Community Care Access Centres : Client Services Policy Manual

Public Information Health Care Providers News Media Text Only Version

Community Care Access Centres Client Services Policy Manual September 2006 Download Manual

This CCAC Client Services Policy Manual sets out the requirements of the Ministry of Health and Long-Term Care (MOHLTC) relating to the primary service functions of the Community Care Access Centre (CCAC) as follows

assessing client needs determining client eligibility developing a plan of service and providing or arranging for professional personal support and homemaking services

providing information and referral services to the public about other community agencies and services admission into long-term care (LTC) homes

The CCAC is required to comply with all laws The CCAC Client Services Policy Manual sets out some of these legislative and regulatory requirements as well as the policies with which the CCAC is required to comply

This manual is written for CCACs and focuses on the delivery of services to clients Statutory and regulatory provisions are usually quoted directly Where interpretation is needed examples and further explanatory notes are provided

For situations not covered in this manual or situations that are covered but require special consideration staff should consult senior management and management may contact the MOHLTC for further consultation or direction

The manual is intended to be a comprehensive document that will require updates and additions to reflect changes in legislation regulations and policies This manual replaces the Home Care Policies and Procedures Manual (1984) and the Placement Coordination Services Manual issued in 1994

The manual is downloadable in individual sections below

INDIVIDUAL SECTIONS Notice 1 page | 696 Kb | PDF

Chapter 1 Introduction to the Manual 16 pages | 78 Kb | PDF

11 Overview of the Manual

12 Overview of Ontarios Long-Term Care System

13 Community Support Services

14 Long-Term Care Homes

15 The Ministry of Health and Long-Term Care

16 Development of the Community Care Access Centre

17 The Community Care Access Centre

Access to Home and Community Care Services (flowchart)

Chapter 2 Legislation 15 pages | 56 Kb | PDF

21 Introduction

22 Long-Term Care Act 1994

23 Ontario Regulation 552 under the Health Insurance Act

24 Community Care Access Corporations Act 2001

25 Legislation Governing Long-Term Care Homes

26 French Language Services Act

Chapter 3 Eligibility Criteria for CCAC Services 21 pages | 71 Kb | PDF

31 Overview of Eligibility Criteria

32 Validation of Ontario Health Cards

33 Residency Requirements for OHIP Coverage

34 Persons without OHIP Coverage are Ineligible for CCAC Services

35 Out-of-Province Applicants to Ontarios Long-Term Care Homes

36 OHIP CoverageCCAC Services for Homeless Persons

37 OHIP CoverageCCAC Services for Refugees

38 OHIP CoverageCCAC Services for a Person on Leave of Absence from a LTC Home

39 Eligibility for Adult Day Services

310 Eligibility for Enhanced Respite Funding

311 Services to First Nations Persons

Chapter 4 Consent to Treatment Admission to Long-Term Care Home and Community Services 52 pages | 148 Kb | PDF

41 Overview of Consent Provisions

42 Definitions of Terms of Health Care Consent Act 1996

43 Consent to Treatment

44 Capacity to Consent to Treatment

45 Consent to Treatment on Behalf of an Incapable Person

46 Emergency Treatment Without Consent

47 Applications to the Consent and Capacity Board Regarding Treatment

48 Consent to Admission to a Long-Term Care Home

49 Consent to Admission to a Long-Term Care Home on Behalf of an Incapable Person

410 Applications to the Consent and Capacity Board Regarding Admission to a Long-Term Care Home

411 Consent to Personal Assistance Services

Chapter 5 Information and Referral Services 9 pages | 35 Kb | PDF

51 Overview of Information and Referral Services

52 Design of the Information and Referral Service

53 Required Information Services

54 Monitoring the Information and Referral Service

55 CCAC Information or Referral Services to Specific Communities

Chapter 6 CCAC Case Management 17 pages | 63 Kb | PDF

61 Introduction to Case Management

62 Responsibilities of Case Managers

63 Case Management Staff Qualifications

64 Supports to the Case Management Function

Chapter 7 CCAC Home Care Services 21 pages | 72 Kb | PDF

71 Professional Services

72 Personal Support and Homemaking Services

73 Management of Waiting Lists for CCAC Services

74 Ambulance Services for CCAC Clients

75 Drug Benefits for CCAC Clients

76 Influenza Services

77 Residential Hospices

Chapter 8 Supplementary Services 7 pages | 36 Kb | PDF

81 Home Oxygen Program

82 Northern Health Travel Grant Program

Chapter 9 CCAC School Services 30 pages | 111 Kb | PDF

91 Overview of CCAC School Services

92 Eligibility for CCAC School Services

93 Service Maximums

94 Equipment Relating to School Services

95 Transportation Relating to School Services

96 Case Management Function Relating to the Provision of CCAC School Services

97 CCAC Approaches to Service Delivery for School Services

98 Service Termination in Public Private and Home Schools

99 CCAC Liaison Activities

910 Other Service Delivery Models

911 Responsibilities in Emergencies

Chapter 10 Complaints and Appeals 18 pages | 62 Kb | PDF

101 Complaint Resolution - Community Services

102 Appeal of CCAC Decisions - Community Services

103 Appeal Process Relating to Admission to a Long-Term Care Home

Chapter 11 Admission to Long-Term Care Homes 48 pages | 149 Kb | PDF

111 Introduction

112 Eligibility Criteria

113 Application Process for Long-Stay Eligibility Determination

114 Consents Required for Long-Stay Placement

115 LTC Home Selection for Long-Stay Applicants

116 Request for Approval of Admission and Response from the LTC Home

117 Accepting the Offer of Long-Stay Admission Accommodation and Bed-Holding Fees

118 CCAC Authorization of Long-Stay Admission

119 Short-Stay Programs Respite Care and Supportive Care (Convalescent Care)

Chapter 12 Management of Long-Term Care Home Waiting Lists by CCACs 43 pages | 696 Kb | PDF

121 Overview of Prioritization of Long-Term Care Home Waiting Lists

122 Crisis Admissions ndash Category 1A

123 Prioritization Criteria ndash Category 1A1

124 Prioritization Criteria ndash Category 1B

125 Prioritization Criteria ndash Category 2

127 Non-Numbered Categories

128 Ranking of Priority Categories

129 Waiting Lists for Interim Beds in LTC Homes

1210 Refusals of Offers of Long-Stay Admission to LTC Homes

1211 Waiting Lists for Short-Stay Programs

1212 Refusals of Offers of Short-Stay Admissions to LTC Homes

APPENDICES

Appendix A ndash Glossary of Terms Appendix B ndash Website Addresses

To view PDF format files you need to have Adobe Acrobatreg Reader installed on your computer You can download this free software from the Adobe Web site

Call the ministry INFOline at 1-800-268-1154 (Toll-free in Ontario only) In Toronto call 416-314-5518 TTY 1-800-387-5559 Hours of operation 830am - 500pm

copy Queens Printer for Ontario 2002 | Privacy Policy | Disclaimers | Last Modified 09192006 155511

Version Date September 2006

Notice

This CCAC Client Services Policy Manual (ldquoManualrdquo) sets out the policy of the Ontario Ministry of Health and Long-Term Care (MOHLTC) relating to the provision of services by CCACs The Manual overrides all prior MOHLTC policies relating to these services

The contents of this Manual are subject to change without notice from time to time and are for informational purposes only and are not intended to provide any legal financial or professional advice or recommendations in any circumstances The MOHLTC cannot and does not represent or guarantee that the information in the Manual is current accurate complete or free of errors Any reliance upon any information contained in the Manual is solely at the risk of the user of the Manual

The user should always seek legal financial or such other professional advice relating to the information contained in the Manual

The MOHLTC assumes no responsibility for any changes errors or omissions in any of the information contained in the Manual The MOHLTC makes no representation or warranty of any kind whatsoever with respect to this Manual In no event shall the MOHLTC the Province of Ontario and their respective officers employees servants or agents be liable for any failure to keep the content of this Manual up to date for errors or omissions contained in the Manual or for any damages (including without limitation damages for loss of profits business interruption or direct indirect incidental special consequential or punitive damages) arising out of or related to the use of this Manual (including all contents) whether under contract in tort or under any other basis of liability

This Manual is the property of the MOHLTC and it shall not in whole or in part be reproduced without the MOHLTCrsquos prior written permission

CCAC Client Services Policy Manual Chapter 1 Introduction to the Manual

September 2006 1

Introduction to the Manual

11 Overview of the Manual 111 Purpose of the Manual

This CCAC Client Services Policy Manual sets out the requirements of the Ministry of Health and Long-Term Care (MOHLTC) relating to the primary service functions of the Community Care Access Centre (CCAC) as follows bull assessing client needs determining client eligibility developing a plan of service and

providing or arranging for professional personal support and homemaking services bull providing information and referral services to the public about other community agencies

and services bull admission into long-term care (LTC) homes The CCAC is required to comply with all laws The CCAC Client Services Policy Manual sets out some of these legislative and regulatory requirements as well as the policies with which the CCAC is required to comply This manual is written for CCACs and focuses on the delivery of services to clients Statutory and regulatory provisions are usually quoted directly Where interpretation is needed examples and further explanatory notes are provided For situations not covered in this manual or situations that are covered but require special consideration staff should consult senior management and management may contact the MOHLTC for further consultation or direction The manual is intended to be a comprehensive document that will require updates and additions to reflect changes in legislation regulations and policies This manual replaces the Home Care Policies and Procedures Manual (1984) and the Placement Coordination Services Manual issued in 1994

September 2006 2

112 How to Use the Manual

This manual is divided into chapters (eg chapter 4 is Consent to Treatment andor Admission to Long-Term Care Home chapter 9 is CCAC School Services) Each chapter starts on a new page and is divided into subsections Chapter numbers are on every page Page numbering starts again at the beginning of each chapter Thus if a chapter is revised the pages can be removed and replaced with new material The internet version of the manual is the authoritative reference The manual is available online at the MOHLTC website at [httpwwwhealthgovoncaenglishprovidersproviders_mnhtml]

The MOHLTC is responsible for maintaining and updating the internet version Readers should ensure they are using the current hard copy by comparing the date in the footer with the online version ldquoNotesrdquo are used in this manual to draw attention to information requiring special consideration or extra caution ldquoClarificationrdquo statements further explain or interpret cited legislation Legislation regulations and document titles are in italics If the date is part of an Actrsquos official title the date is included in the full name but not in the acronym Each CCAC is advised to review applicable laws including the cited legislation and to seek legal advice when questions arise

See Appendix A in this manual for a glossary of terms including the Acts and regulations definitions acronyms and abbreviations used throughout this manual For first references in each chapter and section terms are expressed in full form followed by the acronym in parentheses This manual also references website addresses to provide readers with access to applicable legislation forms and other related information See Appendix B in this manual for a complete list of these website addresses Information on procurement policies and procedures for CCACs can be found in the following documents developed in July 2003 bull Client Services Procurement Policy for Community Care Access Centres and bull Client Services Procurement Procedures for Community Care Access Centres

Information on the management information system (MIS) home care standards (including service recipient codes) is available on the MOHLTC Finance and Information Management (FIM) website (private site)

September 2006 3

12 Overview of Ontariorsquos Long-Term Care System

Ontario has developed a system of home and community care with the following partners the Ministry of Health and Long-Term Care (MOHLTC) Community Care Access Centres (CCACs) community services and long-term care (LTC) homes The partners work together in different combinations to meet the diverse needs of people accessing their services bull MOHLTC funds the LTC homes to meet the needs of people who can no longer live in

their own homes and the CCAC manages admissions to LTC homes bull The MOHLTC the CCACs and community service agencies work together to provide

support to people of all ages in their places of residence and in their communities In the home and community care sector 42 CCACs and over 800 community service agencies receive funding from the Ontario government to help people remain independent and to live with dignity in their homes and communities Services include professional services personal support and homemaking meals community transportation acquired brain injury (ABI) services assisted living services in supportive housing (ALSSH) and elderly persons centres Provision of community-based health and support services may be bull temporary or periodic (eg to enable a person to recover or receive treatment at home

rather than in a hospital) or bull ongoing or long-term (eg an elderly person who requires assistance with personal care

needs such as bathing or dressing to remain at home or a child with a physical disability who needs professional support to attend school)

121 Need for Home and Community Services

Two major factors affect the demand for home and community services in Ontario

1 As Ontariorsquos population ages the demand for community-based health and support services increases

2 The increased volume of referrals from hospitals hospital restructuring has resulted in

shorter hospital stays for patients and a greater need for in-home supports to address care needs after hospital discharge In addition in-home supports can reduce the need for hospital admissions

September 2006 4

122 Goals of the Home and Community Care System

The MOHLTC CCACs community support services ALSSH and ABI service agencies together form the system of home and community care which provides services to people living in their homes or other community settings The goals of the system of home and community care are bull to ensure people have access to the services they need when they need them bull to continue to develop a modern comprehensive health care system to meet future needs

and ensure access to key community health services for people of all ages and bull to ensure that community-based health and support services are available to serve a

growing aging population The remainder of this chapter provides the context for the CCAC by giving a brief description of its three key partners bull community support services (see subsection 13 in this manual) bull LTC homes (see subsection 14 in this manual) and bull the MOHLTC (see subsection 15 in this manual)

(Also see subsection 17 in this manual for a brief description of the CCAC)

September 2006 5

Community support services are fully or partially funded by the Ministry of Health and Long-Term Care (MOHLTC) and are delivered by community-based not-for-profit agencies that rely heavily on volunteers Historically services were developed locally in response to local needs and vary from community to community Clients can access services directly through self-referral The 15 key community support services (as per the 20012002 Planning Funding and Accountability Policies and Procedures Manual for Long-Term Care Community Services) are bull meal services bull transportation services bull caregiver support services (these services include counselling information and education to

caregivers and family members who have emotional severe stress or mental health problems impeding their ability to provide care and support for the client)

bull respite (these services replace the efforts of family and caregiver supports This occurs both in peoples homes and outside the home)

bull homemaking bull adult day services (ADS) bull home maintenance and repair services bull volunteer hospice services bull palliative care consultation services (eg pain and symptom management) bull palliative education (this includes both physician palliative care education and community

and facility palliative care interdisciplinary education for front line health care staff) bull Alzheimer services (eg public education coordinators and psychogeriatric resource

consultants) bull friendly visiting services bull security checks bull social or recreational services (including services delivered by both elderly persons centres

as well as other community support service agencies) and bull services for persons with physical disabilities (these are services specifically for persons

with physical disabilities including attendant outreach direct funding and special services for the blind and hearing impaired This also includes foot care aphasia and personal support and homemaking services)

Some of these services are also provided to clients in assisted living services in supportive housing (ALSSH) and there are services specifically for clients with acquired brain injury (ABI)

September 2006 6

132 Legislation

Section 3 of the Long-Term Care Act 1994 (LTCA) states

For the purpose of this Act the following are community services 1 Community support services 2 Homemaking services 3 Personal support services 4 Professional services

Section 4 of the LTCA states

For the purpose of this Act the following are community support services 1 Meal services 2 Transportation services 3 Caregiver support services 4 Adult day programs 5 Home maintenance and repair services 6 Friendly visiting services 7 Security checks or reassurance services 8 Social or recreational services 9 Providing prescribed equipment supplies or other goods 10 Services prescribed as community support services

September 2006 7

Long-term care (LTC) homes (nursing homes charitable homes for the aged and municipal homes for the aged) provide care for people who are not able to live independently in their own homes and who require 24-hour nursing or personal care support andor supervision

141 Funding of Long-Term Care Homes

LTC homes have two main sources of funds Ministry of Health and Long-Term Care (MOHLTC) funding for care and services and funding received from residents who pay accommodation fees

The MOHLTC provides funding to LTC homes according to a funding formula known as the ldquoenvelope systemrdquo These funding envelopes are bull nursing and personal care bull programming and support services bull raw food and bull other accommodation

The MOHLTC also provides supplementary funding to support operating costs MOHLTC funding for nursing and personal care services is based on a resident needs-based funding formula with MOHLTC paying the full amount The MOHLTC pays a fixed per diem for program and support services which includes recreational activities therapists quality of life and other programs designed to assist residents to maintain their optimal level of functioning The MOHLTC also assists residents who have limited income with their accommodation charges The MOHLTC pays the LTC home the difference between the basic accommodation rate and what the resident can afford Further information about MOHLTC policies with respect to LTC homes can be found in the Long-Term Care Home Program Manual 1993 as revised in 1995 1998 and 2006 available in MOHLTC offices

September 2006 8

This subsection describes the role of the Ministry of Health and Long-Term Care (MOHLTC) as it relates to the Community Care Access Centre (CCAC)

151 Role of the Ministry of Health and Long-Term Care

MOHLTC provides funding administers legislation and regulations and sets and ensures compliance with policies and guidelines for Ontariorsquos health care system The goal is enhancing physical and mental health in all of lifersquos stages through a high quality system that is easily accessible for all Ontarians MOHLTC is responsible for managing Ontariorsquos health care system including health insurance drug benefits assistive devices care for the mentally ill community services home care community health health promotion and disease prevention hospitals and long-term care (LTC) homes

152 Role of Local Health Integration Networks Local Health Integration Networks (LHINs) are non-profit organizations funded by the Government of Ontario through the MOHLTC It is intended that LHINs will have authority to make local decisions about health services and perform some functions that are currently done centrally by the MOHLTC Fourteen LHINs have been established in Ontario each with specific geographic boundaries The intent is that LHINs will eventually be responsible for planning integrating and funding local health services LHIN functions will be phased in over time LHINs will commence with planning and community engagement responsibilities move then to service coordination and system integration and finally to funding and resource allocation LHINs will also be responsible for engaging the health care providers and community stakeholders in their areas throughout their evolution LHINs will eventually fund certain health service providers including CCACs and community service agencies which will be accountable to the LHIN Additional information is available at [httpwwwlhinsoncaenglishmainhomeasp]

153 Community Health Division

The Community Health Division of the MOHLTC is responsible for programs relating to community health centres CCACs community services LTC homes mental health community services and the Psychiatric Patient Advocacy Office The Community Health Division also shares responsibility with the Acute Services Division for MOHLTC regional offices the Finance and Information Management Branch French Language Services and the Strategic Projects Unit

September 2006 9

The Community Health Division funds its programs supports best practices monitors compliance and takes corrective action concerning the provincersquos LTC homes and the community agencies providing home and community care services to seniors adults with physical disabilities and people of any age who need health services at home or in school

154 The Home Care and Community Support Branch

The vision of the Home Care and Community Support Branch is ldquoGetting care to people who need it in their home and community settingrdquo The branchrsquos mission

bull develops and supports the implementation of policy for home care and community services

under the direction of the government and in consultation with stakeholder groups bull assists regional offices in appropriate and consistent policy implementation across Ontario bull establishes standards for operation of home and community care programs bull develops program performance measures monitoring and evaluation mechanisms for

application across the province and bull promotes legislative and government intent through funding monitoring and evaluating

service delivery Given the vision and mission of the Home Care and Community Support Branch of the MOHLTC the key functions of the branch include bull development of legislation and regulations for the home and community care system bull development of operational policies aimed at ensuring the consistent administration

implementation and management of community-based programs and services across the province

bull training and orientation on new program designs and bull provision of support to the regional offices in their role of monitoring home and community

care services

155 Regional Offices

Seven MOHLTC regional offices (North East Central East Toronto Central West Central South and South West) lead and support communities in developing and sustaining a locally responsive accountable and quality system of services in the areas of acute and community health

