

(6) the Retirement and Lodging Homes Action Team and Retirement Homes Hotline continue on an ongoing basis as effective tools for problem identification in those facilities most in need of regulatory oversight;

(7) as part of the 2000 budget process, the Commissioner of Community and Neighbourhood Services, in consultation with the Medical Officer of Health and the Commissioner of Urban Development Services, report on any additional resources required and financial impacts of implementing Council's recommendations respecting retirement homes (inclusive of Recommendations Nos. (5) and (6));

(8) the above report be sent to Policy and Finance Committee for consideration; and

(9) the appropriate City officials be authorized and directed to take the necessary action to give effect thereto.

Background:

In order to resolve concerns about the treatment of retirement home residents, Council adopted recommendations to proceed with a two-tier strategy:

(1) a Retirement and Lodging Homes Action Team to deal with immediate complaints about substandard facilities and resident conditions; and

(2) an interdepartmental work group operating with direction from the Retirement Homes Advisory Committee (RHAC) to develop options for permanent solutions to poor conditions in unregulated facilities. The RHAC was chaired by Councillor Ootes with Councillors Duguid, Filion, Flint, Jones and Johnston as members.

As directed by Council, this report provides information on "the scope of the problem, issues related to the development and monitoring of mechanisms for ensuring quality and other standards of care, and possible roles for the City, the Province and other stakeholders in this regard." Council also adopted a recommendation from the Policy and Finance Committee that the final report contain "a determination of how the housing issues faced by senior citizens fit with the retirement homes issue". This report provides some of the information necessary to make such a determination.

The immediate focus of this initiative is the elderly with expansion at a later stage to deal with the range of vulnerable people living in retirement and lodging homes.

Comments:

Progress of the Retirement and Lodging Homes Action Team:

The Action Team established the Retirement Homes Hotline in mid-October to pinpoint problem facilities and provide information on the retirement home sector. A full report on the results to mid-December is attached as Appendix A. Operating out of Toronto Public Health, health inspectors with a public health nurse as back-up, take calls from residents, family members or the public concerned about conditions in specific retirement and lodging homes. The inspectors on the telephone use a questionnaire to assist in assessing the type and seriousness of the problems in the facilities. They use the results of the questionnaire and their professional judgement to decide whether the complaint requires a follow-up inspection by either a health inspector or a team of health, fire and buildings inspectors. Total staff complement from Public Health for the first three months of operation was eight inspectors, one administrative clerk and one manager.

The availability of the hotline provides a measure of public oversight in a private, unregulated sector. Inspections carried out with an interdepartmental team encourage compliance. While no facilities have been closed, charges have been laid and inspectors are working with operators to improve conditions for residents.

Public Health has employed a number of strategies to publicize the hotline. All major media received notice of the hotline when it opened in October. During November, Corporate Communications sent a release to ethnic and community newspapers and provided information to all City Councillors for inclusion in their newsletters. Public Health developed an information sheet and referral form which was sent to just under 200 social services agencies most likely to connect with a retirement home population. Information about the hotline is posted on the City of Toronto website.

While the hotline has been successful in improving the conditions in retirement and lodging homes and has increased public confidence in City activities in this regard, there are a few weaknesses:

(1) In the absence of provincial standards of care, inspectors must fall back on existing health, fire and building legislation. These do not contain the standards of care and quality of life provisions that are of concern to the City, residents, families and the general public.

(2) Despite a strong effort at outreach, there is concern that the most vulnerable residents may not know about the hotline or be able to call.

(3) The health, fire and buildings orientation does not cover landlord-tenant issues - an area where problems with attention to residents' rights and financial abuse may occur. It is recommended that City staff collaborate over the next six months to develop strategies within the City Rental Housing Office and the Homelessness Initiatives Fund that will meet the unique needs of retirement and lodging home residents.

Results of Consultation:

The Toronto District Health Council assisted in obtaining community and industry advice for the retirement and lodging homes initiative via a consultation process that included ten key informants, six focus groups, written input and informal sources. The consultation included approximately 70 people representing all aspects of retirement and lodging homes, advocates for seniors and other vulnerable populations, academics, the legal system, the health care system, and long-term care.

The consultation identified a number of common themes:

(1) Lack of common definition for retirement homes:

There is a lack of clarity around what constitutes a retirement home. This is articulated in a variety of ways depending on whether an operator or a member of the public is speaking.

Participants not actually working in the field were unaware of the differences in mandate, funding and regulation in the retirement home and regulated long-term care sectors. In addition, some believed that seniors apartments, which often do not provide care or service, were part of the retirement home sector.

Operators and others active in the retirement home sector had other concerns about the lack of common definition. The development of a definition of a retirement home was seen as a way of differentiating between those facilities that provided housing with some care services to primarily a seniors population and those more often seen as lodging homes that provide housing and care to other vulnerable groups such as psychiatric out-patients and younger people with disabilities.

Self-regulation is cited as one of the key ways of supporting this kind of differentiation as it would allow the industry to set criteria that would be used to more fully define a retirement homes. However, recognizing that retirement homes sometimes have non-seniors residents and seniors often live in what are referred to as lodging homes, industry representatives suggested that any facility meeting industry standards and participating in the process attached to self-regulation could be termed a retirement home.

(2) Lack of standards and a need for regulation:

Virtually all participants agreed on the need for some type of regulation in the sector, although there were many suggested approaches. In addition, virtually all participants supported provincial oversight. Participants outside the sector supported government legislation, by-laws and standards. The legal services organizations and advocates supported licensing.

The retirement home industry supported self-regulation, although participants were split on the issue of what constitutes the self-regulating body. The Ontario Residential Care Association (ORCA) would like to take on that role and currently enforces a self-regulation framework that includes all of its members. However, support for the proposal that ORCA be the self-regulating body for all retirement homes is very weak among non-ORCA members. In addition, while ORCA will take any facility meeting its criteria as a member, their main focus is seniors and an industry self-regulation direction would likely exclude most of Toronto's lodging home facilities. ORCA facilities generally occupy the high end of the market.