September 2006 10

Regional offices bull provide a primary point of contact and provide program expertise for MOHLTC transfer

payment agencies in the acute and community care health sectors bull enable co-ordination and collaboration in the delivery of services across the region bull facilitate an integrated approach to services resulting in better solutions for service issues bull flow funding directly to hospitals LTC homes CCACs community services community

health centres and mental health and addictions programs in the regions consistent with corporate direction

bull serve as a monitoring and accountability point for program delivery including program reviews

bull work with transfer payment partners to develop and execute accountability frameworks bull ensure compliance with legislation regulations and policies bull facilitate co-ordination of approvals and requests with other MOHLTC or health care

program divisional units and bull collaborate on policy development and implement MOHLTC policies strategic directions

and government initiatives within the region

156 Regional Office Staff

Program Consultants Program consultants are the point of contact for CCACs hospitals LTC homes community services agencies and mental health and addiction program agencies Program consultants in the regional offices bull ensure CCAC compliance with MOHLTC legislation regulations and policies bull provide individual transfer payment agencies with funding for services provided within

defined accountabilities bull support the community in developing and sustaining local programs bull facilitate integrated approaches to services and bull serve as the point of contact for the public to receive advice or complaints on MOHLTC

programs Finance and Information Staff Finance and information staff ensure a strong financial controllership function is in place in the region Regional financial staff are responsible for

bull cash flow to transfer payment agencies bull year-end reconciliation bull ensuring expenditures are appropriate bull resolving financial issues and bull ensuring that meaningful financial data is available to assist in planning

September 2006 11

Planning Staff Planning staff in regional offices are responsible for

bull developing planning processes and helping to set planning agendas for MOHLTC regional

offices bull co-ordinating regional issues and communications bull developing and implementing internal management processes for the regional office bull working with external planning and health service delivery stakeholders to improve

decisions related to health services planning and delivery and bull providing project management facilitation negotiation research and information analysis

services to the region LTC Home Compliance Staff (Nursing Environmental Health and Dietary) LTC home compliance staff monitor LTC home compliance with legislation regulations MOHLTC policies service agreements and the standards and criteria contained in the Long-Term Care Home Program Manual Compliance staff are responsible for reviewing resident care services programs and operational aspects of LTC homes

September 2006 12

The Ontario Minister of Health and Long-Term Care announced the creation of the Community Care Access Centre (CCAC) on January 25 1996 On January 1 1998 implementation of 43 CCACs across Ontario was completed consolidating the services formerly provided by 38 home care programs and 36 placement co-ordination services

161 History of Ontariorsquos Home Care and Placement Co-ordination Services

Date Description

1958 Six acute home care pilot projects funded with federal health grants and assistance from the Ontario Hospital Services Commission

1971 Three placement co-ordination pilots introduced

1972 Acute home care services implemented province-wide as an insured benefit under the Ontario Health Insurance Plan (OHIP)

1975-84 Chronic home care services phased in province-wide

1978-84 Placement co-ordination services for admission to long-term care (LTC) homes phased in province-wide

1984 School services in publicly-funded schools implemented to support provincial education reforms and enable universal access to public education for students with physical or developmental delays

1986 Integrated Homemaker Program phased in province-wide to provide homemaking and personal care for adults who were living with a physical disability or were frail and elderly

1993 The Long-Term Care Statute Law Amendment Act 1993 (LTCSLAA) required all admissions to LTC homes (nursing homes and homes for the aged) be authorized by placement co-ordination services Policy direction was provided to CCACs in 1994

1995 The Long-Term Care Act 1994 (LTCA) proclaimed into force

1995 Regulation made under the LTCA relating to the conveyance of assets of an approved agency

1995-96 Acute chronic school health and homemakers programs integrated into a single service-based model

September 2006 13

Date Description

1996-98 Establishment across the province of 43 CCACs consolidating 38 home care programs and 36 placement co-ordination services under new community boards

1999 Regulation made under the LTCA setting out eligibility criteria for persons receiving homemaking services and maximums for homemaking personal support and nursing services

2000 Regulation made under the LTCA setting out eligibility and service maximums for school health professional services to be provided to children attending private schools and home schools (Regulation under the Health Insurance Act (HIA) relating to these services was revoked)

2000 Regulation made under the LTCA setting out the eligibility criteria and service maximums for school services to be provided to children attending private and home schools Policy direction was provided to CCACs in 2001

2001 Community Care Access Corporations Act 2001 (CCACA) proclaimed into force making CCACs statutory corporations with Order in Council appointments for board members and executive directors

2002 Forty-one of 43 CCACs were designated as statutory corporations by regulation on February 16 (Two CCACs governed by integrated health service agencies Muskoka East Parry Sound and West Parry Sound Health Centre did not change their governance structures) Regulation also deemed CCACs to be approved agencies under the LTCA and approved CCACs to provide all professional services and personal support services listed in the LTCA as well as all homemaking services except for ironing and mending

2002 Regulation 38699 under the LTCA amended to prohibit a CCAC from providing personal support services to a person unless the person is insured under the HIA

2003 The Etobicoke and York CCACs merged bringing the total CCACs in Ontario to 42 (from 43)

The CCACA was amended to allow for the reorganization and dissolution of CCACs in support of their alignment with LHINs Other changes allow for an expanded role for CCACs as navigators for a wider range of services

September 2006 14

The Ministry of Health and Long-Term Care (MOHLTC) established CCACs across the province to provide simplified access to home and community care to deliver and make the arrangements for the delivery of home care services to people in their homes schools and communities to provide information and referral to the public on community-related services and to authorize admissions to long term care (LTC) homes There is no age restriction and no charge for services provided by the CCAC The duration of service depends on a personrsquos needs

The CCAC is responsible for bull assessment of applicantrsquos requirements and determination of eligibility for professional

health services homemaking (excluding ironing and mending) and personal support services provided in peoplersquos homes schools and in the community

bull assessment of applicantrsquos requirements and determination of eligibility for professional health and personal support services for children in schools and receiving home schooling

bull development of plans of service bull information and referral for the public to home and community care and related services bull purchasing home care services from service providers through a procurement process bull admission to LTC homes and bull co-ordination of the delivery of home care services provided by the CCAC The CCAC plays an important role in collecting reviewing and conveying information regarding service needs trends or gaps in the community The CCAC participates with other key health system partners (eg hospitals) on key community health system committees and works in collaboration with other service providers planning agencies and educational institutions to enhance services for people in the community CCAC services provided in the home or school on a visitation basis enable home care recipients resident pupils as defined by the Education Act (EA) and those who are home instructed to bull remain in their own homes bull return home more quickly from hospital bull delay or prevent the need for admission to a hospital or LTC home and bull attend school and participate in school routines and receive instruction or receive home

schooling

The CCAC accomplishes these objectives directly or indirectly by providing or purchasing and arranging the following community services on behalf of eligible clients bull nursing bull personal support and homemaking

September 2006 15

bull physiotherapy bull occupational therapy bull speech-language pathology bull social work bull dietetics bull medical supplies and dressings bull hospital and sickroom equipment bull assistance in obtaining drug card bull laboratory and diagnostic services and bull transportation to medical appointments and hospitals

The CCAC serves clients who may be bull recovering from an acute illness bull living with a chronic disease or are in the convalescent rehabilitative or terminal stage of

disease bull requiring support because of frailty or disability or bull requiring service to participate in school or home schooling

September 2006 16

As shown by the above diagram CCACs are the first point of contact to home care services in the community CCAC case managers will assess a personrsquos needs determine eligibility for services develop a plan of care and arrange for the delivery of professional services and personal support and homemaking services the provision of medical equipment and supplies and authorize admission into long-term care (LTC) homes The CCAC case manager will also make referrals for a client and provide information including information on how to access community services such as meal delivery transportation and attendant care services

ACCESS TO HOME ANDACCESS TO HOME ANDCOMMUNITY CARECOMMUNITY CARE

SERVICES SERVICES

COMMUNITY SERVICES(EG MEAL PROGRAMS

TRANSPORTATIONASSISTED LIVING SERVICES IN SUPPORTIVE HOUSING

ATTENDANT SERVICES ADULT DAY PROGRAMSACQUIRED BRAIN INJURY)

HEALTH amp SUPPORT SERVICES

(eg NURSING PERSONAL SUPPORT AND

HOMEMAKING)CCACCCAC

CASEMANAGEMENT

WITH CLIENT

DIRECTACCESSINFORMATION amp

REFERRAL

ADMISSIONTOLONG-TERM CARE

CCAC Client Services Policy Manual Chapter 2 Legislation

September 2006 1

Legislation

21 Introduction

The Community Care Access Centre (CCAC) is required to comply with all laws The following legislation is particularly significant to the government-funded system of community services and placement co-ordination services that the CCAC is required to provide bull Long-Term Care Act 1994 (LTCA) bull Health Insurance Act (HIA) bull Community Care Access Corporations Act 2001 (CCACA) bull Nursing Homes Act (NHA) bull Charitable Institutions Act (CIA) bull Homes for the Aged and Rest Homes Act (HARHA) bull Local Health System Integration Act 2006 (LHSIA) and bull French Language Services Act (FLSA) Each CCAC must also be familiar with the all other relevant laws including but not limited to bull Health Care Consent Act 1996 (HCCA) bull Substitute Decisions Act 1992 (SDA) bull Personal Health Information Protection Act 2004 (PHIPA) and bull Ministry of Health Appeal and Review Boards Act 1998 (MHARBA)

211 Background

A large portion of the current legislative framework was developed and implemented during the first half of the 1990s as part of a major reform of Ontariorsquos long-term care system The reform of the long-term care system was initiated in July 1993 with the enactment of the Long-Term Care Statute Law Amendment Act 1993 (LTCSLAA) which focused primarily on reforms related to admission to and operation of long-term care (LTC) homes The LTCSLAA amended the NHA the CIA and the HARHA to provide consistent expectations about admission to and operation of all LTC homes The amendments included

bull setting out the admission process and role of placement co-ordinators bull requiring all admissions to LTC homes to be conducted by placement co-ordinators

September 2006 2

bull a service agreement between the province and each home bull maximum resident charges bull a plan of care for each resident bull a quality management system in each home bull requirements to give notice and post specific documents in the home bull residentsrsquo councils at each home and bull new inspection criteria with protection from reprisals for persons making disclosures to an

inspector Two years later in March 1995 the LTCA came into force The LTCA represented the second phase of legislative change undertaken to support the reform of long-term care The Act created a new system of community-based long-term care home and community services for people of all ages including seniors adults with physical disabilities and people of any age who need health services at home or in school There was also continued reliance on the regulations under the HIA that addressed nursing and other professional home care services Following implementation of the LTCA the Ministry of Health and Long-Term Care (MOHLTC) established CCACs across the province between 1996 and 1998 by consolidating 38 home care programs and 36 placement co-ordination services under new community boards The intent was to provide Ontarians with simplified access to bull home and community care including services in schools and bull LTC homes Separate legislation governing the structure and operations of the CCACs was subsequently passed in December 2001 The CCACA was introduced to strengthen consistency and accountability of CCAC operations across the province

September 2006 3

22 Long-Term Care Act 1994 221 Purpose of Act and Bill of Rights

As the primary legislation covering community-based long-term care home and community services the Long-Term Care Act 1994 (LTCA) provides the authority for a significant portion of the services provided by each Community Care Access Centre(CCAC) The LTCA sets out the purpose of the Act

Purposes of Act s 1 The purposes of this Act are (a) to ensure that a wide range of community services1 is available to people in their own homes and in other community settings so that alternatives to institutional care exist (b) to provide support and relief to relatives friends neighbours and others who provide care for a person at home (c) to improve the quality of community services and to promote the health and well-being of persons requiring such services (d) to recognize in all aspects of the management and delivery of community services the importance of a personrsquos needs and preferences including preferences based on ethnic spiritual linguistic familial and cultural factors (e) to integrate community services that are health services with community services that are social services in order to facilitate the provision of a continuum of care and support (f) to simplify and improve access to a continuum of community services by providing a framework for the development of multi-service agencies2 (g) to promote equitable access to community services through the application of consistent eligibility criteria and uniform rules and procedures (h) to promote the effective and efficient management of human financial and other resources involved in the delivery of community services (i) to encourage local community involvement including the involvement of volunteers in planning co-ordinating integrating and delivering community services and in governing the agencies that deliver community services (j) to promote co-operation and co-ordination between providers of community services and providers of other health and social services and (k) to ensure the co-ordination of community services provided by multi-service agencies with those services offered by hospitals long-term care facilities mental health services health care professionals and social service agencies and to promote a continuum of health and social services

The LTCA also sets out the Bill of Rights for persons receiving community services The Bill of Rights has been developed and enshrined in the LTCA in order to protect and promote an individualrsquos personal well-being and safety It outlines the privileges choices and protections available to individuals receiving community services under the LTCA

1 See chapter 7 in this manual for definition of ldquocommunity servicesrdquo 2 Multi-service agencies do not exist however references to them have not yet been repealed from the LTCA

September 2006 4

In the following passages from the LTCA ldquoservice providerrdquo means the CCAC all community service agencies and all service providers with whom the CCAC has service contracts

Bill of Rights s 3(1) A service provider shall ensure that the following rights of persons receiving community services from the service provider are fully respected and promoted 1 A person receiving a community service has the right to be dealt with by the service provider in a courteous and respectful manner and to be free from mental physical and financial abuse by the service provider 2 A person receiving a community service has the right to be dealt with by the service provider in a manner that respects the personrsquos dignity and privacy and that promotes the personrsquos autonomy 3 A person receiving a community service has the right to be dealt with by the service provider in a manner that recognizes the personrsquos individuality and that is sensitive to and responds to the personrsquos needs and preferences including preferences based on ethnic spiritual linguistic familial and cultural factors 4 A person receiving a community service has the right to information about the community services provided to him or her and to be told who will be providing the community services 5 A person applying for a community service has the right to participate in the service providerrsquos assessment of his or her requirements and a person who is determined under this Act to be eligible for a community service has the right to participate in the service providerrsquos development of the personrsquos plan of service the service providerrsquos review of the personrsquos requirements and the service providerrsquos evaluation and revision of the personrsquos plan of service 6 A person has the right to give or refuse consent to the provision of any community service 7 A person receiving a community service has the right to raise concerns or recommend changes in connection with the community service provided to him or her and in connection with policies and decisions that affect his or her interests to the service provider government officials or any other person without fear of interference coercion discrimination or reprisal 8 A person receiving a community service has the right to be informed of the laws rules and policies affecting the operation of the service provider and to be informed in writing of the procedures for initiating complaints about the service provider 9 A person receiving a community service has the right to have his or her records kept confidential in accordance with the law

222 CCAC as an Approved Agency Under the LTCA

Regulation 3302 of the Community Care Access Corporations Act 2001 (CCACA) provides that the CCAC is deemed to be an approved agency under the LTCA As an approved agency the CCAC falls within the definition of ldquoservice providerrdquo under the LTCA The CCAC is therefore required to comply with all the provisions in the LTCA relating to both approved agencies and service providers

September 2006 5

223 LTCA Provisions Applicable to the CCAC

The following provisions of the LTCA apply to the CCAC Section 3 Requires contracted service providers to fully respect and promote the rights of persons receiving community services as set out in the Bill of Rights Subsection 3(3) A service provider is deemed to have entered into a contract with each person receiving a community service from that service provider agreeing to respect and promote the rights set out in the Bill of Rights Section 4 The Minister may fund the provision of community services and make agreements for the provision of these services The Minister may also fund operational and capital expenditures relating to the provision of these services Section 5 The Minister may approve agencies (However a CCAC is deemed to be an approved agency pursuant to the regulation under the CCACA) Section 6 The Minister may approve premises for the provision of community services and provide financial assistance relating to the operation of the premises Section 7 The Minister may impose terms and conditions on any financial assistance and require security for repayment of funds Section 19 The CCAC cannot transfer assign lease encumber or otherwise convey an interest in any of the assets it acquires with financial assistance from the Province of Ontario except in accordance with the regulations The regulations set restrictions on the transfer of assets Section 22 When a person applies to a CCAC for service the CCAC must assess the persons requirements determine the personrsquos eligibility for the services required and develop a plan of service for each person determined eligible The plan of service must set out the amount of service to be provided bull The CCAC must review the personrsquos requirements when appropriate depending on the

persons condition and circumstances evaluate the personrsquos plan of service and revise it as necessary when the personrsquos requirements change The CCAC must also assist the person in co-ordinating the services received in accordance with the personrsquos wishes

bull The CCAC must provide the person their substitute decision-maker or any person designated by the person with an opportunity to participate in the development evaluation and revision of the plan of service In assessing and reviewing a persons requirements the CCAC must take into consideration all assessments and information provided to the CCAC relating to the persons capacity impairment or requirements for health care or community services In developing evaluating and revising a persons plan of service the CCAC must take into account the personrsquos preferences including preferences based on ethnic spiritual linguistic familial and cultural factors In addition in assessing a persons requirements

September 2006 6

determining a persons eligibility and developing evaluating and revising a plan of service the CCAC must comply with the regulations The regulations set out the eligibility criteria and service maximums for personal support services homemaking services and school services as well as service maximums for nursing services (The regulations under the Health Insurance Act (HIA) set out the eligibility criteria for professional services)

Section 23 The CCAC must ensure that the available services in a personrsquos plan of service are provided within a time that is reasonable in the circumstances If the services are not immediately available the CCAC must place the person on a waiting list and advise the person when the service becomes available Section 24 The CCAC must not assess a personrsquos requirements determine eligibility for the program and the service or provide a community service without the consent of the person Section 25 The CCAC must notify a person their substitute decision-maker or anyone designated by the person in writing or in an alternative format prescribed by the regulations of the following bull the personrsquos rights under the Bill of Rights and the obligation upon the CCAC and the

contracted service providers to respect and promote those rights bull the procedure for making complaints or suggestions respecting the CCAC or the contracted

service provider bull the right to access the personrsquos record of personal health information and the procedure for

doing so and bull the right to inspect and review the agreement (Memorandum of Understanding) between the

CCAC and Ministry of Health and Long-Term Care (MOHLTC) for the provision of community service

Section 26 The CCAC must develop and implement a plan for preventing recognizing and addressing physical mental and financial abuse of persons receiving community services provided or arranged by the CCAC The plan must include among other things the education and training of employees and volunteers of the CCAC in methods of preventing recognizing and addressing physical mental and financial abuse Section 27 The CCAC must ensure that a quality management system is developed and implemented for monitoring evaluating and improving the quality of community services provided or arranged by the CCAC Section 28 The CCAC cannot charge or accept payment for professional or personal support services The legislation provides a mechanism for the CCAC to charge for homemaking services in accordance with the regulations however the current regulations do not address this issue and therefore the CCAC is not permitted to charge for homemaking services Section 29 Service providers under contract with the CCAC cannot require or accept payment for CCAC services from anyone other than a CCAC The contracted service provider is

September 2006 7

permitted by the legislation to collect the fees permitted for homemaking services under section 28 of the LTCA on behalf of the CCAC however no fees are permitted at present Section 30 The CCAC must provide the reports information and documents requested by the Minister or as set out in the regulations There are currently no regulations addressing this issue Section 31 The CCAC must post in its business premises a copy of the Bill of Rights the CCACrsquos agreement with the MOHLTC and any other documents and information set out in regulation Section 32-37 The CCAC may not disclose a personrsquos record of personal health information except in accordance with sections 32 33 34 35 and 36 of the LTCA The CCAC must provide an explanation of the plan of service if requested to do so (The CCAC must also comply with the provisions of the Personal Health Information and Protection Act 2004 (PHIPA)) Section 38 In providing or arranging community services the CCAC must comply with the rules and standards and must follow the procedures set out in the regulations There are currently no regulations addressing this issue Sections 39-49 The CCAC must establish a process for reviewing complaints made relating to eligibility exclusion of a particular service from a service plan amount of service termination of service quality of service and violation of the Bill of Rights The legislation sets out requirements relating to time lines notification and appeals Clients can appeal CCAC decisions relating to eligibility exclusion of service amount of service and termination of service to the Health Services Appeal and Review Board (See chapter 10 for information on complaints and appeals) As of February 16 2002 the provisions in sections 50 51 53 54 55 subsections 56(2) (3) (4) (5) (6) and section 57 of the LTCA regarding revocation of approved agency status and takeover powers for approved agencies do not apply to a CCAC Subsection 56(1) The Minister can order a CCAC to suspend or cease an activity and may take other appropriate action if the CCAC is carrying on an activity that is causing or is likely to cause harm to a personrsquos health safety or well-being Section 62 Program supervisors have broad inspection powers to ensure compliance by the CCAC with the LTCA regulations and agreements It is an offence to obstruct a program supervisor Section 66 It is an offence to knowingly provide false information in an application or report notice or other document required under the LTCA or to contravene sections 28 29 30 31 32 34 35 36 37 38 or subsections 59(7) (8) (10) (13) 62(6) (7) or (11)