All participants supported municipal inspection for and enforcement of fire, public health and building standards, although operators noted that frequency of inspections varied by municipality and were inconsistent in some locations.

All participants supported Toronto's Retirement Homes Hotline and the activities of the Retirement and Lodging Homes Action Team.

(3) Lack of linkages with the rest of the long-term care and health system:

Almost all consultation participants recognized that retirement homes were somewhat isolated from the rest of the long term care/health care system. Concerns were raised, on the one hand by operators, that hospital discharge planners favoured a small number of retirement homes thus depriving others of business, and on the other by advocates, that they pushed patients into whatever facility was handy simply to get them out of hospital. The consultation also heard concerns that Community Care Access Centres (CCACs) do not provide necessary home care services to retirement home residents and, conversely, that residents sometimes pay the retirement home for services that they actually receive through the CCAC. Consultation participants noted that formal links with the health care system have the potential to provide a public presence in retirement homes and facilitated moves to different levels care as resident needs changed.

The consultation generated consensus in a number of areas:

(1) Education:

(a) That a public education campaign around the rights of tenants and obligations of retirement home operators be implemented;

(b) that access to information about long-term care services be provided to the public and service providers; and

(c) that linkages be encouraged and developed between the formal health and social services system and retirement homes.

(2) Regulation:

(a) That the Province of Ontario develop regulations that address provision of care, staffing and operations of retirement homes across the Province;

(b) that the Province of Ontario develop a formal system of monitoring the regulation of retirement homes;

(c) that the City of Toronto negotiate with the Province of Ontario to determine the appropriate division of responsibilities between the Province and municipalities in the area of enforcement of regulations for retirement homes; and

(d) that the Province of Ontario consider establishing and funding an independent Ombudsman's Office with appropriate resources, staff and authorities to monitor the sector and mediate disputes.

(3) Monitoring:

(a) That the City of Toronto continue the hotline and inspection team;

(b) that the City of Toronto harmonize the retirement and lodging homes by-laws to the standard of the former City of Etobicoke;

(c) that the City of Toronto use every tool at its disposal to continue to monitor retirement homes in the areas of health, fire and buildings; and

(d) that the City of Toronto considers monitoring care provision and staffing in retirement homes.

The City consultation was followed by a joint provincial/municipal meeting on the issues regarding retirement and lodging homes. Representatives from seven municipalities (including Toronto), the Ontario Seniors' Secretariat and the Ministry of Housing met to exchange information and views. Although this meeting did not include the range of topics covered in the City consultation, there was municipal consistency on the need for provincial standards, either legislated or part of a self-regulatory framework and the importance of establishing links with the long-term care and health systems.

Relationship of Retirement Homes to Long-Term Care Continuum:

Council requested that the relationship of retirement homes to the regulated long-term care system be explored. This section identifies some of the current challenges facing the regulated system, the relationship and impact of those challenges on retirement homes, and the role that retirement homes play in the context of that continuum.

Ontario has some significant weaknesses in the current regulated long-term care system. Two issues pose particular challenges:

(1) Resources for funded home care are restricted:

The Province has established a maximum of 60 hours of home care per person per month or approximately two hours per day. However, this is a maximum, not an average and Community Care Access Centres are funded at a much lower average number of per person hours. For example, the Toronto CCAC caseload is funded at an average of 19 hours per person per month, a little over 0.5 hour per person per day. To serve some clients at the maximum, others receive less than the average numbers of hours of care. Agencies working with seniors are well aware that timely, appropriate and sufficient help at home is one of the main strategies for keeping the elderly out of facilities.

(2) There is a Province-wide waiting list of approximately 10,000 individuals for beds in the funded and regulated nursing homes and homes for the aged.

Although, in 1998, the Province tendered 6,700 of a promised 20,000 new long-term care beds, they are still under construction. The 5,790 beds in the 1999 tender are still in the development phase. A survey by Care Planning Partners estimates that these new beds will just keep pace with the growth in the number of 75-year-olds in the population. The survey points out that in 1986, Ontario had 154 long-term care beds for every 1,000 over-75-year-olds. By 1998, the ratio of beds to seniors over 75 had dropped to 54 per 1,000. The 6,700 additional beds will bring the ratio up to 106 per 1,000. Care Planning Partners estimates that, even with the completion of all 20,000 beds, the supply will still be 2,200 beds short of 1986 levels.

It is clear that a serious shortfall exists in services for the elderly and others needing assistance with housing and what are often called activities of daily living. In the past 10 years, there has been a significant rhetorical shift to the promotion of home care over facilities. Government, communities and seniors themselves recognize that facility care is neither needed nor desired in many, if not most, instances where an elderly person requires some assistance with day to day activities.

However, the under-resourcing of funded home care renders this recognition more theory than reality. In the situations where funded home care is not available at a level sufficient to allow a senior to remain in her or his home and private home care to fill the gap is unaffordable, individuals and their families turn to facilities. Increasingly, those facilities are in the unregulated sector. Care Planning Partners cites a 6.5 percent growth in demand Province-wide for each of 1997 and 1998.

Retirement Homes in Toronto:

Specific to Toronto, staff will continue to use a working estimate of 250 retirement and lodging homes City-wide. An effort to co-ordinate all existing lists resulted in what is possibly the first coherent count of retirement and lodging homes in the amalgamated City. There are 190 facilities on the co-ordinated list. The list provides information on number of facilities plus, where available, the number of beds and focus of facility (e.g., seniors). This is a minimum number. Because the sector is unregulated and most of the City is not covered by a by-law, staff anticipate that there are a number of facilities that do not appear on any of the existing lists and, therefore, are not a part of the new master list.