September 2006 8

23 Ontario Regulation 552 Under the Health Insurance Act

The regulatory provisions under the Long-Term Care Act 1994 (LTCA) that support Community Care Access Centre (CCAC) service decisions do not include eligibility criteria for the professional services the CCAC is mandated to provide (Professional services include nursing occupational therapy physiotherapy social work speech-language pathology and dietetic services) The eligibility requirements for these services are set out in the regulations under the Health Insurance Act (HIA) CCACs are ldquohome care facilitiesrdquo under subsection 13(3)(b) of the HIA regulation A ldquohome care facilityrdquo means ldquoan agency approved by the Minister to provide home care servicesrdquo The HIA regulation states

s 13(1) In this section home care services means (a) the services that are provided on a visitation basis by a nurse or a nursing assistant3 (b) the services provided on a visiting basis by a physiotherapist occupational therapist speech therapist social worker or nutritionist4 (c) the provision of dressings and medical supplies (d) the provision of diagnostic and laboratory services (e) the provision of hospital and sickroom equipment (f) the provision of transportation services to and from the home to a hospital health facility or the attending physicians office as the case may be

Furthermore the HIA establishes the requirement that a person must be insured under the Ontario Health Insurance Plan (OHIP) (ie the person must have a valid health insurance number) and sets out the remaining conditions under which these services can be provided (ie eligibility requirements) The HIA states

s 13(3) Home care services provided by a home care facility to an insured person in his or her home are prescribed as insured services Clarification To be eligible for service from a CCAC a person must be insured under the OHIP Generally this means that the person is a resident of Ontario and is eligible and entitled to receive Ontariorsquos health care services s 13(4) It is a condition of payment for insured services under subsection (3) that (a) Revoked O Reg 17395 s 1 (1) (b) the services are necessary to enable the insured person to remain in his or her home or to make possible the insured persons return to his or her home from a hospital or other institution

3 Nursing assistants are also referred to as Registered Practical Nurses See subsection 711 in this manual 4 See ldquoDieteticsrdquo in subsection 713 in this manual

September 2006 9

(c) the needs of the insured person cannot be met on an out-patient basis (d) the insured person is in need of at least one professional service if the service for which payment is sought is described in clause (c) (d) (e) or (f) of the definition of home care services in subsection (1) Clarification The person must need at least one professional service in the home (ie nursing physiotherapy occupational therapy or speech therapy Note that social workers and dietitians are excluded from the definition of professional services for this purpose) in order to be eligible for dressings and medical supplies diagnostic and laboratory services hospital and sickroom equipment transportation services to and from home to a hospital health facility or attending physicianrsquos office s 13(4)(e) the services are provided in the insured persons home where such has been approved by the Minister as being suitable to enable the required care to be given Clarification The setting where the service is delivered must be appropriate in terms of safety space and privacy and adequate to support the necessary equipment and supplies that may be required Where the setting is not appropriate every effort must be made to adapt the program or equipment to fit the space or to assist the person to modify his or her environment in order to allow the service to be provided there When such arrangements cannot be made alternative courses of action should be discussed with the individual Every effort should be made before declaring the person ineligible on the grounds that the setting is unsuitable This section also restricts service provision to a personrsquos home to the exclusion of other sites s 13(4)(f) the services are available in the area where the insured person resides and Clarification The person can only access the services that are available within the personrsquos CCAC catchment area (eg in some cases not all services may be available within the area) s 13(4)(g) the services are reasonably expected to result in progress towards rehabilitation

Clarification It must be shown that the provision of service is goal oriented The HIA extends the provision of physiotherapy occupational and speech therapy to include persons in long-term care homes

s 13(5) Physiotherapy occupational therapy and speech therapy provided by a home care facility to an insured person who (a) is a resident in a nursing home (b) is a resident in a home for the aged established and maintained under the Homes for the Aged and Rest Homes Act or (c) is a resident in a charitable institution approved under the Charitable Institutions Act are prescribed as insured services

September 2006 10

The HIA also sets out the eligibility criteria for these services s 13(6) It is a condition of payment for insured services under subsection (5) that (a) Revoked O Reg 17395 s 1 (3) (b) Revoked O Reg 17395 s 1 (3) (c) the needs of the insured person cannot be met on an out-patient basis (d) the services are available in the area of the facility in which the insured person is a resident and (e) the services are reasonably expected to result in progress toward rehabilitation

September 2006 11

The Community Care Access Corporations Act 2001 (CCACA) governs the continuation creation reorganization and dissolution of Community Care Access Centres (CCACs) It also sets out the objects and powers of CCACs and provides for the composition and powers of boards of directors of these corporations CCAC board members and executive directors are appointed by Order in Council Concerning the objects of CCACs the CCACA states

s 5 The following are the objects of a community care access corporation 1 To provide directly or indirectly health and related social services and supplies and equipment for the care of persons 2 To provide directly or indirectly goods and services to assist relatives friends and others in the provision of care for such persons 3 To manage the placement of persons into long-term care facilities 4 To provide information to the public about community-based services long-term care facilities and related health and social services 5 To co-operate with other organizations that have similar objects (CCACA) 6 To carry out any charitable object that is prescribed and that is related to any of the objects described in paragraphs 1 to 5 Pursuant to section 2 of the CCACA the following CCACs are Community Care Access Corporations under the Act bull Access Centre for Community Care in Lanark Leeds and Grenville bull Access Centre for Hastings amp Prince Edward Counties bull Algoma Community Care Access Centre bull Brant Community Care Access Centre bull ChathamKent Community Care Access Centre bull Cochrane District Community Care Access CentreCentre drsquoaccegraves aux soins

communautaires du district de Cochrane bull Community Care Access Centre (CCAC) ndash Oxford bull Community Care Access Centre for Huron bull Community Care Access Centre for Kenora and Rainy River Districts bull Community Care Access Centre for the Eastern CountiesCentre drsquoaccegraves aux soins

communautaires pour les comteacutes de lrsquoEst bull Community Care Access Centre Niagara bull Community Care Access Centre of Halton bull Community Care Access Centre of London and MiddlesexCentre drsquoaccegraves aux soins

communautaires de London et Middlesex bull Community Care Access Centre of PeelCentre drsquoaccegraves aux soins communautaires de Peel bull Community Care Access Centre of The District of Thunder Bay bull Community Care Access Centre of Waterloo Region

September 2006 12

bull Community Care Access Centre of Wellington-Dufferin bull Community Care Access Centre of York Region bull Community Care Access Centre Perth County bull Community Care Access Centre Simcoe County Centre drsquoaccegraves aux soins communautaires

comteacute de Simcoe bull Community Care Access Centre Timiskaming Centre drsquoaccegraves aux soins communautaires

Timiskaming bull Durham Access to Care bull East York Access Centre for Community ServicesCentre drsquoaccegraves aux services

communautaires drsquoEast York bull Elgin Community Care Access Centre bull Etobicoke Community Care Access Centre Centre drsquoaccegraves aux soins communautaires

drsquoEtobicoke bull Grey-Bruce Community Care Access Centre bull Haliburton Northumberland and Victoria Long-Term Care Access Centre bull Haldimand-Norfolk Community Care Access Centre bull Hamilton Community Care Access Centre bull Kingston Frontenac Lennox amp Addington Community Care Access Centre bull Manitoulin-Sudbury Community Care Access Centre bull Near North Community Care Access Centre Centre drsquoaccegraves aux soins communautaires du

Moyen-Nord bull North York Community Care Access Centre Centre drsquoaccegraves aux soins communautaires de

North York bull Ottawa-Carleton Community Care Access CentreCentre drsquoaccegraves aux soins communautaires

drsquoOttawa-Carleton bull Renfrew County Community Care Access Centre bull SarniaLambton Community Care Access Centre bull Scarborough Community Care Access Centre Centre drsquoaccegraves aux soins communautaires de

Scarborough bull The Peterborough Community Access Centre Incorporated bull Toronto Community Care Access Centre bull WindsorEssex Community Care Access Centre and bull York Community Care Access CentreCentre drsquoaccegraves aux soins communautaires de York Two other CCACs that were not designated as corporations when the CCACA came into force are governed by integrated health service agencies that include hospitals LTC homes and CCACs These are bull Muskoka-East Parry Sound Community Care Access Centre and bull West Parry Sound Health Centre Community Care Access Centre Note On April 1 2003 the Etobicoke and York Community Care Access Centres merged bringing the total number of CCACs to 42

September 2006 13

Regulation 3302 also sets out the community services that a CCAC is approved to provide as follows bull all the professional services listed in the Long-Term Care Act 1994 (LTCA) (nursing

occupational therapy physiotherapy social work speech-language dietetics training a person to provide these services and providing equipment supplies or other goods relating to these services)

bull all the personal support services listed in the LTCA (personal hygiene activities routine personal activities of living assisting a person with these activities training a person to carry out or assist with these activities and providing equipment supplies or other goods relating to these services) and

bull the following homemaking services listed in the LTCA (housecleaning doing laundry shopping banking paying bills planning menus preparing meals caring for children assisting a person with these activities training a person to carry out or assist with these activities and providing equipment supplies or other goods relating to these activities)

Note The CCAC does not have the authority to provide ironing and mending services

September 2006 14

The legislation governing long-term care (LTC) homes sets out a standard province-wide placement co-ordination system Under this system responsibility for long-term care home placements resides with third party placement co-ordinators that are designated by the Minister of Health and Long-Term Care Under the current system the Community Care Access Centre (CCAC) is the designated placement co-ordinator with responsibility for authorizing admissions to LTC homes according to the legislated requirements The following three acts set out the requirements for admission bull Nursing Homes Act (NHA) ndash governs nursing homes bull Charitable Institutions Act (CIA) ndash governs charitable homes for the aged and bull Homes for the Aged and Rest Homes Act (HARHA) ndash governs municipal homes for the

aged The CCAC through its placement function is responsible for bull determining a personrsquos eligibility for LTC home placement bull if the person is determined eligible authorizing the personrsquos admission to the LTC home of

the personrsquos choice bull prioritizing persons for admission and bull keeping and managing the waiting list for admission to LTC homes In order to perform the placement services the CCAC is expected to have detailed information about the LTC homes in its area such as available programming unique features (including ethnic linguistic and dietary matters) in-house staffing number of beds and performance of each home In addition the CCAC is required to provide information about retirement homes and other alternative services to persons who wish to seek admission to a LTC home In carrying out these functions the CCAC is required to comply with the relevant provisions of the above listed statutes and their regulations Note Placement related provisions of the above statutes are discussed in greater detail in chapters 11 and 12 in this manual

September 2006 15

Community Care Access Centres (CCACs) fall within the definition of a government agency under section 1(b) of the French Language Services Act (FLSA) The 22 CCACs that serve areas designated under the FLSA (designated areas) are required to provide all their services (including communications for the purpose of providing or arranging these services) in English and French in accordance with clientsrsquo preferences The CCACs are accountable for services provided both directly and indirectly Request for proposal documents and contracts for in-home services must therefore clearly address French language service delivery obligations for service providers The CCACs are required to ensure compliance with the following criteria bull permanency and quality of service in French bull access to services provided in French (including communication for the purpose of

services) bull accountability for French language services and bull performance measures regarding French language services

CCAC Client Services Policy Manual Chapter 3 Eligibility Criteria for CCAC Services

September 2006 1

Eligibility Criteria for CCAC Services

The Community Care Access Centre (CCAC) must determine eligibility for professional personal support and homemaking services supplies equipment or other goods within their legislative authority school services (professional and personal support services) and equipment for childrenyouths in schools and receiving home schooling within their legislative authority and long-term care (LTC) homes Chapter 7 in this manual describes eligibility criteria for CCAC home care services and chapter 9 in this manual describes eligibility criteria for CCAC school services Subsection 39 in this manual describes eligibility for adult day services (ADS) while subsection 310 in this manual describes eligibility for Enhanced Respite funding services This section outlines the legislation regulations and policies relating to Ontario Health Insurance Plan (OHIP) coverage as the primary eligibility requirement for CCAC services Subsection 2(1) of Regulation 3302 of the Community Care Access Corporations Act 2001 (CCACA) provides that the CCAC is deemed to be an approved agency under the Long-Term Care Act 1994 (LTCA) The LTCA states

Plan of service s 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges the agency shall (a) assess the personrsquos requirements (b) determine the personrsquos eligibility for the services that the person requires and (c) for each person who is determined to be eligible develop a plan of service that sets out the amount of each service to be provided to the person

311 Legislated Criteria

Subsections 13(3) and (4) of Regulation 552 of the Health Insurance Act (HIA) provide the conditions under which home care services are prescribed as insured services The HIA states s 13(3) Home care services provided by a home care facility to an insured person in his or her home are prescribed as insured services

September 2006 2

Clarification To be eligible for service from a CCAC a person must be insured under the OHIP Generally this means that the person is a resident of Ontario and is eligible and entitled to receive Ontariorsquos health care services s 13(4) It is a condition of payment for insured services under subsection (3) that (a) Revoked O Reg 17395 s 1 (1) (b) the services are necessary to enable the insured person to remain in his or her home or to make possible the insured persons return to his or her home from a hospital or other institution (c) the needs of the insured person cannot be met on an out-patient basis (d) the insured person is in need of at least one professional service if the service for which payment is sought is described in clause (c) (d) (e) or (f) of the definition of home care services in subsection (1) (See definition of home care services in subsection 23 in this manual)

Clarification The person must need at least one professional service in the home (ie nursing physiotherapy occupational therapy or speech language pathology Note that social workers and dietitians are excluded from the definition of professional services for this purpose) in order to be eligible for dressings and medical supplies diagnostic and laboratory services hospital and sickroom equipment and transportation services to and from home to a hospital health facility or attending physicianrsquos office

s 13(4)(e) the services are provided in the insured persons home where such has been approved by the Minister as being suitable to enable the required care to be given Clarification The setting where the service is delivered must be appropriate in terms of safety space and privacy and adequate to support the necessary equipment and supplies that may be required Where the setting is not appropriate every effort must be made to adapt the program or equipment to fit the space or to assist the person to modify his or her environment in order to allow the service to be provided there safely and adequately When such arrangements cannot be made alternative courses of action should be discussed with the individual or the individualrsquos substitute decision-maker (SDM) Every effort should be made before declaring the person ineligible on the grounds that the setting is unsuitable This section also restricts service provision to a personrsquos home to the exclusion of other sites

s 13(4)(f) the services are available in the area where the insured person resides and

Clarification The person can only access the services that are available within the personrsquos CCAC catchment area (eg in some cases not all services may be available within the area)

s 13(4)(g) the services are reasonably expected to result in progress towards rehabilitation

Clarification It must be shown that the provision of service is goal-oriented

September 2006 3

To be eligible for Community Care Access Centre (CCAC) services under the Long-Term Care Act 1994 (LTCA) a person must be an insured person under the Health Insurance Act (HIA) pursuant to Regulation 38699 under the HIA Individuals who have not applied for a health card number may apply to become insured persons and receive a health card in accordance with section 11 of the HIA and sections 2 3 and 31 of Regulation 552 of the HIA All Ontario health card numbers must be verified by the CCAC for all services and admissions to long-term care (LTC) homes

321 Validation Process

The CCAC must verify an applicantrsquos Ontario health card number by using one of the following three health card validation systems 1 The Ministry of Health and Long-Term Care (MOHLTC) Interactive Voice Response

(IVR) system 1-800-262-6524 The IVR system enables the CCAC to determine the status of a health card number and version code at the time of service IVR is accessed using a MOHLTC approved PIN number and a touch tone phone

2 The MOHLTC Health Number Look-Up (HNLU) service 1-800-228-6519

The HNLU service is appropriate to use in situations where a client does not have his or her health numberversion code available at the time of service or if after validating the health numberversion code using the IVR system the IVR system indicates the client has an incorrect version code Client consent is required before releasing any information Health Number Release form (014-1265-84) can be printed from website [httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailopenformampENV=WWEampNO=014-1265-84] (For clients not having a health card or number in their possession see subsection 322 in this manual)

3 For additional information the CCAC can contact a MOHLTC staff person as follows

bull call the local OHIP office (The number is in blue pages of the telephone book under Health)

bull check the website at [httpwwwhealthgovoncaenglishpublicpublic_mnhtml] and go to OHIP

bull from anywhere in Ontario call the general information line at 1-800-268-1154 or bull from area code 416 call (416) 314-5518

Hours of operation for these services are 830 am to 500 pm Monday through Friday

September 2006 4

322 Client Does Not Have a Health Card or Number in His or Her Possession

A CCAC that is registered with the HNLU system will ask the person who does not have his or her health card or number in his or her possession to complete and sign the Health Number Release form (014-1265-84) which can be printed from website [httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailopenformampENV=WWEampNO=014-1265-84] Client Has OHIP Coverage bull With the release form completed the CCAC calls a HNLU telephone number at anytime

(24 hours seven days a week) bull The HNLU agent provides the number to the CCAC at time of registration bull The CCAC identifies itself with its designated HNLU PIN number bull An HNLU agent releases the required information if available bull The CCAC follows up by faxing the personrsquos completed Health Number Release form to

the HNLU Client Does Not Have OHIP Coverage (See subsection 34 in this manual)

September 2006 5

To qualify for Ontario Health Insurance Plan (OHIP) coverage a person must be a resident of Ontario as defined in Regulation 552 of the Health Insurance Act (HIA) Except for those residents identified in section 11(1)(a) below a resident must ordinarily be present in Ontario which means the resident must make his or her permanent and principal home in Ontario and with some exceptions be present in Ontario for 153 days in any given 12-month period Regulation 552 of the HIA states s 11(1) a ldquoresidentrdquo is an individual (a) who is present in Ontario by virtue of an employment authorization issued under the

Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme administered by the federal Department of Citizenship and Immigration or

(b) who is ordinarily resident in Ontario and who is one of the following

1 A Canadian citizen or a landed immigrant under the Immigration Act (Canada) 2 A person who is registered as an Indian under the Indian Act (Canada) 3 A Convention refugee as defined in the Immigration Act (Canada) 4 A person who has submitted an application for landing under the Immigration Act (Canada) who has not yet been granted landing and who has been confirmed by the federal Department of Citizenship and Immigration as having satisfied the medical requirements for landing 5 Revoked OReg 8795 s 1 6 A person who has finalized a contract of employment or an agreement of employment with a Canadian employer situated in Ontario and who at the time the person makes his or her application to become an insured person holds an employment authorization under the Immigration Act (Canada) which

i names the Canadian employer ii states the persons prospective occupation and iii has been issued for a period of at least six months

7 The spouse same-sex partner or dependent child under the age of 19 years of a person referred to in paragraph 6 if the Canadian employer provides the General Manager with written confirmation of the employers intention to employ the person referred to in paragraph 6 for a period of three continuous years

Note The General Manager is the person responsible for administering OHIP

s 11(1) 8 A member of the clergy of any religious denomination who has finalized an agreement of employment to minister on a full-time basis to a religious congregation in Ontario for a period of not less than six consecutive months and whose duties will consist mainly of preaching doctrine presiding at liturgical functions and spiritual counselling 9 The spouse or same-sex partner and the dependent children under the age of 19 years of a member of the clergy referred to in paragraph 8 if the religious congregation provides the General Manager with written confirmation that it intends to employ the member for a period of at least three consecutive years

September 2006 6

10 A person granted a ministers permit under section 37 of the Immigration Act (Canada) which indicates on its face that the person is a member of an inadmissible class designated as case type 86 87 88 or 89 or if the permit is issued for the purpose of an adoption by an insured person as case type 80 11 A person granted an employment authorization under the Live-in Care Givers in Canada Programme or the Foreign Domestic Movement administered by the federal Department of Citizenship and Immigration

Regulation 552 of the HIA states s 11(1) For the purposes of subsection (1) a person is ordinarily resident in Ontario only if (a) in the case of an insured person or of a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority the person

(i) makes his or her permanent and principal home in Ontario and (ii) subject to subsections (3) (4) (5) and (6) is present in Ontario for at least 153 days in any 12-month period and

(b) in the case of a person who is applying to be an insured person for the first time or who is re-establishing his or her entitlement after having been uninsured for a period of time other than a person who comes to Ontario from another province or territory in which that person was insured by the provincial or territorial health insurance authority the person

(i) intends to make his or her permanent and principal home in Ontario and (ii) is present in Ontario for at least 153 days immediately following the application

Subsections 11(3) and (4) of Regulation 552 of the HIA provide that some persons may be exempted from the requirement to remain in Ontario for 153 days in 12-month period if bull the person is required to travel frequently outside Ontario for his or her employment bull the General Manager has approved payment for a treatment to be provided to the person

outside Canada or bull the person leaves Canada to work to attend a full-time educational program or to engage in

missionary work if he or she intends to return to make a permanent and principle home in Ontario and met the 153 day requirement for the two years immediately prior to leaving Ontario

331 Three-Month Waiting Period for OHIP Coverage

Applications

The HIA states

s 3(1) A resident who is not otherwise an insured person may become an insured person by submitting an application to the General Manager (11)1 An application under subsection (1) shall be in the form approved by the Minister

September 2006 7

(2) A resident making an application under subsection (1) shall be present in Ontario at the time of submitting the application (3) A resident who makes an application under subsection (1) shall only be enrolled as an insured person three months after the day the person becomes a resident

332 Exceptions to the Three-Month Waiting Period for OHIP Coverage

The HIA states s 3(4) The three-month waiting period referred to in subsection (3) does not apply to the following persons who are residents and who apply to become insured persons

1 A child under the age of 16 who is adopted by an insured person 2 A newborn born in Ontario to an insured person 3 A person who satisfies the General Manager that he or she has been resident in Ontario for at least three months at the time of his or her application to become an insured person 4 A member of the Canadian Forces who was an insured person immediately before becoming a member and is discharged from the Canadian Forces 5 A member of the Royal Canadian Mounted Police who had been appointed to a rank therein and who was an insured person immediately before becoming a member and is discharged 6 A Canadian diplomat who returns to Ontario after a posting to a place outside Canada and who was an insured person immediately before the posting 7 The spouse same-sex partner or dependent child under 19 years of age of a Canadian diplomat referred to in paragraph 6 who was an insured person immediately before the posting of the Canadian diplomat 8 An inmate at a penitentiary as defined in the Corrections and Conditional Release Act (Canada) who is released 9 An inmate at a correctional institution established or designated under Part II of the Ministry of Correctional Services Act who is released 10 A person who

i takes up residence in Ontario directly from elsewhere in Canada where the person was insured under a government health plan or a hospital insurance plan and ii upon taking up residence in Ontario becomes a resident of an approved charitable home for the aged under the Charitable Institutions Act a home under the Homes for the Aged and Rest Homes Act or a nursing home under the Nursing Homes Act

11 A Convention refugee as defined in the Immigration Act (Canada) 12 A person who has made a claim to be a Convention refugee under the Immigration Act (Canada) and in respect of whom

i a senior immigration officer has determined that the person is eligible to have his or her claim determined by the Refugee Division and ii a removal order as defined in the Immigration Act (Canada) has not been executed

13 A person granted a Ministers permit under section 37 of the Immigration Act (Canada) which indicates on its face that the person is a member of an inadmissible class designated as case type 86 87 88 or 89 or if the permit is issued for the purpose of an adoption by an insured person as case type 80

September 2006 8

14 A person who is present in Ontario by virtue of an employment authorization issued under the Caribbean Commonwealth and Mexican Seasonal Agricultural Workers Programme administered by the federal Department of Citizenship and Immigration 15 A pregnant woman who became pregnant before April 1 1994 and who applied to become an insured person during the course of that pregnancy 16 A pregnant woman who

i has submitted an application for landing under the Immigration Act (Canada) and has not yet been granted landing ii became pregnant before April 1 1994 and applied to become an insured person during the course of that pregnancy and iii has been confirmed by the federal Department of Citizenship and Immigration as having satisfied A all the medical requirements for landing or B all the medical requirements for landing except for the requirement to submit to an x-ray

September 2006 9

34 Persons without OHIP Coverage are Ineligible for CCAC

Services

Ontario Health Insurance Plan (OHIP) coverage is one eligibility criterion for Community Care Access Centre (CCAC) services This subsection identifies the circumstances under which a person may or may not be covered by OHIP and where CCAC services can be provided

341 Persons Who May be Eligible for OHIP Coverage

bull Newcomers to Ontario from another country may be eligible for CCAC services if they have applied for and are entitled to OHIP coverage and have served their three-month waiting period

bull Newcomers from another Canadian province or territory who have moved to Ontario may be eligible for CCAC services if they have applied and qualify for OHIP coverage and have served their three-month waiting period

(See other eligibility criteria in section 31 in this manual)

342 Persons Without OHIP Coverage Not Eligible for CCAC Services

bull Visitors to Ontario from another province or country including foreign students are not eligible to receive CCAC services

bull Royal Canadian Mounted Police (RCMP) are not eligible to receive CCAC services if these services are covered by their Public Service Health Care Plan

Note RCMP personnel are not entitled to receive a drug card from the CCAC as drug coverage is available through their Public Service Health Care Pan

bull Canadian Armed Forces personnel are not eligible to receive CCAC services if these services are covered by the National Defense Medical Centre

bull Inmates of federal penitentiaries are not eligible for OHIP as their health insurance coverage is through the Canadian government (although inmates of the Province of Ontario corrections institutions are covered by OHIP for their period of incarceration CCACs must assess whether these inmates require CCAC services if similar services are provided by correctional institutions)

343 Visitors from Other ProvincesTerritories Not Eligible for CCAC Services

May be Eligible for Hospital and Primary Care Services

Visitors to Ontario from another province or territory who require emergency or in-patient services in a hospital are covered for these services by their home provincersquos or territoryrsquos health insurance plan through a reciprocal agreement between provinces or territories Visitors who require the services of a physiciannurse practitioner in an office clinic or community

September 2006 10

health centre may receive those services and the physicianclinic may directly bill the visitorrsquos health insurance program of their home province or territory Alternatively the physicianclinic may bill the visitor for the service and the visitor should submit the bill for reimbursement to the health insurance plan in the visitorrsquos home province

344 Role of the Case Manager When a Person is Deemed Ineligible for Service

Because He or She Does Not Have a Valid Ontario Health Card

When an individual is deemed ineligible for CCAC services because the individual does not have valid OHIP coverage the case manager must bull explain the reasons for not providing CCAC funded service bull assist the person with his or her options (including directing the person to the local OHIP

office to confirm whether OHIP coverage is a possibility) and bull link the person to the appropriate health social service or community resources that can

address the personrsquos needs The case managerrsquos judgement will determine the duration of the provision of case management service to the individual (eg families requiring ongoing assistance with end of life care to a loved one who does not have OHIP coverage may receive case management services)

September 2006 11

35 Out-of-Province Applicants to Ontariorsquos Long-Term Care

Residents of other provinces or a territory who plan to move to Ontario and need to be placed in a long-term care (LTC) home are first required to have prior approval of Ontario Health Insurance Plan (OHIP) coverage

351 Pre-Registration Process for Obtaining an Ontario Health Card

When a Community Care Access Centre (CCAC) receives a request for placement of a person who is planning to move from another province directly into a LTC home the CCAC must redirect the person or the personrsquos lawfully authorized substitute decision-maker (SDM) to OHIP head office at the following address OHIP Pre-Registration for Long-Term Care Eligibility and Portability Services Registration and Claims Branch Ministry of Health and Long-Term Care 49 Place drsquoArmes 3rd floor Kingston ON K7L 5J3 telephone (613) 548-6363 facsimile (613) 548-6557 Eligibility Services will provide a Registration for Ontario Health Coverage form and pre-registration information to the person or the personrsquos lawfully authorized substitute (eg power of attorney) The person or his or her SDM will complete and return the OHIP registration form to Eligibility Services along with a copy of a suitable citizenship or immigration document such as a Canadian birth certificate landed immigrant document or Canadian passport If the applicant is eligible for OHIP coverage Eligibility Services will give prior approval of the applicantrsquos OHIP coverage and send a letter confirming prior approval to the CCAC This letter will serve temporarily to fulfill the eligibility requirement that the person is insured under the Health Insurance Act (HIA) and allows the CCAC to proceed with the applicantrsquos eligibility determination and authorization of admission processes The applicant is not registered for OHIP coverage or issued a health insurance number until after the applicant has arrived in Ontario and has been admitted to a LTC home On the day of admission to the LTC home the CCAC must send Eligibility Services a completed Authorization for Admission to a LTC Facility indicating that the applicant has been placed Eligibility Services will then complete the applicantrsquos OHIP registration issue the new resident an Ontario health insurance number that is effective on the day of admission to the LTC home and will advise the CCAC

September 2006 12

Note To be eligible for this pre-registration process the applicant must be an insured resident of another province or territory in Canada when applying for OHIP coverageadmission to the LTC home and the applicant must move directly into a provincially-regulated LTC home (eg a resident in Winnipeg must move directly into a LTC home in Toronto) Applicants living outside Canada are not eligible for this pre-registration process even if they are Canadian citizens returning to Ontario

September 2006 13

Homeless persons do not always have Ontario Health Insurance Plan (OHIP) coverage or the supporting documentation required to obtain coverage With the personrsquos consent a Community Care Access Centre (CCAC) must contact the local district OHIP office to confirm whether the individual has valid OHIP coverage using the Health Number Release form process (outlined in subsection 32 in this manual) A homeless person who does not have OHIP coverage nor the documents required to obtain coverage can apply for coverage with the support of an agency (as approved under the Long-Term Care Act 1994 (LTCA)) that works with the homeless The local OHIP office can advise how to assist the person The process is as follows bull To eliminate barriers to health care access the Ministry of Health and Long-Term Care

(MOHLTC) policy permits an ldquoapproved agencyrdquo dedicated to serving the homeless to issue a special ldquoagency letterrdquo that confirms the personrsquos identity and supports the personrsquos application for OHIP coverage In the letter the agency commits to assisting the person in obtaining necessary documents to meet eligibility requirements for health coverage and to provide the agencyrsquos residentialmailing address for the person

bull The homeless person visits a local MOHLTC office or an outreach registration site (usually a community health centre) and provides the ldquoagency letterrdquo plus whatever documents the person has to register for health coverage

bull The MOHLTC will usually provide the person with one-year interim health coverage to allow the agency to assist the person in obtaining necessary documentation to meet eligibility requirements for health coverage

bull Persons who use the ldquoagency letterrdquo process to obtain health coverage must meet the photo and signature requirements of the photo health card There are no exemptions

September 2006 14

37 OHIP CoverageCCAC Services for Refugees 371 Interim Federal Health Program

Essential medical coverage for refugee claimants in Ontario is usually paid for by the Interim Federal Health (IFH) program administered by Citizenship and Immigration Canada The purpose of the IFH is to pay for in-Canada health care for certain immigrants who are unable to pay for expenses related to urgent and essential services Coverage is provided pending their qualification for other means of payment This applies principally to refugee claimants convention refugees and members of the humanitarian designated classes The fund is not meant to replace provincial health plans and does not provide the same extent of coverage allowed to permanent residents The IFH program benefits are limited to bull essential health services for the treatment and prevention of serious medical and dental

conditions (including immunizations and other vital preventative medical care) bull essential prescription medications bull contraception prenatal and obstetrical care and bull the immigration medical examination for those individuals who are unable to pay for the

Note The IFH program does not cover routine medical or eye or dental exams 372 Eligibility for Interim Federal Health Program

Eligibility for the IFH program is determined by Citizenship and Immigration Canada

373 Process to Obtain Approval for CCAC In-home and School Services

Before a Community Care Access Centre (CCAC) may provide service to a refugee prior approval is required from Citizenship and Immigration Canada The person must be in possession of an Interim Health Certificate of Eligibility a document issued to the person by an immigration officer Attached to the certificate is a letter that outlines the benefits to which the person is entitled The CCAC must fax a copy of the Interim Health Certificate of Eligibility document and background information that outlines the services required the reason for home care an estimate of the time frame for the service to be carried out and the expected date of discharge from service to

September 2006 15

Medical Director IFHCIC Interim Federal Health Program Jean Edmonds Building 365 Laurier Avenue West South Tower 14th Floor Ottawa ON K1A 1L1 toll free facsimile 1-800-362-7456

Note The Interim Federal Health Program Information Handbook for Health Care Providers can be accessed at [httpwwwfasadmincomimagespdfifh_information_handbookpdf] Once the Medical Director of the IFH program reviews the information the CCAC is advised if the service has been approved and CCAC services may be initiated The CCAC must send a copy of the Interim Health Certificate of Eligibility with the first invoice submission and monthly invoices to FAS Benefit Administrators Ltd 9707-110 Street 9th Floor Edmonton AB T5K 3T4 toll free telephone (English and French) 1-800-770-2998 e-mail infofasadmincom website wwwfasadmincom

September 2006 16

38 OHIP CoverageCCAC Services for a Person on Leave of

Absence from a LTC Home

A person who is a resident of a long-term care (LTC) home and who is on a leave of absence from the LTC home (eg on vacation or as a result of a home outbreak) may be eligible to receive home care services from the Community Care Access Centre (CCAC) The same applies to a person who is in the LTC home Convalescent Care Program or on a leave of absence from a hospital The person must have valid Ontario Health Insurance Plan (OHIP) coverage and must be assessed as eligible and needing services provided by the CCAC The CCAC must determine the priority for the person to receive the assessed services

September 2006 17

39 Eligibility for Adult Day Services 391 Program Description

Adult day services (ADS) are community support services that provide supervised individual programming in a group setting in order to

bull assist individuals to achieve and maintain their maximum level of functioning bull prevent premature and inappropriate institutionalization and bull provide respite information and support to caregivers ADS are intended to provide services to individuals with high care needs and their caregivers ADS serve the frail elderly andor individuals with Alzheimer disease progressive cognitive disorders or dementias Components of the service include planned social recreational and physical activities meals transportation (if required) personal supportattendant care and minor health care services (eg monitoring medications)

Note Medical services are not included in the range of services offered in ADS

392 Community Care Access Centre and Adult Day Services

In some cases the Community Care Access Centre (CCAC) and the ADS may agree that the CCAC will be responsible for assessments and determination of eligibility for ADS In collaboration with staff of the Ministry of Health and Long-Term Care (MOHLTC) regional office both the CCAC and ADS must establish local eligibility criteria for priority admission to the ADS The CCAC must develop agreements with other CCACs regarding the acceptance and processing of applications from outside their catchment area

393 Optional Trial Period

An optional trial period is available to assess whether ADS can appropriately serve a person who is deemed eligible by the CCAC For example ADS may not be suitable for a person in situations where the safety of other clients is compromised or the care needs of the client exceed the ability of the services

September 2006 18

310 Eligibility for Enhanced Respite Funding 3101 Program Description

Enhanced Respite for Children who are Medically Fragile andor Technology Dependent (Enhanced Respite) is a grant paid to eligible families who are caring for a child at home who is medically fragile andor technology dependent The Ministry of Children and Youth Services (MCYS) is responsible for the provision of funding and policies related to Enhanced Respite including the criteria used by the Community Care Access Centre (CCAC) to determine eligibility for funding Families caring for medically fragile andor technology dependent children often need more services and supports than may be available through other programs and service providers The respite needs of these parents are typically very high Families may provide 16 or more hours of care daily and routinely provide monitoring and care at night1 Under Enhanced Respite a family may receive up to $3500 per eligible child annually There are no restrictions on the type of respite a family may purchase Funds may be used flexibly to purchase in-home or out-of-home services or a combination of in-home and out-of-home services The grant is provided in addition to care treatment andor funding from other sources The Enhanced Respite funding must not result in any reduction in existing funding from other sources This includes but is not limited to funds provided under the Special Services at Home andor the Assistance for Children with Severe Disabilities programs and home care services arranged by the CCAC

3102 CCAC Responsibilities

The CCAC is responsible for determining a childrsquos eligibility in accordance with approved eligibility criteria Related CCAC responsibilities include the following activities bull provide eligible families with written notification of their eligibility for Enhanced Respite

and bull notify the Ministry of Children and Youth Services-Ministry of Community and Social

Services (MCYS-MCSC) regional office of decisions of eligibility made on behalf of children

1 Enhanced Respite for Families Caring for Medically Fragile andor Technology Dependent Children at Home Implementation Plan 1999-2000

September 2006 19

3103 Role of the MCYS-MCSS Regional Office

The regional offices which administer the funding paid on behalf of eligible families are responsible for the following activities bull inform eligible families of the amount approved for the current fiscal year and provide the

families with authorization numbers bull reimburse families based on submitted invoices for respite services or pay the service

provider directly and bull monitor the Enhanced Respite resources provided to eligible families

3104 Eligibility Criteria for Enhanced Respite Funding

Eligibility Criteria2 Only medically fragile andor technology dependent children with chronic conditions who meet the following eligibility criteria based on their age and care requirements will qualify for the enhancement

bull age children under 18 years of age and bull care requirements

bull childrsquos care requirements resulting from medical or physiological condition(s) that require ongoing frequent or time-consuming caregiver intervention and monitoring on a 24-hour basis for survival

bull there must be a demonstrable risk of significant exacerbation of the childrsquos health status associated with not meeting the 24-hour care requirements

bull children with behavioural disorders alone are not eligible and bull only children who meet the above criteria and fall within the following categories of care

requirements will qualify

September 2006 20

Group Care RequirementsNeeds

Group 1 Children dependent at least part of each day on mechanical ventilators

Group II Children requiring prolonged intravenous administration of bull nutritional substances bull drugs

Group III Children with prolonged dependence on other device-based support for bull tracheotomy tube care bull suctioning bull oxygen support bull tube feeding

Group IV Children with prolonged dependence on other devices which compensate for vital body functions who require daily or near daily nursing care including children requiring bull apnea monitors (cardio respiratory) bull renal dialysis due to kidney failure bull urinary catheters or colostomy bags plus substantial nursing care

Group V3 Medically fragile who meet care requirements but do not use technological device

bull Children who are medically fragile according to the care requirements but do not use a technological device are eligible even if the child sleeps through the night Eligibility should not be declined solely because the child sleeps through the night

bull Enhanced Respite funding for a Group V child may be used to purchase either in-home or out-of-home respite services or a combination of in-home and out-of-home respite There is no restriction on the type of respite care that may be purchased by a family

Note It is recognized that aspects of the eligibility criteria for Enhanced Respite funding would benefit from additional clarification Such requests most often are related to the Group V category children who are medically fragile according to the care requirements but who do not use a technological device

3 The addition of a fifth category of care was made in a February 15 1999 memorandum sent to CCACs from the Office of the ADM Office of Integrated Services for Children (OISC)