By contrast, there are 69 long-term care facilities (11,700 beds) in Toronto. Approximately 50 percent of Toronto's 2,550 chronic care beds are located in seven chronic care hospitals with the other half spread throughout 17 acute care hospitals.

Changing Role of Retirement Homes:

Retirement homes are, in part, a pressure valve for the regulated long-term care system, although, at present, demand in all sectors seems to exceed supply. While in the past they may have been a lifestyle choice for the well elderly and in many cases still play that role, increasingly, the frail elderly are a part of the retirement home resident population. The question has become: are retirement homes simply a housing option or have they become a combination of home and a source of essential health care for many residents?

The retirement home industry recognizes this question. The Care Planning Partners survey, supported, in part, by the owners of long-term care multi-sector businesses or chains, refers to the services provided by the sector as "retirement care or assisted living" or "housing with care". A majority - 69.8 percent of the retirement homes in the Province and 63.5 percent in Toronto -responded to the survey. Of these, a significant number stated that they provide services that go beyond what is generally considered retirement home services. For example, 14 percent of respondents have a special care wing, 79 percent provide respite care, 60 percent provide convalescent care and 32 percent provide palliative care.

Views have changed on the appropriate role and mandate of institutions. Seniors who, ten years ago, may have qualified for a bed in a nursing home or home for the aged, are now encouraged to stay in the community longer and therefore constitute potentially more frail candidates for home care or retirement homes. Retirement homes, in a significant minority of cases, are providing health care similar to that found in regulated facilities such as nursing homes.

In addition, facilities defined as a retirement home or lodging home house people with physical and developmental disabilities, mental health challenges and in some instances, multiple problems, as well as patients discharged from hospital more quickly than they would have been in the past.

In this context - a context of change where a field that may once have been perceived as providing choice in accommodation but is now, even by its own admission providing health care to at least some residents-what are the respective roles for the province and the municipalities?

Legislation and Regulation in Provinces and Municipalities:

The full account of the regulatory environment appears in Appendix B. The main findings of a scan of the regulatory environment across the country are:

(1) Generally, across Canada, no residential accommodation is completely unregulated, as municipal zoning, fire safety and public health codes apply almost universally to homes and facilities that provide accommodation and care to persons who are unrelated to the owner/operator. However, these codes vary widely across the country and what may be considered a rigorous standard by one jurisdiction may not be considered rigorous by the standard applied in another one.

(2) Ontario and Alberta have extensive nursing home regulations, but are lax in their approach to retirement homes. Ontario is the Province least involved in this area. Staff research indicates that no other jurisdiction expects municipal regulation of standards of care in retirement homes.

The following chart summarizes provincial activity regarding retirement homes in eight of ten provinces:

(3) Of the five large Ontario municipalities that have by-laws covering retirement, care or lodging homes, four, i.e., the former municipalities of Etobicoke and Toronto, Hamilton, and Windsor, have passed by-laws to regulate care homes. Peel and Chatham-Kent are considering future direction.

(4) The gaps identified by the interdepartmental workgroup in current municipal regulations involve staff qualifications, minimum number of qualified staff, protection of residents in financial matters and residents' rights.

Self-Regulation:

Although no other province has adopted this strategy, self-regulation is an alternative to government enforcement of standards of care in retirement and lodging homes at either provincial or municipal levels. The consultation indicated that stakeholders would accept a self-regulation structure consisting of a body at arm's length from the retirement home industry that enforced Province-wide standards of care. The Province would develop the standards and fund the enforcement. Municipalities would continue their current health, fire and buildings inspections.

As an example, a retirement and care home council would administer the regulatory requirements established by the provincial government, including standards for resident care, for retirement and lodging homes. In addition, it would provide consumer/resident protection.

A council would be administered by a board of directors which would include representatives from industry organizations and operators of retirement and lodging homes plus appointments to represent consumers, advocates and government.

The council's mandate would cover:

(1) mandatory registration, including processing applications, and maintaining a registrant database;

(2) compliance, including inspection, investigation and enforcement of relevant legislation or regulations, and providing applicable sanctions against members;

(3) consumer protection, including resolving consumer complaints, consumer education and awareness, and establishing mechanisms to protect the consumer; and

(4) standards, including setting the standards for obtaining and maintaining licensing and membership in RHCO, and developing and promoting professional development.

Options for Toronto:

The overall goal of this initiative is to ensure that retirement and lodging homes are operated in ways that ensure a decent standard of living for residents. The options outlined in this section are not mutually exclusive. Recommended for Council's approval are Options 1 and 3a.

Regardless of the regulatory and enforcement options selected, it is also recommended that the City continue the Retirement and Lodging Homes Action Team and the hotline on an ongoing basis and increase the number of health, fire and buildings inspectors dealing with retirement homes. These measures have been effective in improving the quality of life for retirement and lodging home residents; will strengthen the City's traditional role in this area; and will not force the City to voluntarily download an area of provincial jurisdiction.

The rationale used for deciding which options to recommend are:

(1) Effectiveness:

Both on-the-ground experience and research tell us that regulation and enforcement do work to ensure quality of care. The consultation revealed strong support for government regulation and enforcement. Industry self-regulation is not seen as being as effective. However, there is no evidence that a self-regulating body removed from the retirement home industry and enforcing provincial standards, if properly established, would be less effective than government enforcement.

It is important to state that, whatever the vehicle, regulation and standards should go beyond simple monitoring of facilities and procedures and be developed in ways that will ensure positive outcomes in all aspects of resident life. The Legal Division advises that licensing with accompanying remedies are essential tools for enforcement.

(2) Jurisdiction/Enforcement:

As stated above, the consultation indicated that there is strong support for Province-wide standards of care along with enforcement at the municipal level of current legislation, regulation and by-laws.