September 2006 21

3111 Services to Persons Residing in First Nations Communities

Health and social services in First Nations communities are funded by both federal and provincial levels of government through the Federal Department of Indian and Inuit Affairs Health Canadarsquos Medical Services Branch and the Ontario Ministry of Health and Long-Term Care (MOHLTC) The First Nations manage and deliver various health and social services such as healing centres clinics offering medical services and some long-term care services for their members The numbers and types of such services have been negotiated over time under various initiatives and funding sources and vary from community to community Individuals residing in First Nations communities are eligible for Community Care Access Centre (CCAC) services CCACs must first assess whether these individuals require CCAC services if similar services are provided through the First Nations community CCAC services should coordinate with and complement services available in the First Nations community rather than duplicate those services To achieve this goal CCAC staff need to be aware of the services available in First Nations communities within their service area The CCAC may enter into formal agreements with First Nations or organizations representing First Nations (eg Union of Ontario Indians) in order to formalize a process that will facilitate and ensure that ongoing effective linkages are maintained

3112 Long-Term Care Services to Aboriginal Persons Not Residing in First Nations Communities Aboriginal people not living in First Nations communities may also receive services from the CCAC CCACs must assess requirements and determine eligibility for services on the same basis as any other Ontario resident The MOHLTC provides funding to some aboriginal organizations to provide home and community care services to aboriginal people both on and off reserve The types and availability of services vary across the province

CCAC Client Services Policy Manual Chapter 4 Consent to Treatment Admission to Long-Term Care Home and Community Services

September 2006 1

Consent to Treatment Admission to Long-Term Care Home and Community Services

Client consent is a critical component of the various pieces of legislation that affect the functions of the Community Care Access Centre (CCAC) The Nursing Homes Act (NHA) the Homes for the Aged and Rest Homes Act (HARHA) the Charitable Institutions Act (CIA) the Long-Term Care Act 1994 (LTCA) and the Health Care Consent Act 1996 (HCCA) set out the provisions that the CCAC must follow when obtaining consent from a person or where the person is incapable from the personrsquos lawfully authorized substitute decision-maker (SDM) for decisions regarding consent to community service treatment andor admission to a long-term care (LTC) home A person who makes decisions for another person is called a ldquosubstitute decision-makerrdquo (SDM) All legislative references in this chapter unless stated otherwise are to the HCCA Subsections 43 to 47 in this manual outline the processes for seeking consent to treatment and subsections 48 to 410 outline the processes for seeking consent to admission to a LTC home

411 Applicable Legislation

Long-Term Care Act 1994 Section 24 of the LTCA states that ldquoNothing in this Act authorizes an approved agency to assess a personrsquos requirements determine a personrsquos eligibility or provide a community service to a person without the personrsquos consentrdquo Before the CCAC is authorized to assess a personrsquos requirements determine eligibility or provide any community service (eg homemaking or personal support services) informed consent must be obtained from the person Subsection 3(1)6 of the LTCA states that ldquoa person has the right to give or refuse consent to the provision of any community servicerdquo

September 2006 2

Under subsection 2(3) of the LTCA community services are community support services homemaking services personal support services and professional services Each of these services is defined in subsections 2(3) to (7) of the LTCA

Under section 10 of the HCCA a health practitioner (a defined term under the HCCA) must not administer ldquotreatmentrdquo (also a defined term under the HCCA) and must take reasonable steps to ensure that it is not administered unless he or she is of the opinion that the person is capable with respect to the treatment and the person has given consent If the person is not capable of giving consent to the ldquotreatmentrdquo consent must be sought from the personrsquos legally authorized SDM who has the authority to make the decision Therefore the CCAC must obtain consent from the person or the personrsquos SDM where applicable to both the assessment for eligibility and if determined to be eligible the delivery of services (See subsection 22 in this manual for an overview of the LTCA)

Health Care Consent Act 1996 The HCCA comprehensively deals with the issue of consent to treatment and contains a substitute decision-making scheme to obtain consent to treatment on behalf of persons who are incapable of making a treatment decision The HCCA also provides a substitute decision-making scheme to obtain consent on behalf of persons who are incapable of making decisions about admission to ldquocare facilitiesrdquo (LTC homes) and the use of personal assistance services in a LTC home The HCCA bull confirms the right of capable individuals to make informed decisions about treatment bull sets out the elements of consent and informed consent to treatment in one piece of

legislation that applies to treatment in all settings by health practitioners specified in the HCCA

bull provides a mechanism to obtain decisions from a SDM for those who at the time treatment admission to a LTC home or personal assistance service in a LTC home is proposed or required are not mentally capable of making the decision on their own behalf

bull allows persons who are found incapable of consenting to treatment admission to a LTC home or a personal assistance service in a LTC home to apply to the Consent and Capacity Board to have the finding reviewed and

bull requires that wishes regarding treatment admission to a LTC home and personal assistance services expressed by a person while capable and after reaching the 16 years of age be followed by the SDM when making a decision on behalf of an incapable person

Substitute Decisions Act 1992

The Substitute Decisions Act 1992 (SDA) is also relevant when considering decision-making for persons that are incapable of making decisions about their personal care and managing their property The SDA governs what may happen when a person is not mentally capable of making certain decisions about their own property (including finances) or personal care

September 2006 3

Under the SDA a person who is capable of doing so may through the following documents appoint a SDM to make decisions on his or her behalf if he or she becomes incapable of making these decisions in the future

bull Continuing power of attorney for property a legal document in which a person gives someone else (the attorney(s) for property) the legal authority to make decisions regarding his or her finances (property) if he or she becomes mentally incapable of making those decisions The power of attorney may provide that it comes into effect on a specified date or when a specified contingency happens (such as when the person becomes incapable of managing property) A person must be at least 18 years old in order to make a continuing power of attorney for property

bull Power of attorney for personal care a legal document in which a person gives someone else (the attorney(s) for personal care) the legal authority to make personal care decisions (regarding health care nutrition shelter clothing hygiene or safety) on his or her behalf if he or she becomes mentally incapable of making decisions about any or all of those matters A person must be at least 16 years old to make a power of attorney for personal care

A person who is incapable of making decisions about property or personal care may still be capable of making a power of attorney The person named in the power of attorney to make the decisions is called the ldquoattorneyrdquo in this context attorney does not mean a lawyer The attorney is the SDM for the person when a valid power of attorney becomes effective There is no legal requirement that a person must appoint an attorney for property or personal care Where there is no power of attorney document or there are other circumstances that make appointing a guardian necessary the SDA sets out the circumstances and procedures for the appointment of a guardian who is authorized to act as the SDM for property or personal care for a person who is mentally incapable It should not be assumed that attorneys or guardians have the authority to make all personal care or property decisions on behalf of the incapable person The terms of the power of attorney or the court order appointing the guardian indicate the scope of the SDMrsquos authority to make decisions and any limitations on the authority The SDA and the HCCA operate in tandem with each other The SDA provides that the SDM (either the attorney for personal care or guardian for personal care for an incapable person) is required to follow the provisions of the HCCA when making decisions on the incapable personrsquos behalf to which the HCCA applies Decisions to which the HCCA applies are treatment admission to a LTC home and personal assistance services in a LTC home When an incapable person does not have an SDM under the SDA with the authority to make a decision under the HCCA the HCCA permits other persons to act as the SDM to make decisions about treatment admission to a LTC home and personal assistance services in a LTC home without a court appointment These other persons are family members including spouses a board appointed representative or the Public Guardian and Trustee See the discussion below for more details about the HCCA

September 2006 4

42 Definitions of Terms in the Health Care Consent Act 1996

Subsection 2(1) of the Health Care Consent Act 1996 (HCCA) sets out the following definitions Board means the Consent and Capacity Board care facility means (a) an approved charitable home for the aged as defined in the Charitable Institutions Act (b) a home or joint home as defined in the Homes for the Aged and Rest Homes Act (c) a nursing home as defined in the Nursing Homes Act or (d) a facility prescribed by the regulations as a care facility Note The care facilities listed above are referred to as long-term care (LTC) homes throughout this manual At this time there are no regulations prescribing other facilities under (d) course of treatment means a series or sequence of similar treatments administered to a person over a period of time for a particular health problem health practitioner means (a) a member of the College of Audiologists and Speech-Language Pathologists of Ontario (b) a member of the College of Chiropodists of Ontario including a member who is a podiatrist (c) a member of the College of Chiropractors of Ontario (d) a member of the College of Dental Hygienists of Ontario (e) a member of the Royal College of Dental Surgeons of Ontario (f) a member of the College of Denturists of Ontario (g) a member of the College of Dietitians of Ontario (h) a member of the College of Massage Therapists of Ontario (i) a member of the College of Medical Laboratory Technologists of Ontario (j) a member of the College of Medical Radiation Technologists of Ontario (k) a member of the College of Midwives of Ontario (l) a member of the College of Nurses of Ontario (m) a member of the College of Occupational Therapists of Ontario (n) a member of the College of Optometrists of Ontario (o) a member of the College of Physicians and Surgeons of Ontario (p) a member of the College of Physiotherapists of Ontario (q) a member of the College of Psychologists of Ontario (r) a member of the College of Respiratory Therapists of Ontario (s) a naturopath registered as a drugless therapist under the Drugless Practitioners Act or (t) a member of a category of persons prescribed by the regulations as health practitioners Note At this time there are no regulations that prescribe additional categories of health practitioners Social workers are not considered health practitioners under the HCCA

September 2006 5

personal assistance service means assistance with or supervision of hygiene washing dressing grooming eating drinking elimination ambulation positioning or any other routine activity of living and includes a group of personal assistance services or a plan setting out personal assistance services to be provided to a person but does not include anything prescribed by the regulations as not constituting a personal assistance service plan of treatment means a plan that (a) is developed by one or more health practitioners (b) deals with one or more of the health problems that a person has and may in addition deal with one or more of the health problems that the person is likely to have in the future given the persons current health condition and (c) provides for the administration to the person of various treatments or courses of treatment and may in addition provide for the withholding or withdrawal of treatment in light of the persons current health condition treatment means anything that is done for a therapeutic preventive palliative diagnostic cosmetic or other health-related purpose and includes a course of treatment plan of treatment or community treatment plan but does not include (a) the assessment for the purpose of this Act of a persons capacity with respect to a treatment admission to a care facility or a personal assistance service the assessment for the purpose of the Substitute Decisions Act 1992 of a persons capacity to manage property or a persons capacity for personal care or the assessment of a persons capacity for any other purpose (b) the assessment or examination of a person to determine the general nature of the persons condition (c) the taking of a persons health history (d) the communication of an assessment or diagnosis (e) the admission of a person to a hospital or other facility (f) a personal assistance service (g) a treatment that in the circumstances poses little or no risk of harm to the person (h) anything prescribed by the regulations as not constituting treatment Section 9 provides that in Part II of the HCCA dealing with treatment a substitute decision-maker (SDM) means a person who is authorized under section 20 to give or refuse consent to a treatment on behalf of a person who is incapable with respect to the treatment

421 Capacity and Presumption of Capacity

The HCCA states Capacity s 4(1) A person is capable with respect to a treatment admission to a care facility or a personal assistance service if the person is able to understand the information that is relevant to making a decision about the treatment admission or personal assistance service as the case may be and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision

September 2006 6

Presumption of capacity s 4(2) A person is presumed to be capable with respect to treatment admission to a care facility and personal assistance services Exception s 4(3) A person is entitled to rely on the presumption of capacity with respect to another person unless he or she has reasonable grounds to believe that the other person is incapable with respect to the treatment the admission or the personal assistance service as the case may be Note The Community Care Access Centre (CCAC) may rely on the presumption that a person has capacity unless reasonable grounds exist to believe otherwise

Capacity with respect to personal care refers to a personrsquos ability to understand information relevant to making decisions about aspects of the personrsquos personal care such as health care nutrition shelter clothing hygiene or safety and ability to appreciate the reasonably foreseeable consequences of a decision or lack of decision (If the health care decisions are about treatment admission to a long-term care (LTC) home or personal assistance services for a resident in a LTC home the HCCA governs the substitute decision-making) A person may be capable of making decisions about one or more aspects of personal care but not others For example a person may be capable of making decisions about clothing but not health care a person may be capable of making decisions about health care but may no longer be capable1 of making decisions about property (eg banking paying bills managing investments) and vice versa It should also be noted that a person who is physically unable to care for himself or herself may be capable of making decisions about personal care

422 Wishes of Capable Person

The HCCA states Wishes s 5(1) A person may while capable express wishes with respect to treatment admission to a care facility or a personal assistance service Manner of expression s 5(2) Wishes may be expressed in a power of attorney in a form prescribed by the regulations in any other written form orally or in any other manner Later wishes prevail s 5(3) Later wishes expressed while capable prevail over earlier wishes

1 Under the SDA a person is incapable of managing property if the person is not able to understand information that is relevant to making a decision in the management of his or her property or is not able to appreciate the reasonably foreseeable consequences of a decision or lack of decision

September 2006 7

423 Restraint Confinement The HCCA does not affect the duty to restrain or confine a person in certain circumstances s 7 This Act does not affect the common law duty of a caregiver to restrain or confine a person when immediate action is necessary to prevent serious bodily harm to the person or to others

September 2006 8

The Community Care Access Centre (CCAC) must not administer treatment to a person without the express or implied consent (see subsection 434 in this manual) of the person who is the subject of the treatment If the person is incapable of making the decision the consent of the legally authorized substitute decision-maker (SDM) is required Legislative references in subsection 43 in this manual are all from the Health Care Consent Act 1996 (HCCA)

431 No Treatment Without Consent s 10(1) A health practitioner who proposes a treatment for a person shall not administer the treatment and shall take reasonable steps to ensure that it is not administered unless (a) he or she is of the opinion that the person is capable with respect to the treatment and the person has given consent or (b) he or she is of the opinion that the person is incapable with respect to the treatment and the persons substitute decision-maker has given consent on the persons behalf in accordance with this Act) Opinion of Board or court governs s 10(2) If the health practitioner is of the opinion that the person is incapable with respect to the treatment but the person is found to be capable with respect to the treatment by the Board on an application for review of the health practitionerrsquos finding or by a court on an appeal of the Boardrsquos decision the health practitioner shall not administer the treatment and shall take reasonable steps to ensure that it is not administered unless the person has given consent

432 Elements of Consent

s 11(1) The following are the elements required for consent to treatment 1 The consent must relate to the treatment 2 The consent must be informed 3 The consent must be given voluntarily 4 The consent must not be obtained through misrepresentation or fraud

433 Informed Consent

s 11(2) A consent to treatment is informed if before giving it (a) the person received the information about the matters set out in subsection (3) that a reasonable person in the same circumstances would require in order to make a decision about the treatment and (b) the person received responses to his or her requests for additional information about those matters

September 2006 9

s 11(3) The matters referred to in subsection (2) are 1 The nature of the treatment 2 The expected benefits of the treatment 3 The material risks of the treatment 4 The material side effects of the treatment 5 Alternative courses of action 6 The likely consequences of not having the treatment Consent is only valid if the person has capacity to make the decision

434 Express or Implied Consent

Section 11(4) of the HCCA states ldquoconsent to treatment may be express or impliedrdquo

Express consent is consent that is written or spoken Implied consent occurs when the person whose consent is needed does something that in the circumstances a reasonable person would understand to indicate that the person consents For example if a staff member says that they are offering a person a spoonful of cough medicine and the person opens his or her mouth and swallows the medicine the person has impliedly consented to take the medicine In this example the staff member cannot rely on the implied consent unless the person is capable of making the decision to consent to taking cough medicine

435 Withdrawal of Consent

The client or the SDM if the client is incapable may withdraw the consent to treatment at any time The HCCA states s 14 A consent that has been given by or on behalf of the person for whom the treatment was proposed may be withdrawn at any time (a) by the person if the person is capable with respect to the treatment at the time of the withdrawal (b) by the persons substitute decision-maker if the person is incapable with respect to the treatment at the time of the withdrawal

436 Responsibility for Consent to Treatment

The health practitioner proposing the particular treatment is responsible for determining whether or not the person is capable with respect to the treatment The HCCA states s 10(1) A health practitioner who proposes a treatment for a person shall not administer the treatment and shall take reasonable steps to ensure that it is not administered unless (a) he or she is of the opinion that the person is capable with respect to the treatment and the person has given consent or

September 2006 10

(b) he or she is of the opinion that the person is incapable with respect to the treatment and the persons substitute decision-maker has given consent on the persons behalf in accordance with this Act

September 2006 11

Legislative references in subsection 44 in this manual are all from the Health Care Consent Act 1996 (HCCA)

441 Presumption that a Person is Capable The HCCA states in section 4(2) ldquoA person is presumed to be capable with respect to treatment admission to a care facility and personal assistance servicesrdquo The Community Care Access Centre (CCAC) must presume that a person is capable of making a decision with respect to treatment as defined in the HCCA (ie nursing occupational therapy physiotherapy speech-language pathology or dietetics services) unless there are reasonable grounds to believe that the person is not capable (See Consent to Treatment subsection 43 in this manual)

442 Capacity to Consent to Treatment Under the HCCA Capacity depends on treatment

s 15(1) A person may be incapable with respect to some treatments and capable with respect to others Capacity depends on time s15 (2) A person may be incapable with respect to a treatment at one time and capable at another Return of capacity s 16 If after consent to a treatment is given or refused on a persons behalf in accordance with this Act the person becomes capable with respect to the treatment in the opinion of the health practitioner the persons own decision to give or refuse consent to the treatment governs If in the opinion of the health practitioner capacity returns then the personrsquos own decision to give or refuse consent governs For example due to an injury or illness a person may be incapable of making a decision about a surgical intervention After recovering from surgery the personrsquos capacity may return If capacity returns the capable person makes the decision to give or refuse consent to treatment

443 Information to be Provided by Health Practitioner Information

s17 A health practitioner shall in the circumstances and manner specified in guidelines established by the governing body of the health practitioners profession provide to persons

September 2006 12

found by the health practitioner to be incapable with respect to treatment such information about the consequences of the findings as is specified in the guidelines Health practitioners must follow their professional governing bodyrsquos guidelines with respect to the information that must be provided to incapable persons about the consequences of the finding of incapacity The information referred to in section 17 includes advising persons that they have the right to apply to the Consent and Capacity Board (the Board) (see definition of Board in subsection 47 in this manual or Appendix A in this manual) to review the finding of incapacity

444 Treatment Must Not Begin in Certain Circumstances

Section 18 of the HCCA deals with circumstances when treatment must not begin for a certain period of time Treatment must not begin s 18(1) This section applies if (a) a health practitioner proposes a treatment for a person and finds that the person is incapable with respect to the treatment (b) before the treatment is begun the health practitioner is informed that the person intends to apply or has applied to the Board for a review of the finding and (c) the application to the Board is not prohibited by subsection 32(2) Same s 18(2) This section also applies if (a) a health practitioner proposes a treatment for a person and finds that the person is incapable with respect to the treatment (b) before the treatment is begun the health practitioner is informed that

(i) the incapable person intends to apply or has applied to the Board for appointment of a representative to give or refuse consent to the treatment on his or her behalf or (ii) another person intends to apply or has applied to the Board to be appointed as the representative of the incapable person to give or refuse consent to the treatment on his or her behalf and

(c) the application to the Board is not prohibited by subsection 33(3) (3) In the circumstances described in subsections (1) and (2) the health practitioner shall not begin the treatment and shall take reasonable steps to ensure that the treatment is not begun (a) until 48 hours have elapsed since the health practitioner was first informed of the intended application to the Board without an application being made (b) until the application to the Board has been withdrawn (c) until the Board has rendered a decision in the matter if none of the parties to the application before the Board has informed the health practitioner that he or she intends to appeal the Boardrsquos decision or (d) if a party to the application before the Board has informed the health practitioner that he or she intends to appeal the Boardrsquos decision

September 2006 13

(i) until the period for commencing the appeal has elapsed without an appeal being commenced or (ii) until the appeal of the Boardrsquos decision has been finally disposed of