The provincial government currently has direction to pursue industry self-regulation through the Ontario Residential Care Association. This position receives strong support only from ORCA and its members. Provincial staff have not ruled out the possibility of a change in direction that could include a stronger provincial role vis-a-vis retirement homes.

At this point, a municipal by-law with standards of care and an enforcement regime is not recommended because it (a) could discourage future provincial activity in the area of standards of care; (b) would move into a traditionally provincial sphere of activity (i.e., health care); and (c) would mean significant municipal resources.

Stability of Housing:

The options attempt to strike a balance between the need to develop a regulatory framework that will ensure standards of care in retirement and lodging homes while taking care not to create a situation that will encourage facility closures with the resultant de-housing of seniors and other vulnerable populations.

Options-Standards:

Option 1: Province:

The provincial government to develop Province-wide standards of care for retirement and lodging homes.

(a) Advantages:

(i) Province-wide consistency in standards of care;

(ii) improves resident care and quality of life in substandard facilities;

(iii) keeps within current jurisdictional environment in that Province sets standards for health and social services;

(iv) Province-wide standards supported by all stakeholders; and

(v) less impact on City resources if Province agrees to cover costs of developing and enforcing standards of care.

(b) Disadvantages:

(i) significant impact on City resources if City is expected to enforce a provincial standard and the provincial government does not cover cost of enforcement; and

(ii) a few advocates may perceive increased provincial regulation as a move towards increased institutionalization of seniors.

Option 2: Municipality:

In the absence of provincial standards, City to harmonize retirement and lodging home by-laws to the standard of the former City of Etobicoke with the addition of standards including but not limited to staff qualifications, number of qualified staff, financial protection for residents and residents rights and using the following definition:

"Personal Care Home" means any dwelling the occupancy of which includes more than three unrelated persons requiring personal care services, which services the owner, operator or an employee thereof offers for a fee and which services are available 24 hours a day, but does not include a hotel, hospital, nursing home, group home, student housing operated by a college or a university, home for the young or aged, or an institution which is licensed or regulated under any general or special Act.

"Personal Care Services" means services that promote or maintain an individual's health or welfare, including but not limited to feeding, washing, dressing, grooming, assistance with taking prescription medication and assistance with toilet hygiene.

(a) Advantages:

(i) provides a regulatory structure for enforcement of health, fire and buildings legislation and codes as well as provision of care;

(ii) improves resident care and quality of life in substandard facilities;

(iii) provides consistency throughout entire City; and

(iv) does not exceed the recognized industry standard for quality care and accommodation.

(b) Disadvantages:

(i) does not contribute to provincial consistency in standards of care;

(ii) City avoidance of expenditure of significant resources is dependent on provincial funding for the enforcement of standards of care;

(iii) any City activity beyond the current regulatory situation may allow the Province to avoid responsibility in the area of standards and resources for enforcement;

(iv) new standards will mean increased costs for some operators and, as a result, may increase charges for residents;

(v) operators wishing to avoid regulation may leave Toronto to open in a less strict environment with the resultant de-housing of residents; and

(vi) Province has not yet decided whether retirement homes constitute "residential units" and are therefore outside the scope of municipal licensing.

Options - Enforcement:

Option 3a: Province:

The provincial government to legislate mandatory Province-wide self-regulation of retirement homes via a new special purpose body at arm's length from both government and the retirement home industry.

(a) Advantages:

(i) special purpose body can enforce provincially legislated standards of care resulting in Province-wide consistency of standards;

(ii) self-regulation can be combined with provincial licensing as a support to enforcement;

(iii) improves resident care and quality of life in substandard facilities;

(iv) no resource impact on municipal government;

(v) although provincial government currently considering industry self-regulation, an arm's length self-regulating body may be more acceptable than government enforcement;

(vi) self-regulation broadly supported by retirement home industry; and

(vii) advocates and community organizations will accept self-regulation via an arm's length body.

(b) Disadvantages:

(i) support among advocates and community organizations weaker than for government regulation; and

(ii) new standards will mean increased costs for some operators and, as a result, may increase charges for residents.

Option 3b: Province:

The provincial government to legislate mandatory Province-wide self-regulation of retirement homes via the Ontario Residential Care Association.

(a) Advantages:

(i) Province-wide consistency in standards:

(ii) improves resident care and quality of life in substandard facilities;

(iii) no resource impact on municipal government; and

(iv) provincial government already considering this option.

(a) Disadvantages:

(i) self-regulation via ORCA is not supported by many non-ORCA members;

(ii) advocates and community organizations do not trust the industry to police its members' activities;

(iii) new standards will mean increased costs for some operators and, as a result, may increase charges for residents; and

(iv) ORCA's focus on seniors may leave other vulnerable groups of residents unprotected.

Option 4: Municipality:

City to license retirement and lodging homes:

(a) Advantages:

(i) provides the municipality with a number of important powers including but not limited to the power to prohibit the carrying-on of a business without a licence, the power to grant or refuse a licence, the power to set and collect licensing fees, the power to impose special conditions and the power to suspend or revoke a licence;

(ii) strengthens enforcement of standards of care; and

(iii) generates revenue from licencing fees.

(b) Disadvantages:

(i) revocation of a license results in closure of a facility with impacts on stability of housing; and

(ii) higher licensing fees could result higher costs to residents or facility closure.

Conclusions:

The overall goal of this initiative is to ensure that retirement and lodging homes are operated in ways that ensure a decent standard of living for residents. The Retirement and Lodging Homes Action Team and the Retirement Homes Hotline have proven to be effective short-term responses to meeting this goal. It is therefore recommended that the Hotline and the Action Team continue on an ongoing basis pending response by the provincial government to the recommendations in this report. Further, it is proposed that the Fire Department, Public Health Department and Planning Department consider increasing the number of inspectors in each of their departments.

As identified in the report, there was a consensus around the need for regulation of standards of care in retirement homes. The background review of current practice in other jurisdictions supports this direction. Therefore, it is recommended that the provincial government be requested to introduce Province-wide standards of care for retirement homes, such standards to be enforced by a body at arm's length from the retirement home industry and government. The provincial government is requested to respond to this report by April 2000.

The recommendations in this report, if adopted, would strengthen the City's ability to ensure quality of life for residents in Toronto's retirement and lodging homes. The recommendations also ensure that the City stay within its traditional role and powers and leave it with the ability to put strong pressure on the provincial government to develop and ensure the enforcement of Province-wide standards of care.

Contact:

Julie Mathien, Tel: 392-8334/Fax: 392-8492, E-mail: jmathien@toronto.ca

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Appendix A

Retirement and Lodging Home Project Update

Date:19 October to 12 December, 1999

Hotline Information

Number and Types of Inquiries by Location Per Week

Week 1 (19 Oct. - 24 Oct.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	61 (56.5%)	53	1	7
North Region (North York)	12 (11%)	7	2	3
East Region (Scarborough and East York)	13 (12%)	7	4	2
West Region (Etobicoke and York)	10 (9.3%)	7	2	1
Outside Toronto (GTA)	12 (11%)	9	2	1
Total:	108	83	11	14

Week 2 (25 Oct. - 31 Oct.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	38 (47.5%)	35	2	1
North Region (North York)	7 (8.8%)	3	2	2
East Region (Scarborough and East York)	12 (15%)	6	1	5
West Region (Etobicoke and York)	8 (10%)	3	2	3
Outside Toronto (GTA)	15 (18.8%)	9	4	2
Total:	80	56	11	13

Week 3 (1 Nov. - 7 Nov.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	24 (63.2%)	18	1	5
North Region (North York)	4 (10.5%)	2	2	0
East Region (Scarborough and East York)	0	0	0	0
West Region (Etobicoke and York)	3 (7.9%)	2	1	0
Outside Toronto (GTA)	7 (18.4%)	1	1	5
Total:	38	23	5	10

Week 4 (8 Nov. - 14 Nov.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	32 (72.7%)	26	0	6
North Region (North York)	0	0	0	0
East Region (Scarborough and East York)	4 (9.1%)	4	0	0
West Region (Etobicoke and York)	6 (13.6%)	5	0	1
Outside Toronto (GTA)	2 (4.5%)	1	0	1
Total:	44	36	0	8

Week 5 (15 Nov. - 21 Nov.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	23 (60.5%)	15	2	6
North Region (North York)	0	0	0	0
East Region (Scarborough and East York)	5 (13.2%)	4	1	0
West Region (Etobicoke and York)	6 (15.8%)	5	0	1
Outside Toronto (GTA)	4 (10.5%)	3	0	1
Total:	38	27	3	8

Week 6 (22 Nov. - 28 Nov.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	18 (85.7%)	14	0	4
North Region (North York)	1 (4.8%)	1	0	0
East Region (Scarborough and East York)	1 (4.8%)	1	0	0
West Region (Etobicoke and York)	0	0	0	0
Outside Toronto (GTA)	1 (4.8%)	1	0	0
Total:	21	17	0	4

Week 7 (29 Nov. - 5 Dec.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	6 (42.9%)	4	1	1
North Region (North York)	1 (7.1%)	0	1	0
East Region (Scarborough and East York)	4 (38.6%)	4	0	0
West Region (Etobicoke and York)	1 (7.1%)	1	0	0
Outside Toronto (GTA)	2 (14.3%)	1	0	1
Total:	14	10	2	2

Week 8 (6 Dec. - 12 Dec.)

Regions	Total #	Retirement and Lodging Homes	Nursing Homes and Homes for the Aged	Other types (Senior Apt. and Group Homes)
South Region (Toronto)	7 (58.3%)	5	1	1
North Region (North York)	1 (8.3%)	0	1	0
East Region (Scarborough and East York)	1 (8.3%)	1	0	0
West Region (Etobicoke and York)	0	0	0	0
Outside Toronto (GTA)	3 (25%)	2	0	1
Total:	12	8	2	2

Types of Concerns from Callers

Inspection Planned and Conducted since 19 October, 1999

Highlight of Investigations:

During the past month, the hotline staff continued to receive calls regarding lack of staff in Retirement and Nursing Homes, staff/resident ratio, education level of staff and their knowledge in handling resident and medication etc. These issues are not covered by the Municipal By-laws.

Public Health Inspectors have inspected 56 premises since October 19, 1999, after complaints were received by the hotline. Most premises inspected have some minor violations such as housekeeping issues, no soap and towel, missing thermometer in refrigeration or freezer, menu not posted or available on file, dining area not clean etc.

A few premises have serious violations. Inspectors observed heavy rodent and cockroach infestation, poor sanitation, fire door left open, poor medication handling and storage, lack of hot and cold running water for washing and bathing, poor condition of building, lack of personal care services, dishwasher not in working condition, poor food handling and storage technique (violations under Food Premises Regulation). Two operators were charged under the Health Protection and Promotion Act and the Municipal By-law. The conditions have improved after charges were laid.

Two operators in the South Region (Toronto) were found operating retirement homes without proper Personal Care Rooming House licence, as required under the by-law. Toronto Building Department will investigate these two operations regarding by-law violations.

One operation in Scarborough was investigated after a complaint was received. The Public Health Inspectors observed major building defects inside this house. The floor was in poor condition and was very unsafe. Evidence of a sewage backup was observed in the basement area and a strong odour was detected. This premise was operating as a boarding house. Scarborough Building/By-law Officer and Public Health Inspector will conduct a follow up investigation.

The Public Health Team is developing the following health promotion programs. Implementing such programs can lead to improvement of the conditions in retirement and lodging homes:

(1) A health promotion package containing information on medication handling and storage, food safety tips, sanitation, pest control, personal care services etc. This information package can be provided to the operators and staff during an investigation or inspection.