Emergency s 18 (4) This section does not apply if the health practitioner is of the opinion that there is an emergency within the meaning of subsection 25 (1) Note There are situations where treatment can be provided in an emergency (See subsection 46 in this manual)

September 2006 14

If a person is incapable of consenting to a treatment the legally authorized substitute decision-maker (SDM) may give or refuse consent to the treatment on the personrsquos behalf Legislative references in subsection 45 in this manual are all from the Health Care Consent Act 1996 (HCCA)

451 Substitute Decision-Maker

The SDM for treatment means a person who is authorized under section 20 of the HCCA to give or refuse consent to a treatment on behalf of a person who is incapable with respect to the treatment (See section 9 of the HCCA)

452 Information Required by the Substitute Decision-Maker Information s 22(1) Before giving or refusing consent to a treatment on an incapable persons behalf a substitute decision-maker is entitled to receive all the information required for an informed consent as described in subsection 11(2) Conflict s 22(2) Subsection (1) prevails despite anything to the contrary in the Personal Health Information Protection Act 2004 The SDM has the right to receive all the information needed for an informed consent before making treatment decisions

453 Identifying the Substitute Decision-Maker

List of persons who may give or refuse consent s 20(1) If a person is incapable with respect to a treatment consent may be given or refused on his or her behalf by a person described in one of the following paragraphs 1 The incapable persons guardian of the person if the guardian has authority to give or refuse consent to the treatment 2 The incapable persons attorney for personal care if the power of attorney confers authority to give or refuse consent to the treatment 3 The incapable persons representative appointed by the Board under section 33 if the representative has authority to give or refuse consent to the treatment 4 The incapable persons spouse or partner 5 A child or parent of the incapable person or a childrens aid society or other person who is lawfully entitled to give or refuse consent to the treatment in the place of the parent This paragraph does not include a parent who has only a right of access If a childrens aid society or other person is lawfully entitled to give or refuse consent to the treatment in the place of the parent this paragraph does not include the parent

September 2006 15

6 A parent of the incapable person who has only a right of access 7 A brother or sister of the incapable person 8 Any other relative of the incapable person Note This above list includes siblings friends (under 1 2 or 3) same sex partners or spouses The list of possible SDMs is ranked in descending order of priority with 1 being the highest priority Those persons higher on the list take precedence over those below as long as they meet the requirements of a SDM A power of attorney for personal care may authorize the attorney to make decisions regarding the incapable personrsquos health care (including treatment admission to a long-term care (LTC) home a personal assistance service in a LTC home under the HCCA) nutrition shelter clothing hygiene or safety The power of attorney may not authorize the SDM to make decisions about all these things for example a person may choose to limit the power of attorney to one or more of these areas of personal care including health care Similarly a court appointing a guardian of the person may limit the types of decisions that the guardian has the authority to make For more information on the authority of an attorney or guardian for personal care see the Substitute Decisions Act 1992 (SDA) With respect to the list in subsection 20(1) the HCCA also provides the following Meaning of ldquospouserdquo s 20(7) Subject to subsection (8) two persons are spouses for the purpose of this section if (a) they are married to each other or (b) they are living in a conjugal relationship outside marriage and

(i) have cohabited for at least one year (ii) are together the parents of a child or (iii) have together entered into a cohabitation agreement under section 53 of the Family Law Act

Not spouse s 20(8) Two persons are not spouses for the purpose of this section if they are living separate and apart as a result of a breakdown of their relationship Meaning of partner s 20(9) For the purpose of this section partner means (a) Repealed (b) either of two persons who have lived together for at least one year and have a close personal relationship that is of primary importance in both persons lives Meaning of ldquorelativerdquo s 20(10) Two persons are relatives for the purpose of this section if they are related by blood marriage or adoption

September 2006 16

454 Requirements of a Substitute Decision-Maker A SDM (as defined the subsection 20(1) of the HCCA and subsection 453 in this manual) may give or refuse consent only if he or she

Requirements s 20(2)(a) is capable with respect to the treatment (b) is at least 16 years old unless he or she is the incapable persons parent (c) is not prohibited by court order or separation agreement from having access to the incapable person or giving or refusing consent on his or her behalf (d) is available and (e) is willing to assume the responsibility of giving or refusing consent Meaning of available s 20(11) For the purpose of clause (2)(d) a person is available if it is possible within a time that is reasonable in the circumstances to communicate with the person and obtain a consent or refusal

455 Role of the Public Guardian and Trustee No person in subs (1) to make decision

s 20(5) If no person described in subsection (1) meets the requirements of subsection (2) the Public Guardian and Trustee shall make the decision to give or refuse consent Conflict between persons in same paragraph s 20(6) If two or more persons who are described in the same paragraph of subsection (1) and who meet the requirements of subsection (2) disagree about whether to give or refuse consent and if their claims rank ahead of all others the Public Guardian and Trustee shall make the decision in their stead

The Public Guardian and Trustee shall make the decision to give or refuse consent to treatment if bull there is no person on the list of SDMs set out in subsection 20(1) who meets the

requirements of a SDM in subsection 20(2) or bull there is a disagreement about whether to give consent between or among two or more

equally ranking potential substitute decision-makers if their claims rank ahead of all others in the list for example two children of the incapable person disagree about the decision and there is no person listed in number 1 through 4 of the list children being ranked number 5 (See HCCA subsections 20(5) and (6) and the list of substitute decision-makers in subsection 20(1) or 453 in this manual)

456 Principles for Giving or Refusing Consent ndash Prior Capable Wishes

The HCCA requires the SDM to make decisions about treatment in accordance with any known wishes applicable to the circumstances that were expressed by the incapable person while

September 2006 17

capable and after reaching the age of 16 years If there are no such wishes the decisions are required to be made in the best interests of the incapable person Best interests is a defined term (see subsection 457 in this manual) In certain circumstances the SDM or the health practitioner proposing the treatment may apply to the Consent and Capacity Board (the Board) (see definition of Board in subsection 47 in this manual or Appendix A in this manual) for directions about the expressed wishes Principles for giving or refusing consent s 21(1) A person who gives or refuses consent to a treatment on an incapable personrsquos behalf shall do so in accordance with the following principles 1 If the person knows of a wish applicable to the circumstances that the incapable person expressed while capable and after attaining 16 years of age the person shall give or refuse consent in accordance with the wish 2 If the person does not know of a wish applicable to the circumstances that the incapable person expressed while capable and after attaining 16 years of age or if it is impossible to comply with the wish the person shall act in the incapable personrsquos best interests

457 Principles for Giving or Refusing Consent ndash Best Interests

Best interests s 21(2) In deciding what the incapable persons best interests are the person who gives or refuses consent on his or her behalf shall take into consideration (a) the values and beliefs that the person knows the incapable person held when capable and

believes he or she would still act on if capable (b) any wishes expressed by the incapable person with respect to the treatment that are not

required to be followed under paragraph 1 of subsection (1) and (c) the following factors

1 Whether the treatment is likely to i improve the incapable persons condition or well-being ii prevent the incapable persons condition or well-being from deteriorating or iii reduce the extent to which or the rate at which the incapable persons condition or well-being is likely to deteriorate

2 Whether the incapable persons condition or well-being is likely to improve remain the same or deteriorate without the treatment 3 Whether the benefit the incapable person is expected to obtain from the treatment outweighs the risk of harm to him or her 4 Whether a less restrictive or less intrusive treatment would be as beneficial as the treatment that is proposed

458 Consent to Ancillary Treatment

s 23 Authority to consent to a treatment on an incapable persons behalf includes authority to consent to another treatment that is necessary and ancillary to the treatment even if the incapable person is capable with respect to the necessary and ancillary treatment

September 2006 18

For example where a SDM has given consent to surgery the SDM can give consent to pre or post-operative treatment that is necessary or ancillary to the surgery even where the incapable person is capable of making decisions about the pre or post-operative treatment

September 2006 19

In emergency circumstances a person may be incapable of consenting to treatment because the person is unconscious or severely traumatized or unable to communicate with health practitioners due to a language difficulty or for some other reason Section 25 of the Health Care Consent Act 1996 (HCCA) allows treatment of a person without consent in emergency situations when the delay required to obtain consent or refusal from either the person or the personrsquos substitute decision-maker (SDM) will prolong the personrsquos suffering or put the person at risk of serious bodily harm Legislative references in subsection 46 in this manual are all from the HCCA

461 Definition of Emergency Under the HCCA

Meaning of emergency s 25(1) For the purpose of this section and section 27 there is an emergency if the person for whom the treatment is proposed is apparently experiencing severe suffering or is at risk if the treatment is not administered promptly of sustaining serious bodily harm

462 Examination Without Consent

In some situations it may be necessary for a health practitioner to examine a person without consent in order to determine whether or not an emergency exists The HCCA states s 25(4) Despite section 10 an examination or diagnostic procedure that constitutes treatment may be conducted by a health practitioner without consent if (a) the examination or diagnostic procedure is reasonably necessary in order to determine whether there is an emergency and (b) in the opinion of the health practitioner

(i) the person is incapable with respect to the examination or diagnostic procedure or (ii) clauses (3) (b) and (c) apply to the examination or diagnostic procedure

Clauses 25(3)(b) and (c) of the HCCA state s 25(3)(b) the communication required in order for the person to give or refuse consent to the treatment cannot take place because of a language barrier or because the person has a disability that prevents the communication from taking place (c) steps that are reasonable in the circumstances have been taken to find a practical means of enabling the communication to take place but no such means has been found

463 Emergency Treatment Without Consent Incapable Person

The following provisions apply when the person for whom the emergency treatment is proposed is incapable of making a decision to consent or refuse consent to treatment The

September 2006 20

HCCA states Emergency treatment without consent incapable person s 25(2) Despite section 10 a treatment may be administered without consent to a person who is incapable with respect to the treatment if in the opinion of the health practitioner proposing the treatment (a) there is an emergency and (b) the delay required to obtain a consent or refusal on the persons behalf will prolong the suffering that the person is apparently experiencing or will put the person at risk of sustaining serious bodily harm Continuing treatment s 25(6) Treatment under subsection (2) may be continued only for as long as is reasonably necessary to find the incapable persons substitute decision-maker and to obtain from him or her a consent or refusal of consent to the continuation of the treatment Search s 25(8) When a treatment is begun under subsection (2) or (3) the health practitioner shall ensure that reasonable efforts are made for the purpose of finding the substitute decision-maker or a means of enabling the communication to take place as the case may be Return of capacity s 25(9) If after a treatment is begun under subsection (2) the person becomes capable with respect to the treatment in the opinion of the health practitioner the persons own decision to give or refuse consent to the continuation of the treatment governs

464 Emergency Treatment Without Consent Capable Person

The following provisions apply when the person for whom the emergency treatment is proposed is apparently capable of consenting or refusing to consent to treatment A health practitioner may provide treatment to a capable person in an emergency under certain circumstances set out in the HCCA Therefore where those circumstances exist the CCAC health practitioner may authorize the provision of service which is treatment to a capable person without the personrsquos consent The HCCA states Emergency treatment without consent capable person s 25(3) Despite section 10 a treatment may be administered without consent to a person who is apparently capable with respect to the treatment if in the opinion of the health practitioner proposing the treatment (a) there is an emergency (b) the communication required in order for the person to give or refuse consent to the treatment cannot take place because of a language barrier or because the person has a disability that prevents the communication from taking place (c) steps that are reasonable in the circumstances have been taken to find a practical means of enabling the communication to take place but no such means has been found

September 2006 21

(d) the delay required to find a practical means of enabling the communication to take place will prolong the suffering that the person is apparently experiencing or will put the person at risk of sustaining serious bodily harm and (e) there is no reason to believe that the person does not want the treatment s25(7) Treatment under subsection (3) may be continued only for as long as is reasonably necessary to find a practical means of enabling the communication to take place so that the person can give or refuse consent to the continuation of the treatment Search s25(8) When a treatment is begun under subsection (2) or (3) the health practitioner shall ensure that reasonable efforts are made for the purpose of finding the substitute decision-maker or a means of enabling the communication to take place as the case may be

465 No Treatment Contrary to Expressed Capable Wishes

No treatment contrary to wishes s 26 A health practitioner shall not administer a treatment under section 25 if the health practitioner has reasonable grounds to believe that the person while capable and after attaining 16 years of age expressed a wish applicable to the circumstances to refuse consent to the treatment Despite section 25 of the HCCA emergency treatment without consent is prohibited when the health care practitioner has reasonable grounds to believe that the person expressed a prior capable wish to not have the treatment An example of this would be the inability of a physician to provide a person of the Jehovahrsquos Witness faith with a blood transfusion if there are reasonable grounds to believe that the person while capable and after attaining the age of 16 years expressed a wish not to have such treatment A person may carry a card that identifies himself or herself as a Jehovahrsquos Witness and indicates that he or she is not to be given a blood transfusion even for life saving purposes

466 Emergency Treatment Despite Refusal by the SDM

If a SDM has refused to consent to emergency treatment on behalf of an incapable person but the health care practitioner has reason to believe that the SDM has not made the decision in accordance with the required principles for making a decision the health care practitioner may proceed to administer the emergency treatment The HCCA states Emergency treatment despite refusal s 27 If consent to a treatment is refused on an incapable persons behalf by his or her substitute decision-maker the treatment may be administered despite the refusal if in the opinion of the health practitioner proposing the treatment (a) there is an emergency and (b) the substitute decision-maker did not comply with section 21

September 2006 22

See section 21 of the HCCA or principles for giving or refusing consent in subsection 456 in this manual The required principles are that the SDMrsquos decision must be made in accordance with the incapable personrsquos wishes applicable to the circumstances that were expressed while capable and after reaching the age of 16 years If there are no such wishes the decision must be made in accordance with the SDMrsquos determination of the incapable personrsquos best interests as defined in the HCCA

467 Keeping Records

Immediately after administering an emergency treatment without consent for a capable person or an incapable person the health care practitioner must record the reasons for the emergency intervention The HCCA states Record s 25(5) After administering a treatment in reliance on subsection (2) or (3) the health practitioner shall promptly note in the persons record the opinions held by the health practitioner that are required by the subsection on which he or she relied

September 2006 23

47 Applications to the Consent and Capacity Board Regarding

Treatment

The Consent and Capacity Board (the Board) is an independent adjudicative body created to conduct hearings under the Mental Health Act (MHA) and the Health Care Consent Act 1996 (HCCA) The Board also conducts hearings about consent and capacity issues under the Personal Health Information Protection Act 2004 (PHIPA) A person who is found by a health practitioner to be incapable with respect to treatment has the right to have that finding reviewed by the Board Under the HCCA there are several applications that can be made to the Board and these include

Application Reference in this Manual

Application for review of finding of incapacity 471

Application for appointment of a representative who will act as the substitute decision-maker (SDM) on behalf of an incapable person

Application by a proposed representative to act as the SDM on behalf of an incapable person

Application by a SDM or health practitioner for directions regarding wishes expressed about treatment

Application by a SDM or health practitioner to obtain permission for the SDM to depart from wishes expressed by the incapable person

Application by a health practitioner seeking determination as to whether a SDM complied with principles for giving or refusing consent

Legislative references in subsection 47 in this manual are all from the HCCA

471 Application for a Review of Finding of Incapacity Application for review of finding of incapacity

s 32(1) A person who is the subject of a treatment may apply to the Board for a review of a health practitioners finding that he or she is incapable with respect to the treatment

Exception s 32(2) Subsection (1) does not apply to (a) a person who has a guardian of the person if the guardian has authority to give or refuse consent to the treatment

September 2006 24

(b) a person who has an attorney for personal care if the power of attorney contains a provision waiving the persons right to apply for the review and the provision is effective under subsection 50 (1) of the Substitute Decisions Act 1992

Parties

s 32(3) The parties to the application are 1 The person applying for the review 2 The health practitioner 3 Any other person whom the Board specifies Decision of the Board Regarding Finding of Incapacity

Powers of Board s 32(4) The Board may confirm the health practitionerrsquos finding or may determine that the

person is capable with respect to the treatment and in doing so may substitute its opinion for that of the health practitioner

Restriction on repeated applications

s 32(5) If a health practitionerrsquos finding that a person is incapable with respect to a treatment is confirmed on the final disposition of an application under this section the person shall not make a new application for a review of a finding of incapacity with respect to the same or similar treatment within six months after the final disposition of the earlier application unless the Board gives leave in advance Same s 32(6) The Board may give leave for the new application to be made if it is satisfied that there has been a material change in circumstances that justifies reconsideration of the personrsquos capacity

Decision effective while application for leave pending s 32(7) The Boardrsquos decision under subsection (5) remains in effect pending an application for leave under subsection (6) If the Board agrees with the health practitionerrsquos finding of incapacity the person cannot apply for another review regarding the same or similar treatment until six months after the Boardrsquos decision unless the Board gives permission to do so Subsection 32(6) of the HCCA sets out when the Board would give permission for a further review before six months has elapsed

472 Application for Appointment of Representative ndash by Incapable Person

An incapable person may ask the Board to appoint someone to give or refuse consent to a proposed treatment on his or her behalf Such an application may be made in circumstances where there is no court appointed guardian with the authority to make the decision and the incapable person did not make a power of attorney document while capable of doing so and does not want a family member listed in subsection 20(1) in the HCCA to be the SDM A

September 2006 25

representative appointed by the Board ranks above listed family members (See list of SDMs in subsection 453 in this manual) s 33(1) A person who is 16 years old or older and who is incapable with respect to a proposed treatment may apply to the Board for appointment of a representative to give or refuse consent on his or her behalf s 33(3) Subsections (1) and (2) do not apply if the incapable person has a guardian of the person who has authority to give or refuse consent to the proposed treatment or an attorney for personal care under a power of attorney conferring that authority

473 Application for Appointment of Representative ndash by Proposed

Representative The proposed representative may make the application to the Board to be appointed as the representative s 33(2) A person who is 16 years old or older may apply to the Board to have himself or herself appointed as the representative of a person who is incapable with respect to a proposed treatment to give or refuse consent on behalf of the incapable person s 33(3) Subsections (1) and (2) do not apply if the incapable person has a guardian of the person who has authority to give or refuse consent to the proposed treatment or an attorney for personal care under a power of attorney conferring that authority

474 Appointment of Representative ndash Applicable Provisions The following apply to applications to appoint a representative as described in subsections 472 and 473 in this manual

Parties s 33(4) The parties to the application are

1 The incapable person 2 The proposed representative named in the application 3 Every person who is described in paragraph 4 5 6 or 7 of subsection 20 (1) 4 The health practitioner who proposed the treatment 5 Any other person whom the Board specifies Appointment s 33(5) In an appointment under this section the Board may authorize the representative to give or refuse consent on the incapable persons behalf (a) to the proposed treatment (b) to one or more treatments or kinds of treatment specified by the Board whenever a health practitioner proposing that treatment or a treatment of that kind finds that the person is incapable with respect to it or

September 2006 26

(c) to treatment of any kind whenever a health practitioner proposing a treatment finds that the person is incapable with respect to it Criteria for appointment s 33(6) The Board may make an appointment under this section if it is satisfied that the following requirements are met 1 The incapable person does not object to the appointment 2 The representative consents to the appointment is at least 16 years old and is capable with respect to the treatments or the kinds of treatment for which the appointment is made 3 The appointment is in the incapable persons best interests

Powers of Board s 33(7) Unless the incapable person objects the Board may (a) appoint as representative a different person than the one named in the application (b) limit the duration of the appointment (c) impose any other condition on the appointment (d) on any persons application remove vary or suspend a condition imposed on the appointment or impose an additional condition on the appointment Termination s 33(8) The Board may on any persons application terminate an appointment made under this section if (a) the incapable person or the representative requests the termination of the appointment (b) the representative is no longer capable with respect to the treatments or the kinds of treatment for which the appointment was made (c) the appointment is no longer in the incapable persons best interests or (d) the incapable person has a guardian of the person who has authority to consent to the treatments or the kinds of treatment for which the appointment was made or an attorney for personal care under a power of attorney conferring that authority