(2) Food safety workshops to be provided to all retirement and lodging home operators and staff in order to improve their knowledge on safe food handling.

(3) Information sharing and training sessions to be provided by Public Health Inspectors to staff of agencies that are responsible for placing residents in retirement and lodging homes. These agency staff is also responsible for monitoring the health and safety condition of these premises.

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Appendix B:Regulatory Environment

Provincial Activity:

At the outset, it is must be noted that it is very difficult to draw a line between regulated and unregulated forms of care. Generally, across Canada, no residential accommodation is completely unregulated, as municipal zoning, fire safety and public health codes apply almost universally to homes and facilities that provide accommodation and care to persons who are unrelated to the owner/operator. However, these codes vary widely across the country and what may be considered a rigorous standard by one jurisdiction may not be considered rigorous by the standard applied in another one.

At the high regulation end of the continuum, two provinces, Saskatchewan and New Brunswick, make provision for licensing of any facility that provides accommodation and care to one or more persons unrelated to the operator. In these jurisdictions, it is safe to say that there are very few establishments providing accommodation and care that do not require a licence.

Ontario and Alberta are at the other end of the continuum. Each of these provinces has extensive nursing home regulations; however, both provinces are lax in their approach to the regulation of social care facilities. Alberta licenses these facilities, but does not inspect them unless violations, usually of sanitation and culinary standards are reported by local public health authorities. Ontario does not license residential care facilities and leaves inspection up to local municipal, fire, and public health authorities.

British Columbia, Manitoba, and Nova Scotia lie in between the two ends of the continuum but they are close to the high regulation end rather than its opposite. The difference between the provinces at the high end are minimal (e.g., B.C. differs slightly in the minimum number of residents a facility must have to be licensed and inspected (e.g., 3 vs. 1). Manitoba is currently reviewing its care home regulations

Ontario, therefore, is somewhat of an outlier in the spectrum of provincial legislation. Most of the protection that exists for residents is contained in provincial health, fire and buildings legislation that is enforced by municipalities. None of this legislation contains provisions that cover standards of care or quality of life. Staff research indicates that no jurisdiction in North America leaves regulation of retirement homes solely to municipalities.

The Tenant Protection Act (TPA) is the other piece of legislation dealing with retirement homes in Ontario. The TPA has special rules that apply only to what it refers to as care homes, which include retirement and lodging homes.

The legislation and regulations contained in the TPA state that residents must be charged separately for accommodation and services (meals and care). Rent control applies to accommodation costs only. The operator (landlord) may increase the charges for meals and care services by any amount, but must give 90 days written notice of the increase. There is concern that residents are being charged for care services to which they are already entitled under the Long Term Care program.

Residents of retirement and lodging homes are subject to the same security of tenure and eviction provisions as all other tenants. However, an operator of a home may apply to the Ontario Rental Housing Tribunal to evict a tenant if there is a change in the amount of care needed by the tenant. In this instance, the operator must provide appropriate accommodation. In the case where a resident is evicted due to facility renovation or demolition, the operator must make reasonable efforts to find other accommodation. A tenant may leave a retirement home with 30 days notice.

Retirement Home operators must provide residents with a Care Home Information Package (CHIP) prior to their move in. The CHIP outlines the type of accommodation and charges for the meals and care services that the resident is to receive. The operator cannot raise the accommodation or service costs without presenting a CHIP.

Consultation participants cited the following problems in the enforcement of the TPA:

Operators do not provide a CHIP to residents or provide one only when the resident moves in and not when making subsequent changes in accommodation or services charges. This can be an area of financial abuse.

Residents do not know about the Tribunal, do not understand that they can appeal evictions or illegal increases in charges and may not be realistically capable of appealing to the Tribunal. The window for appealing to the Tribunal is very short (10 days).

Municipal Activity:

In the absence of provincial regulation and licensure of residential care facilities a number of Ontario municipalities have taken the direction of developing by-laws to regulate care in these establishments.

Of the five large Ontario municipalities that have by-laws covering retirement, care or lodging homes, four, i.e., the former municipalities of Etobicoke and Toronto, Hamilton, and Windsor, have passed by-laws to regulate care homes. The fifth municipality, Ottawa-Carleton, regulates 600 beds in care homes through purchase of service agreements with operators of domicialiary hostels who provide accommodation and care to "persons in need" as defined in provincial social assistance legislation. None of the other retirement homes are regulated. While Ottawa's approach to regulation is different, the scope of the standards set out in its purchase of service agreement is similar to that of the by-laws in the other four municipalities.

Definition of Care Home:

Each municipality attempts to regulate a similar type of facility, i.e., a rooming house or boarding and lodging, rest, or retirement home, in which an owner/operator provides, on a user pay basis, accommodation, meals, and assistance with the activities of daily living, to a minimum number of persons, who not related to the owner/operator. In addition, in three of the five municipalities (i.e., Etobicoke, Ottawa and Windsor), the by-law/agreement also sets a minimum staff to residents ratio which applies over a 24-hour period.

Standards:

The standards set out in the municipal by-laws/agreement cover the following areas: building maintenance, occupancy, fire safety, sanitation, housekeeping and living standards, nutrition, personal/medical care and assistance, administration of medications, operator and employee qualifications and responsibilities; record-keeping, and inspections.

Four out of the five municipalities address these areas through a single by-law. The former City of Toronto had taken a different approach by adopting three separate by-laws to regulate such facilities. The three by-laws dealt with property standards, rooming house licensing, and standards for personal care in rooming houses.

Nevertheless, Toronto's personal care by-law has less detail and also some gaps in comparison to the other by-laws, including the Lodging Home by-law in the former City of Etobicoke. For example, there are no standards relating to: the minimum number of residents, the ratio of staff to residents, assistance with activities of daily living (e.g., the phrase "caring for their personal needs and health" is not defined), and the minimum requirements for owners/operators and employees. In addition, all the other by-laws/agreement, except for Toronto's personal care by-law, make provision for mandatory periodic inspections by municipal staff, usually from Public Health.

The gaps identified by the workgroup in current municipal regulations involve staff qualifications, minimum number of qualified staff, protection of residents in financial matters and residents' rights.

In addition to the above, Fire Services would prefer retirement and lodging homes be governed by Sec. 9.4 Health Care Facilities, a more stringent section of the Fire Code, instead of Sec. 9.3 Rooming Houses, as is now the case.

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Appendix C: Health and Population Context:

In order to safeguard and promote the well being of residents in personal care facilities, it is important to understand the scope and nature of "health". Health is a positive concept - a resource for everyday living which enables people to realise their aspirations, satisfy their needs, and cope with their environment. It is a complex, dynamic, holistic state involving physical, mental, spiritual and social factors. Rather than being the "absence of disease", health is measured along a continuum, and can co-exist with illness and disabilities.

Numerous conditions, or "determinants", influence the resident population's health status in personal care homes, including:

- the physical environment- including air and water quality, housing and safety conditions;

Interpersonal relationships;

- income, social status and an associated sense of control;

- access to preventive health care, medical/ dental treatment, and rehabilitation services;

Education;

- caregiver work conditions and supports;

- lifestyle factors (such as eating habits, exercise and rest patterns, use of tobacco and alcohol);

- coping skills to handle pain, grieving and other stresses; and

- biological factors related to the ageing process, medical conditions, medications, and genetic factors).

In addition, "quality of life" factors in personal care homes, such as promotion of independence, spiritual and cultural expression, and an atmosphere of respect affect residents' psychosocial wellbeing.

The owners, management and staff in personal care facilities are in a pivotal position to positively or negatively affect the health of their residents. Although they can not ensure that all conditions for well-being are met, they are entrusted with providing the basics: a safe physical environment; a supportive social environment, protection from abuse, balanced meals tailored to special dietary needs, access to recreational activities, individually tailored assistance for daily living activities as required (e.g., referrals to community services, completion of applications, forms for transportation etc., managing funds) and flexibility that allows options. These basics can best be provided with a staff who are well-qualified (e.g., through a careful selection process and training opportunities) and work under decent conditions.

Seniors in Toronto - Epidemiological Profile:

Seniors are an important and diverse community. In 1996 Census there were 320,000 seniors in Toronto comprising 13.4 percent of the City's population. Women accounted for 55 percent of the seniors' population and 71 percent of the 85 and over category. According to the 1996 Ontario Health Survey (OHS) immigrants are about 49 percent of the seniors population and 15 percent of seniors do not have knowledge of either English or French. The median income for seniors (single) is $16,400.00.

Seniors can be considered to have two life stages. The first life stage (64-74) is one in which the recently retired, most of whom are independent and healthy, are free to pursue their interests. The second or later state is associated with illness, dependency and eventually death. People in this first stage have more in common with younger people than the very old (generally considered to be above 80 or 85). In 1996, life expectancy at 65 in Canada was 18.4 years. Nine of these 18 years are free of disability and the remaining years include 3 years each of slight, moderate and severe disability.

In Canada in 1995, 78 percent of seniors 65-74 living in the community had a chronic disease compared to 86 percent of seniors 75 and over. However, only 36 percent and 46 percent of seniors in these age groups respectively, report some level of activity restriction (chronic diseases includes conditions such as hypertension which are not limiting in themselves. According to the OHS, 40 percent of seniors in the Toronto community (123,727) report some level of activity limitation and about 21 percent of seniors in the Toronto community have a long term disability or handicap.

Where Seniors Live:

According to the 1996 census the vast majority of Toronto's seniors (300,200 or 94 percent) live in a household (see Table 1). The remainder of the City's seniors population live in what is termed collective dwellings. These are dwellings of a commercial, institutional or communal nature. It would include hospitals, nursing homes, retirement homes, lodging or rooming houses, hotels, communal quarters such as military camps and group homes. In 1996, 19,650 or 6 percent of Toronto lived in this setting (this agrees well with 5 percent figure of seniors in health care related institutions in Canada in the 1994-95 National Population Health Survey). There are approximately 11,735 seniors (3.7 percent of seniors) in long-term care institutions and 2,550 seniors (0.8 percent of seniors) in chronic care beds in Toronto. This leaves 5,365 seniors (1.7 percent of seniors) in some of other form of collective dwelling, such as (but not limited) to retirement homes. This agrees well with the Care Planning Partners estimate of 5,391 seniors living in retirement homes (which may have been calculated in the same way, just a different year). City staff made a coherent count of all retirement homes and derive a count of 3,950 beds. One must remember that an accurate census specific to retirement home residents in Toronto has not been done and that the "real number" of seniors in retirement homes probably lies somewhere in between these two figures. It should also be remembered that not all of these seniors are receiving personal care services.

Assistance in the Community:

Assistance can take many forms. It includes help with shopping or housework or help with personal care such as bathing and going to the washroom. According to Eldercare in Canada: Context, Content and Consequences people receive assistance for three reasons, it is the way things are done (i.e. specific chores are usually done by one person), a temporary disability, or a long-term limitation or health problem. As a group seniors require assistance (broadly defined) on a level with the rest of the population. Nationally, almost 80 percent of non-seniors received assistance versus 73 percent of seniors. However, 22 percent of seniors received this help due to a long-term health problem or physical limitation versus 3 percent of non-seniors. And as people age their requirement for help increased. Only 70 percent of seniors 65-74 received assistance compared to 89 percent of seniors 85 and over. The vast majority of assistance (about 80 percent) is from relatives and friends as opposed to someone paid to provide assistance. Only 7 percent of seniors in the community in Toronto received any form of home care services in 1996. Also, it should be pointed out that seniors themselves are an important source of assistance. For example, of those seniors who gave assistance in 1996, 17 percent helped with child-care.