475 Application for Directions About Wishes Application for directions

s 35(1) A substitute decision-maker or a health practitioner who proposed a treatment may apply to the Board for directions if the incapable person expressed a wish with respect to the treatment but (a) the wish is not clear (b) it is not clear whether the wish is applicable to the circumstances (c) it is not clear whether the wish was expressed while the incapable person was capable or (d) it is not clear whether the wish was expressed after the incapable person attained 16 years of age Notice to substitute decision-maker s 35(11) A health practitioner who intends to apply for directions shall inform the substitute decision-maker of his or her intention before doing so

September 2006 27

1 The substitute decision-maker 2 The incapable person 3 The health practitioner who proposed the treatment 4 Any other person whom the Board specifies Decision of the Board Regarding Directions Directions s 35(3) The Board may give directions and in doing so shall apply section 21 Section 21 sets out the required principles for giving or refusing consent (discussed under subsection 456 in this manual)

476 Application to Depart from Wishes

Application to depart from wishes s 36(1) If a substitute decision-maker is required by paragraph 1 of subsection 21 (1) to refuse consent to a treatment because of a wish expressed by the incapable person while capable and after attaining 16 years of age (a) the substitute decision-maker may apply to the Board for permission to consent to the treatment despite the wish or (b) the health practitioner who proposed the treatment may apply to the Board to obtain permission for the substitute decision-maker to consent to the treatment despite the wish

Notice to substitute decision-maker s 36(11) A health practitioner who intends to apply under clause (1) (b) shall inform the substitute decision-maker of his or her intention before doing so Parties s 36(2) The parties to the application are 1 The substitute decision-maker 2 The incapable person 3 The health practitioner who proposed the treatment 4 Any other person whom the Board specifies

Decision of the Board Regarding Departing from Wishes Criteria for permission s 36(3) The Board may give the substitute decision-maker permission to consent to the treatment despite the wish if it is satisfied that the incapable person if capable would probably give consent because the likely result of the treatment is significantly better than would have been anticipated in comparable circumstances at the time the wish was expressed

September 2006 28

477 Application to Determine Compliance with Section 21 Application to determine compliance with s 21

s 37(1) If consent to a treatment is given or refused on an incapable persons behalf by his or her substitute decision-maker and if the health practitioner who proposed the treatment is of the opinion that the substitute decision-maker did not comply with section 21 the health practitioner may apply to the Board for a determination as to whether the substitute decision-maker complied with section 21 The health practitioner proposing the treatment for the person may apply to the Board for a determination as to whether the SDM followed the required principles set out in section 21 in making a treatment decision on behalf of an incapable person A health practitioner could do this if the practitioner believed that the principles for giving and refusing consent including the personrsquos previously expressed capable wishes or if applicable the personrsquos best interests were not properly considered by the SDM

Parties s 37(2) The parties to the application are 1 The health practitioner who proposed the treatment 2 The incapable person 3 The substitute decision-maker 4 Any other person whom the Board specifies Decision of the Board Regarding Compliance with Section 21

Power of Board s 37(3) In determining whether the substitute decision-maker complied with section 21 the Board may substitute its opinion for that of the substitute decision-maker Directions s 37(4) If the Board determines that the substitute decision-maker did not comply with section 21 it may give him or her directions and in doing so shall apply section 21 Time for compliance s 37(5) The Board shall specify the time within which its directions must be complied with Deemed not authorized s 37(6) If the substitute decision-maker does not comply with the Boardrsquos directions within the time specified by the Board he or she shall be deemed not to meet the requirements of subsection 20 (2) Subsequent substitute decision-maker s 37(61) If under subsection (6) the substitute decision-maker is deemed not to meet the requirements of subsection 20 (2) any subsequent substitute decision-maker shall subject to subsections (62) and (63) comply with the directions given by the Board on the application within the time specified by the Board

September 2006 29

Application for directions s 37(62) If a subsequent substitute decision-maker knows of a wish expressed by the incapable person with respect to the treatment the substitute decision-maker may with leave of the Board apply to the Board for directions under section 35 Inconsistent directions s 37(63) Directions given by the Board under section 35 on a subsequent substitute decision-makerrsquos application brought with leave under subsection (62) prevail over inconsistent directions given under subsection (4) to the extent of the inconsistency PGT s 37(7) If the substitute decision-maker who is given directions is the Public Guardian and Trustee he or she is required to comply with the directions and subsection (6) does not apply to him or her

478 Deemed Application Concerning Capacity

Deemed application concerning capacity s 371 An application to the Board under section 33 34 35 36 or 37 shall be deemed to include an application to the Board under section 32 with respect to the personrsquos capacity to consent to treatment proposed by a health practitioner unless the personrsquos capacity to consent to such treatment has been determined by the Board within the previous six months It should be noted from section 371 that whenever one of the listed applications to the Board is made there is an automatic deemed application to the Board to review the finding of incapacity of the person to consent to the proposed treatment unless the Board has determined the issue of capacity within the previous six months

479 Protection from Liability

The HCCA contains the following protections from liability for health practitioners and SDMs Apparently valid consent to treatment s 29(1) If a treatment is administered to a person with a consent that a health practitioner believes on reasonable grounds and in good faith to be sufficient for the purpose of this Act the health practitioner is not liable for administering the treatment without consent

Apparently valid refusal of treatment s 29(2) If a treatment is not administered to a person because of a refusal that a health practitioner believes on reasonable grounds and in good faith to be sufficient for the purpose of this Act the health practitioner is not liable for failing to administer the treatment Apparently valid consent to withholding or withdrawal s 29(3) If a treatment is withheld or withdrawn in accordance with a plan of treatment and with a consent to the plan of treatment that a health practitioner believes on reasonable

September 2006 30

grounds and in good faith to be sufficient for the purpose of this Act the health practitioner is not liable for withholding or withdrawing the treatment

Emergency treatment administered s 29(4) A health practitioner who in good faith administers a treatment to a person under section 25 or 27 is not liable for administering the treatment without consent Emergency treatment not administered s 29(5) A health practitioner who in good faith refrains from administering a treatment in accordance with section 26 is not liable for failing to administer the treatment Reliance on assertion s 29(6) If a person who gives or refuses consent to a treatment on an incapable personrsquos behalf asserts that he or she (a) is a person described in subsection 20 (1) or clause 24 (2) (a) or (b) or an attorney for personal care described in clause 32 (2) (b) (b) meets the requirement of clause 20 (2) (b) or (c) or (c) holds the opinions required under subsection 20 (4) a health practitioner is entitled to rely on the accuracy of the assertion unless it is not reasonable to do so in the circumstances

Person making decision on anotherrsquos behalf s 30 A person who gives or refuses consent to a treatment on another personrsquos behalf acting in good faith and in accordance with this Act is not liable for giving or refusing consent Admission to hospital etc s 30(1) Sections 29 and 30 except subsection 29 (4) apply with necessary modifications to admission of the incapable person to a hospital psychiatric facility or other health facility referred to in section 24 for the purpose of treatment

Same s 30(2) A health practitioner who in good faith has a person admitted to a hospital or psychiatric facility under section 28 is not liable for having the person admitted without consent

September 2006 31

48 Consent to Admission to a Long-Term Care Home 481 Consent Required

In order for a person to be admitted to a long-term care (LTC) home the consent of the person being admitted is required This requirement for consent is set out in subsection 96(13)(c) of the Charitable Institutions Act (CIA) subsection 201(13)(c) of the Nursing Homes Act (NHA) and subsection 18(13)(c) of the Homes for the Aged and Rest Homes Act (HARHA) Where a person is not capable of making the decision about admission to a LTC home the Health Care Consent Act 1996 (HCCA) in Part III provides a scheme for obtaining a substitute decision The HCCA uses the term ldquothe person responsible for authorizing admissions to the care facilityrdquo This means the Community Care Access Centre (CCAC) as the CCAC is the designated placement co-ordinator responsible for authorizing admissions to LTC homes under the NHA CIA and HARHA Legislative references in subsection 48 in this manual are all from the (HCCA)

482 Presumption that a Person is Capable Presumption of capacity s 4(2) A person is presumed to be capable with respect to treatment admission to a care

facility and personal assistance services Exception s 4(3) A person is entitled to rely on the presumption of capacity with respect to another person unless he or she has reasonable grounds to believe that the other person is incapable with respect to the treatment the admission or the personal assistance service as the case may be The CCAC must presume that a person is capable of making a decision with respect to admission to a LTC home unless there are reasonable grounds to believe that the person is not capable

483 Capacity to Consent to Admission to a LTC Home

s 4(1) A person is capable with respect to a treatment admission to a care facility or a personal assistance service if the person is able to understand the information that is relevant to making a decision about the treatment admission or personal assistance service as the case may be and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision

September 2006 32

A person may be capable of making a decision regarding admission to a LTC home despite being incapable of making decisions about other areas For example a person may be incapable of managing property but he or she may be capable of making a decision regarding his or her admission to a LTC home

484 Determination of Capacity

If there are reasonable grounds to believe that an applicant may be incapable of making a decision regarding his or her admission to a LTC home a determination of capacity must be made by an evaluator who completes an evaluator questionnaire regarding capacity to make admission decisions Reasonable grounds or ldquotriggersrdquo for undertaking an evaluation of capacity may come from observation of the person in the past written documentation observations of the person while the functional assessment is being conducted and information provided by the person family other caregivers or health practitioners (such as the family physician) including medical or psychiatric information Reasonable grounds may include but are not limited to bull unusual behaviour bull disorientation to time person or place bull lack of reasonable judgement and memory bull repetitive speech and bull aggression

485 Capacity Determined by Evaluator

The HCCA states Consent on incapable personrsquos behalf s 40(1) If a personrsquos consent to his or her admission to a care facility is required by law and the person is found by an evaluator to be incapable with respect to the admission consent may be given or refused on the personrsquos behalf by his or her substitute decision-maker in accordance with this Act As noted in subsection 481 in this manual the three statutes governing LTC homes set out the legal requirement for consent for admission

486 Evaluator

The evaluator a defined term under the HCCA is the professional who determines a personrsquos capacity to make a decision to give or refuse consent to the admission to a LTC home

September 2006 33

s 2(2) ldquoevaluator means in the circumstances prescribed by the regulations a person described in clause (a) (l) (m) (o) (p) or (q) of the definition of health practitioner in this subsection or a member of a category of persons prescribed by the regulations as evaluators ldquohealth practitionerrdquo means (a) a member of the College of Audiologists and Speech-Language Pathologists of Ontario (l) a member of the College of Nurses of Ontario (m) a member of the College of Occupational Therapists of Ontario (o) a member of the College of Physicians and Surgeons of Ontario (p) a member of the College of Physiotherapists of Ontario (q) a member of the College of Psychologists of Ontario Subsections 1(1) and (2) of regulation 10496 under the HCCA state s 1(1) For the purpose of the definition of evaluator in subsection 2 (1) of the Act (a) social workers are evaluators (b) social workers and persons described in clause (a) (l) (m) (o) (p) or (q) of the definition of health practitioner in subsection 2 (1) of the Act may act as evaluators for the purpose of determining whether a person is capable with respect to his or her admission to a care facility and for the purpose of determining whether a person is capable with respect to a personal assistance service (2) In this section social worker means a member of the Ontario College of Social Workers and Social Service Workers who holds a certificate of registration for social work

487 Duties of the Evaluator When an evaluator has determined that a person is incapable of making the admission decision the CCAC must ensure that the person has been informed of the following

bull the finding of incapacity and help the person understand the relevant information to the

extent permitted by the personrsquos incapacity bull that the authorized substitute decision-maker (SDM) will be asked to make the admission

decision on the personrsquos behalf and bull his or her right to apply to the Consent and Capacity Board (the Board) for a review of the

finding of incapacity and or for the appointment of a representative of the personrsquos choice to act as the SDM (if there is not a guardian of the person or attorney for personal care with the authority to make the decision on the personrsquos behalf)

The evaluator will usually be the appropriate person to communicate this information to the

person If the evaluator is not employed or contracted by the CCAC the CCAC must ensure that the information is communicated to the person The CCAC will confirm that the information has been provided by the evaluator and where the evaluator has not done so the CCAC will provide the information to the person The CCAC will document these matters in accordance with the documentation standards of the evaluatorrsquos professional governing body and the CCAC policy

September 2006 34

Provision of Information The person found to be incapable ldquothe clientrdquo andor the clientrsquos family may contact the CCAC after being informed of the incapable personrsquos right to have an evaluatorrsquos determination of incapacity reviewed by the Board The CCAC will provide or clarify information about these matters and refer the applicant to appropriate resources for information about the Board process and assistance If the client wishes to have the determination of incapacity reviewed by the Board (subsection 410 in this manual describes the process) or wishes to apply to the Board for the appointment of a representative who will make the admission decision the CCAC will refer the person to the following resources as appropriate bull the Board bull Legal Aid Ontario and bull other legal resources in the community Note The person providing the information to the client is not providing legal advice but is providing information so that the client is able to make choices about how to proceed

September 2006 35

49 Consent to Admission to a Long-Term Care Home on

Behalf of an Incapable Person

The Community Care Access Centre (CCAC) is responsible for finding the authorized substitute decision-maker (SDM) for any person whom an evaluator has determined to be incapable of making a decision regarding his or her admission to a long-term care (LTC) home The search should continue until a person has been found who meets the requirements for a SDM under the Health Care Consent Act 1996 (HCCA)

The CCAC should document efforts to locate a SDM indicate who is the authorized SDM and how that person can be contacted Legislative references in subsection 49 in this manual are all from the HCCA

491 Consent on Behalf of an Incapable Person

Consent on incapable personrsquos behalf s 40(1) If a persons consent to his or her admission to a care facility is required by law and the person is found by an evaluator to be incapable with respect to the admission consent may be given or refused on the persons behalf by his or her substitute decision-maker in accordance with this Act Opinion of Board or court governs s 40(2) If a person who is found by an evaluator to be incapable with respect to his or her admission to a care facility is found to be capable with respect to the admission by the Board on an application for review of the evaluatorrsquos finding or by a court on an appeal of the Boardrsquos decision subsection (1) does not apply As stated in subsection 481 in this manual a personrsquos consent to his or her admission to a LTC home (ldquocare facilityrdquo under the HCCA) is required by the three LTC home statutes

492 Identifying a Substitute Decision-Maker

If a person is determined to be incapable of making a decision regarding admission to a LTC home a SDM will make the decision on his or her behalf The criteria for identifying a SDM for this situation are the same as for cases regarding consent to treatment (Subsection 453 in this manual contains the list of individuals who may act as SDMs in order of priority Also see subsection 455 in this manual for role of the Public Guardian and Trustee)

September 2006 36

493 Information Needed by the Substitute Decision-Maker

The person making an admission decision on behalf of an incapable person has the right to receive all the information required in order to make the decision Information s 43(1) Before giving or refusing consent on an incapable persons behalf to his or her admission to a care facility a substitute decision-maker is entitled to receive all the information required in order to make the decision Conflict s 43(2) Subsection (1) prevails despite anything to the contrary in the Personal Health Information Protection Act 2004

494 Requirements of a Substitute Decision-Maker

A SDM may give or refuse consent as long as he or she meets the requirements of a SDM as specified in the HCCA (For requirements of a SDM see subsection 454 in this manual with necessary modifications for example the SDM making an admission decision must be capable with respect to the admission (not treatment))

495 Principles for Giving or Refusing Consent

The HCCA requires the SDM to make decisions in accordance with any known wishes applicable to the circumstances that were expressed by the incapable person while capable and after reaching the age of 16 years and if there are no such wishes the decisions are to be made in the best interests of the incapable person Best interests is a defined term (see subsection 496 in this manual) In certain circumstances the SDM or the CCAC may apply to the Consent and Capacity Board (the Board) (see definition of Board in subsection 47 in this manual or Appendix A in this manual) for directions about the expressed wishes as described in subsection 4104 in this manual Principles for giving or refusing consent s 42(1) A person who gives or refuses consent on an incapable persons behalf to his or her admission to a care facility shall do so in accordance with the following principles 1 If the person knows of a wish applicable to the circumstances that the incapable person expressed while capable and after attaining 16 years of age the person shall give or refuse consent in accordance with the wish 2 If the person does not know of a wish applicable to the circumstances that the incapable person expressed while capable and after attaining 16 years of age or if it is impossible to comply with the wish the person shall act in the incapable persons best interests

September 2006 37

496 Best Interests of the Incapable Person Best interests

s 42(2) In deciding what the incapable persons best interests are the person who gives or refuses consent on his or her behalf shall take into consideration (a) the values and beliefs that the person knows the incapable person held when capable and believes he or she would still act on if capable (b) any wishes expressed by the incapable person with respect to admission to a care facility that are not required to be followed under paragraph 1 of subsection (1) and (c) the following factors 1 Whether admission to the care facility is likely to

i improve the quality of the incapable persons life ii prevent the quality of the incapable persons life from deteriorating or iii reduce the extent to which or the rate at which the quality of the incapable persons life is likely to deteriorate

2 Whether the quality of the incapable persons life is likely to improve remain the same or deteriorate without admission to the care facility 3 Whether the benefit the incapable person is expected to obtain from admission to the care facility outweighs the risk of negative consequences to him or her 4 Whether a course of action that is less restrictive than admission to the care facility is available and is appropriate in the circumstances Subsection 42(2) sets out what the SDM must take into consideration in making a decision based on the best interests of the incapable person

497 Consent to Ancillary Decisions

Ancillary decisions s 44(1) Authority to consent on an incapable persons behalf to his or her admission to a care facility includes authority to make decisions that are necessary and ancillary to the admission Collection and disclosure of information s44(2) A decision concerning the collection and disclosure of information relating to the incapable person is a decision that is necessary and ancillary to the admission if the information is required for the purpose of the admission and is not personal health information within the meaning of the Personal Health Information Protection Act 2004 Exception s 44(3) Subsection (1) does not authorize the making of a decision concerning the incapable personrsquos property If the person is incapable of managing his or her property only the legally authorized SDM for property can make decisions about property such as payment of the resident co-payment (see subsection 411 in this manual)

September 2006 38

Withdrawal of consent s 45 Authority to consent on an incapable persons behalf to his or her admission to a care facility includes authority to withdraw the consent at any time before the admission

September 2006 39

499 When Admission Must Not be Authorized Admission must not be authorized s 46(1) This section applies if (a) an evaluator finds that a person is incapable with respect to his or her admission to a care facility (b) before the admission takes place the person responsible for authorizing admissions to the care facility is informed that the person who was found to be incapable intends to apply or has applied to the Board for a review of the finding and (c) the application to the Board is not prohibited by subsection 50 (2) Same s 46(2) This section also applies if (a) an evaluator finds that a person is incapable with respect to his or her admission to a care facility (b) before the admission takes place the person responsible for authorizing admissions to the care facility is informed that

(i) the incapable person intends to apply or has applied to the Board for appointment of a representative to give or refuse consent to the admission on his or her behalf or (ii) another person intends to apply or has applied to the Board to be appointed as the representative of the incapable person to give or refuse consent to the admission on his or her behalf and

(c) the application to the Board is not prohibited by subsection 51 (3) Same s 46(3) In the circumstances described in subsections (1) and (2) the person responsible for authorizing admissions to the care facility shall take reasonable steps to ensure that the persons admission is not authorized and that the person is not admitted (a) until 48 hours have elapsed since the person responsible for authorizing admissions to the care facility was first informed of the intended application to the Board without an application being made (b) until the application to the Board has been withdrawn (c) until the Board has rendered a decision in the matter if none of the parties to the application before the Board has informed the person responsible for authorizing admissions to the care facility that he or she intends to appeal the Boards decision or (d) if a party to the application before the Board has informed the person responsible for authorizing admissions to the care facility that he or she intends to appeal the Boards decision