Among seniors with long term health problems a number of factors are associated with receipt of care. This includes perceived health, age, marital status and place of residence. For example, the National Population Health Survey in 1996 found that those 85 and over are five times as likely to receive care as someone 65-74. Widowed seniors are twice as likely to receive care as married seniors.

Institutionalization:

Seniors living in institutions are a small subgroup of the seniors' population overall. According to the 1996 General Social Survey and the 1994-95 National Population Health Survey there are 3.6 million seniors in Canada. About three quarters of a million receive care for long term health problems (22 percent of all seniors) and 186,500 (5 percent of all seniors) live in a health care related institutions. However, rates of institutionalization vary dramatically with age. For seniors 65-74 less than 2 percent have such a living arrangement compared to about 30 percent of seniors 85 and over. Those most at risk of institutionalization have multiple problems relating to a chronic disease, impaired cognition and require assistance for personal care or activities of daily living. Seniors 85 and over and impaired in all three areas have an 80 percent chance of institutionalization. Still this is only 4 percent of seniors in this age group. This means that institutionalization is not simply a result of advanced age or these three factors. Dementias are a significant factor in institutionalization. About on in three residents of a health care-related institution have a dementia. However, the number of seniors in the community with dementia is so low (i.e., less than 1 percent) that it cannot be accurately reported.

Internationally, a number of factors have been found to be associated with an increased risk of admission to a long-term care facility, such as a nursing home. These factors are functional status (ability to carry out personal care and other activities such as housework), mental status, age and social supports. Those who are institutionalized tended to have a more severe functional or mental deficit or combined problems in different areas. However, someone with a relatively high need for assistance could remain in the community if they have enough informal or formal caregivers while another individual with little social support may need to be institutionalized for a less severe problem.

Retirement Homes:

Retirement homes exist within a continuum of care provision. At one end are the 26 percent of Canadian seniors who are completely independent. At the other end are those seniors in hospitals or long-term care facilities. In between are seniors in the community who can get by with some or a lot of assistance. Generally seniors living in the community depend a great deal on friends and relatives to provide much of this help even if they are receiving formal assistance from homecare programs. However, some seniors and their families may feel that a retirement home can better provide this assistance. At a minimum a retirement home can assist with many household activities. At a maximum retirement homes can provide a high level of personal care (dressing, bathing, etc.), an on site nurse and a visiting physician.

Retirement home residents are a diverse group containing seniors with few, if any, limitations and those who could be found in a nursing home. Factors such as age, functional status, and mental status are between that of seniors in the community and seniors in long-term care facilities (see Table 2). The average age for seniors living in the community in Toronto is 73.7 years, 81.8 years in Ontario retirement homes, and 84.8 years in a long term care institution in Ontario. Eight percent of seniors in the Toronto community use some form of mechanical assistance to walk and less than 1 percent use a wheelchair. In Ontario retirement homes, 34.3 percent of seniors use a walker and 12.7 percent use a wheelchair. About 22.6 percent of seniors in long term care use a walker and 53 percent use a wheelchair. Lastly, while rates of dementias are 49.4 percent in long term care and 22.5 percent in retirement homes, the rate of dementias in the community is too low (<1 percent) to be accurately reported. On average those in retirement homes would probably be on the high end of requirements for assistance and medical care if they remained in the community. Their limitations also mean that seniors in retirement homes need help in accessing the factors/determinants which promote health.

The Future:

The number of seniors is expected to grow dramatically in the near future (Table 3). Statistics Canada estimates that there are 345,159 seniors in Toronto in 1999. By 2005 this will increase by 9.2 percent in 2005 and by 17.2 percent in 2010. An even sharper increase will occur in our most frail elderly, those 85 and over. Currently, there are 37,315 seniors 85 and over. This will increase by 22.5 percent in 2005 and by 58 percent in 2010. The need for seniors' assistance of all kinds, including retirement homes will therefore increase as well.

Table 1: Seniors in Toronto and Their Living Arrangements

	Number	% of Total Population	% of Seniors' Population
Total Population	2,385,425	-	-
Seniors	319,850	13.4	-
85+	31,425	1.3	9.8
Households	300,200	12.6	93.9
Collective Dwellings	19,650	0.8	6.1
Long term Care	11,735	0.5	3.7
Chronic Care	2,550	0.1	0.8
Retirement Homes	4,000-5500	0.2	1.3-1.7

Source: Statistics Canada 1996 Census

Table 2: Characteristics of Seniors in the Community, Retirement Homes and Long Term Care Facilities

	Toronto Seniors in the Community	Ontario Seniors in Retirement Homes	Ontario Seniors in Long Term Care
Average Age (years)	73.7	81.8	84.8
Use Walkers/ Mechanical Support (%)	8.0	34.3	22.6
Use Wheelchairs (%)	<1*	12.7	52.8
Bedridden (%)	<1*	3.9	8.8
Dementia/Alzheimer's (%)	<1*	22.5	49.4
Require Assistance with Feeding (%)	NA	9.6	45.2
Incontinent (%)	NA	23.4	63.4

Source: Statistics Canada 1996, Ontario health Survey and Care Planning Partners Care Survey, 1999

* - number is too small to be reported with any confidence in its accuracy

NA - data is not available

Table 3: Population Estimates for Toronto

	Population 65+	% Increase	Population 85+	% Increase
1999	345,159		37,315
2005	376,913	9.2	45,700	22.5
2010	404,414	17.2	58,976	58.0
2015	458,221	32.8	68,299	83.0

Source: Statistics Canada

(A copy of the Table, entitled "Regulation of Retirement Homes in Selected Canadian Provinces," attached to Appendix B was forwarded to all Members of Council with the January 20, 2000, agenda of the Policy and Finance Committee, and a copy thereof is on file in the office of the City Clerk.)