(i) until the period for commencing the appeal has elapsed without an appeal being commenced or (ii) until the appeal of the Boards decision has been finally disposed of

4910 Crisis Admission

Section 46 (discussed in subsection 499 in this manual) does not apply when the CCAC is of the opinion that the incapable person requires immediate admission to a LTC home as a result of a crisis or when the admission is for a definite number of days not exceeding 90

September 2006 40

Crisis s 46(4) This section does not apply if the person responsible for authorizing admissions to the care facility is of the opinion that the incapable person requires immediate admission to a care facility as a result of a crisis Admission for definite stay s 46(5) This section does not apply to a personrsquos admission or the authorization of a personrsquos admission to a care facility for a stay of a definite number of days not exceeding 90

Definition of crisis s 39 In this Part crisis means a crisis relating to the condition or circumstances of the person who is to be admitted to the care facility Under this definition it is not considered to be a crisis if someone other than the person being admitted is experiencing a crisis For example a family in crisis does not warrant the admission of the incapable person to a LTC home without the consent of his or her SDM The crisis must relate directly to the condition or circumstances of the person to be admitted Circumstances could include the fact that the incapable personrsquos primary caregiver is no longer available to assist with the personrsquos care

4911 Crisis Admission of Incapable Person Without Consent

The CCAC may authorize the admission of an incapable person to a LTC home without the consent of the SDM where the CCAC is of the opinion that the incapable person requires immediate admission as a result of a crisis and where it is not reasonably possible to obtain the immediate consent or refusal of the personrsquos SDM When admission is authorized under this provision the CCAC is required to ensure that reasonable efforts are subsequently made to locate the personrsquos SDM in order to obtain his or her consent or refusal of consent to the admission It should be noted that prior to reaching this point in the admission process (that is authorization of admission) the CCAC would have received an application for a determination of the personrsquos eligibility for admission and would have determined the person eligible for admission Authorization of admission without consent s 47(1) Despite any law to the contrary if a person is found by an evaluator to be incapable with respect to his or her admission to a care facility the persons admission may be authorized and the person may be admitted without consent if in the opinion of the person responsible for authorizing admissions to the care facility (a) the incapable person requires immediate admission to a care facility as a result of a crisis and (b) it is not reasonably possible to obtain an immediate consent or refusal on the incapable persons behalf

September 2006 41

Search s 47(2) When an admission to a care facility is authorized under subsection (1) the person responsible for authorizing admissions to the care facility shall ensure that reasonable efforts are made for the purpose of finding the incapable persons substitute decision-maker and obtaining from him or her a consent or refusal of consent to the admission

September 2006 42

Admission to a Long-Term Care Home

Under the Health Care Consent Act 1996 (HCCA) applications may be made to the Consent and Capacity Board (the Board) to deal with the following matters related to long-term care (LTC) home admissions

Application by a SDM or the person responsible for authorizing admissions (the Community Care Access Centre (CCAC)) for directions regarding wishes expressed about admission to a LTC home

Application by a SDM or the person responsible for authorizing admissions (the CCAC) to obtain permission for the SDM to depart from wishes expressed by the incapable person

Application by the person responsible for authorizing admissions (the CCAC) seeking determination as to whether a SDM complied with principles for giving or refusing consent

Each application is briefly described in this subsection Legislative references in subsection 410 in this manual are all from the HCCA

4101 Application for Review of Finding of Incapacity

Application for review of finding of incapacity s 50(1) A person may apply to the Board for a review of an evaluators finding that he or she is incapable with respect to his or her admission to a care facility

September 2006 43

Exception s 50(2) Subsection (1) does not apply to (a) a person who has a guardian of the person if the guardian has authority to give or refuse consent to the persons admission to a care facility (b) a person who has an attorney for personal care if the power of attorney contains a provision waiving the persons right to apply for the review and the provision is effective under subsection 50 (1) of the Substitute Decisions Act 1992 Parties s 50(3) The parties to the application are 1 The person applying for the review 2 The evaluator 3 The person responsible for authorizing admissions to the care facility 4 Any other person whom the Board specifies Subss 32 (4) to (7) apply s 50(4) Subsections 32 (4) to (7) apply with necessary modifications to an application under this section Decision of the Board Regarding Finding of Incapacity The following provisions of the HCCA apply with necessary modifications to applications to review the finding of incapacity regarding admission to a LTC home

person is capable with respect to the treatment and in doing so may substitute its opinion for that of the health practitioner Restriction on repeated applications s 32(5) If a health practitionerrsquos finding that a person is incapable with respect to a treatment is confirmed on the final disposition of an application under this section the person shall not make a new application for a review of a finding of incapacity with respect to the same or similar treatment within six months after the final disposition of the earlier application unless the Board gives leave in advance Same s 32(6) The Board may give leave for the new application to be made if it is satisfied that there has been a material change in circumstances that justifies reconsideration of the personrsquos capacity

Decision effective while application for leave pending s 32(7) The Boardrsquos decision under subsection (5) remains in effect pending an application for leave under subsection (6)

September 2006 44

If the Board agrees with the evaluatorrsquos finding of incapacity the person cannot apply for another review regarding the finding until six months after the Boardrsquos decision unless the Board gives permission to do so Subsection 32(6) of the HCCA sets out when the Board would give permission for a further review before six months has elapsed Opinion of the Board or Court Governs Where a person is found by an evaluator to be incapable regarding admission to a LTC home and the finding has been confirmed by the Board on a review (see definition of Board in subsection 47 in this manual or Appendix A in this manual) or by the court on appeal of the Boardrsquos decision (after an application by the person to review the evaluatorrsquos finding) the person makes the decision not the SDM Opinion of Board or court governs s 40(2) If a person who is found by an evaluator to be incapable with respect to his or her admission to a care facility is found to be capable with respect to the admission by the Board on an application for review of the evaluators finding or by a court on an appeal of the Boards decision subsection (1) does not apply

4102 Application for Appointment of Representative ndash by Incapable Person An incapable person may ask the Board to appoint someone to give or refuse consent to admission on his or her behalf Such an application may be made in circumstances where there is no court appointed guardian with the authority to make the decision and the incapable person did not make a power of attorney document while capable of doing so and does not want a family member listed in subsection 20(1) in the HCCA to be the SDM A representative appointed by the Board ranks above listed family members (See list of SDMs in subsection 453 in this manual) s 51(1) A person who is 16 years old or older and who is incapable with respect to his or her admission to a care facility may apply to the Board for appointment of a representative to give or refuse consent on his or her behalf Exception s 51(3) Subsections (1) and (2) do not apply if the incapable person has a guardian of the person who has authority to give or refuse consent to the personrsquos admission to a care facility or an attorney for personal care under a power of attorney conferring that authority It should be noted that under the legislation governing LTC homes a person must be at least 18 years of age to be eligible for admission to a LTC home The above provision refers to ldquo16 years or olderrdquo as there is power by regulation to prescribe other facilities as ldquocare facilitiesrdquo under the HCCA (currently only LTC homes are ldquocare facilitiesrdquo)

September 2006 45

4103 Application for Appointment of Representative ndash by Proposed Representative The proposed representative may make the application to the Board to be appointed as the representative s 51(2) A person who is 16 years old or older may apply to the Board to have himself or herself appointed as the representative of a person who is incapable with respect to his or her admission to a care facility to give or refuse consent on behalf of the incapable person Exception s 51(3) Subsections (1) and (2) do not apply if the incapable person has a guardian of the person who has authority to give or refuse consent to the personrsquos admission to a care facility or an attorney for personal care under a power of attorney conferring that authority Note The proposed representative may be 16 years of age or older

4104 Appointment of Representative ndash Applicable Provisions The following provisions apply to applications to appoint a representative under either subsection 51(1) or (2) as described in subsections 4102 and 4103 in this manual Parties s 51(4) The parties to the application are 1 The incapable person 2 The proposed representative named in the application 3 Every person who is described in paragraph 4 5 6 or 7 of subsection 20 (1) as it applies for the purpose of section 41 4 The person responsible for authorizing admissions to the care facility 5 Any other person whom the Board specifies Appointment s51(5) In an appointment under this section the Board may authorize the representative to give or refuse consent on the incapable personrsquos behalf (a) to his or her admission to the care facility or (b) to his or her admission to any care facility or to any of several care facilities specified by the Board whenever an evaluator finds that the person is incapable with respect to the admission Subss 33 (6) to (8) apply s 51(6) Subsections 33 (6) to (8) apply with necessary modifications to an appointment under this section

September 2006 46

4105 Application for Directions About Wishes

Application for directions s 52(1) A substitute decision-maker or the person responsible for authorizing admissions to a care facility may apply to the Board for directions if the incapable person expressed a wish with respect to his or her admission to the care facility but (a) the wish is not clear (b) it is not clear whether the wish is applicable to the circumstances (c) it is not clear whether the wish was expressed while the incapable person was capable or (d) it is not clear whether the wish was expressed after the incapable person attained 16 years of age Notice to substitute decision-maker s 52(11) If the person responsible for authorizing admissions to the care facility intends to apply for directions the person shall inform the substitute decision-maker of his or her intention before doing so Parties s 52(2) The parties to the application are 1 The substitute decision-maker 2 The incapable person 3 The person responsible for authorizing admissions to the care facility 4 Any other person whom the Board specifies Directions given by Board s 52(3) The Board may give directions and in doing so shall apply section 42 Note Section 42 of the HCCA and subsection 495 in this manual set out the required principles for the SDM to follow in making the admission decision The CCAC must inform the SDM of its intention to make an application under section 52(1) before doing so

Application to depart from wishes s 53(1) If a substitute decision-maker is required by paragraph 1 of subsection 42 (1) to refuse consent to the incapable persons admission to a care facility because of a wish expressed by the incapable person while capable and after attaining 16 years of age (a) the substitute decision-maker may apply to the Board for permission to consent to the admission despite the wish or (b) the person responsible for authorizing admissions to the care facility may apply to the Board to obtain permission for the substitute decision-maker to consent to the admission despite the wish

September 2006 47

Notice to substitute decision-maker s 53(11) If the person responsible for authorizing admissions to the care facility intends to apply under subsection (1) the person shall inform the substitute decision-maker of his or her intention before doing so Criteria for permission s 53(3) The Board may give the substitute decision-maker permission to consent to the admission despite the wish if it is satisfied that the incapable person if capable would probably give consent because the likely result of the admission is significantly better than would have been anticipated in comparable circumstances at the time the wish was expressed

The CCAC must inform the SDM of its intention to make an application under section 53(1) before doing so

4107 Application to Determine Compliance with Section 42

Application to determine compliance with section 42 s 54(1) If consent to admission to a care facility is given or refused on an incapable persons behalf by his or her substitute decision-maker and if the person responsible for authorizing admissions to the care facility is of the opinion that the substitute decision-maker did not comply with section 42 the person responsible for authorizing admissions to the care facility may apply to the Board for a determination as to whether the substitute decision-maker complied with section 42 Parties s 54(2) The parties to the application are 1 The person responsible for authorizing admissions to the care facility 2 The incapable person 3 The substitute decision-maker 4 Any other person whom the Board specifies The CCAC would make this application if it believes that the principles that a SDM is required to follow when giving or refusing consent including the personrsquos previously expressed capable wishes or if applicable the personrsquos best interests were not properly considered by the SDM in making his or her decision about the personrsquos admission to a LTC home Power of Board s 54(3) In determining whether the substitute decision-maker complied with section 42 the Board may substitute its opinion for that of the substitute decision-maker Directions s 54(4) If the Board determines that the substitute decision-maker did not comply with section 42 it may give him or her directions and in doing so shall apply section 42

September 2006 48

Time for compliance s 54(5) The Board shall specify the time within which its directions must be complied with Deemed not authorized s 54(6) If the substitute decision-maker does not comply with the Boardrsquos directions within the time specified by the Board he or she shall be deemed not to meet the requirements of subsection 20 (2) as it applies for the purpose of section 41 Subsequent substitute decision-maker s 54(61) If under subsection (6) the substitute decision-maker is deemed not to meet the requirements of subsection 20 (2) any subsequent substitute decision-maker shall subject to subsections (62) and (63) comply with the directions given by the Board on the application within the time specified by the Board Application for directions s 54(62) If a subsequent substitute decision-maker knows of a wish expressed by the incapable person with respect to the admission to a care facility the substitute decision-maker may with leave of the Board apply to the Board for directions under section 52 Inconsistent directions s 54(63) Directions given by the Board under section 52 on a subsequent substitute decision-makerrsquos application brought with leave under subsection (62) prevail over inconsistent directions given under subsection (4) to the extent of the inconsistency PGT s 54(7) If the substitute decision-maker who is given directions is the Public Guardian and Trustee he or she is required to comply with the directions and subsection (6) does not apply to him or her

Deemed application concerning capacity s 541 An application to the Board under section 51 52 53 or 54 shall be deemed to include an application to the Board under section 50 with respect to the personrsquos capacity to consent to his or her admission to a care facility unless the personrsquos capacity to consent to such admission has been determined by the Board within the previous six months It should be noted from section 541 that whenever one of the listed applications to the Board is made there is an automatic deemed application to the Board to review the finding of incapacity of the person to consent to the admission unless the Board has determined the issue of capacity within the previous six months Note Further information as well as application forms and detailed contact information for the regional and head offices of the Board can be obtained by calling 1-800-461-2036 or from the Boardrsquos internet website at [httpwwwccboardonca]

September 2006 49

The CCAC case manager who is responsible for authorizing an admission to a LTC home has protection from liability in the following circumstances which relate to the decision of the SDM on behalf of an incapable person Apparently valid consent to admission s 48(1) If the person responsible for authorizing admissions to a care facility admits or authorizes the admission of a person to the care facility with a consent that he or she believes on reasonable grounds and in good faith to be sufficient for the purpose of this Act he or she is not liable for admitting the person or authorizing the personrsquos admission without consent Apparently valid refusal of admission s 48(2) If the person responsible for authorizing admissions to a care facility does not admit or does not authorize the admission of a person to the care facility because of a refusal that he or she believes on reasonable grounds and in good faith to be sufficient for the purpose of this Act he or she is not liable for failing to admit the person or failing to authorize the personrsquos admission Admission s 48(3) If the person responsible for authorizing admissions to a care facility admits or authorizes the admission of a person to the care facility under section 47 in good faith he or she is not liable for admitting the person or authorizing the personrsquos admission without consent Reliance on assertion s 48(4) If a person who gives or refuses consent to admission to a care facility on an incapable personrsquos behalf asserts that he or she (a) is a person described in subsection 20 (1) as it applies for the purpose of section 41 or an attorney for personal care described in clause 50 (2) (b) (b) meets the requirement of clause 20 (2) (b) or (c) as it applies for the purpose of section 41 or (c) holds the opinions required under subsection 20 (4) as it applies for the purpose of section 41the person responsible for authorizing admissions to the care facility is entitled to rely on the accuracy of the assertion unless it is not reasonable to do so in the circumstances The SDM has the following protection from liability Person making decision on anotherrsquos behalf s 49 A person who gives or refuses consent on another personrsquos behalf to his or her admission to a care facility acting in good faith and in accordance with this Act is not liable for giving or refusing consent As indicated in section 48(4) of the HCCA the CCAC is entitled to rely on the accuracy of a personrsquos assertions of the following matters unless it is not reasonable to do so in the circumstances

September 2006 50

bull that the person is the legally authorized SDM (from the list of persons set out in subsection

20(1)) who may give or refuse consent to the admission bull that the person is the attorney for personal care under a power of attorney that contains a

provision waiving the alleged incapable personrsquos right to apply for a review of an evaluatorrsquos finding of incapacity and the provision is effective under subsection 50(1) of the Substitute Decisions Act 1992

bull that the person meets the following requirements of a SDM bull is at least 16 years old (unless he or she is the incapable personrsquos parent) and bull is not prohibited by court order or separation agreement from having access to the

incapable person or giving or refusing consent on his or her behalf and bull that the person believes there is no one else with a higher ranking on the list of those who

may act as the SDM or that there is no one else of the same ranking or that although such a person exists the person does not object to the person making the decision and is not one of the following three persons bull the incapable personrsquos guardian or the person with the authority to make the decision bull the incapable personrsquos attorney for personal care under a power of attorney that confers

the authority to make the decision or bull the incapable personrsquos representative appointed by the Board to make the decision

September 2006 51

Part IV of the Health Care Consent Act 1996 (HCCA) sets out the legislative requirements with respect to consent to a personal assistance service on behalf of a person whom an ldquoevaluatorrdquo finds incapable of making the decision For Part IV of the HCCA evaluator has the same meaning as for Part III which deals with substitute decisions on behalf of persons who are incapable of making a decision about admission to a long-term care (LTC) home (See subsection 48 in this manual) The HCCA provides the following definition s 2(1) personal assistance service means assistance with or supervision of hygiene washing dressing grooming eating drinking elimination ambulation positioning or any other routine activity of living and includes a group of personal assistance services or a plan setting out personal assistance services to be provided to a person but does not include anything prescribed by the regulations as not constituting a personal assistance service Note There are currently no regulations under this provision

4111 Application of Part IV of the HCCA

The provisions in Part IV of the HCCA apply to a ldquorecipientrdquo of a personal assistance service The HCCA defines recipient of personal assistance services referred to in Part IV as s 2(1)hellip a person who is to be provided with one or more personal assistance services (a) in an approved charitable home for the aged as defined by the Charitable Institutions Act (b) in a home or joint home as defined by the Homes for the Aged and Rest Homes Act (c) in a nursing home as defined by the Nursing Homes Act (d) in a place prescribed by the regulations in the circumstances prescribed by the regulations (e) under a program prescribed by the regulations in the circumstances prescribed by the

regulations or (f) by a provider prescribed by the regulations in the circumstances prescribed by the

regulation There are currently no regulations under (d) (e) or (f) above Thus the scheme for substitute decisionmaking for personal assistance services referred to in Part IV of the HCCA apply only to personal assistance services for residents of LTC homes who are incapable of making the decision

4112 Consent to Community Services It should be noted that there is a consent requirement with respect to community services provided under the Long-Term Care Act 1994 (LTCA) Subsection 3(1)6 the Bill of Rights

September 2006 52

under the LTCA (see subsection 221 in this manual) provides that ldquoa person has the right to give or refuse consent to the provision of any community servicerdquo This is a reference to the consent of the client who receives the service In addition the following provision of the LTCA addresses the issue of consent to community services Consent required s 24 Nothing in this Act authorizes an approved agency to assess a personrsquos requirements determine a personrsquos eligibility or provide a community service to a person without the personrsquos consent

4113 Consent to Community Services on Behalf of Incapable Person

As noted in subsection 411 of this manual clients who are incapable of making a decision about a community service may have a substitute decision-maker (SDM) who is authorized under the Substitute Decisions Act 1992 (SDA) to make personal care decisions on their behalf The SDM may be either an attorney for personal care or a guardian of the person who is authorized to make personal care decisions Personal care decisions are decisions about health care nutrition shelter clothing hygiene or safety To the extent that a community service is one of these things (health care nutrition shelter clothing hygiene or safety) the SDM with the required authority may provide consent on behalf of the incapable person

CCAC Client Services Policy Manual Chapter 5 Information and Referral Services

September 2006 1

Information and Referral Services

One of the primary service functions of the Community Care Access Centre (CCAC) is to provide information and referral services to members of the community The CCAC must ensure that this service is timely and responsive to the needs of individuals

511 Legislative Requirements

The Community Care Access Corporations Act 2001 (CCACA) states that one of the objects of a CCAC is to provide information to the public about community-based care services long-term care (LTC) homes and related health and social services

512 Requirements of the CCAC Information and Referral Service

The CCAC must ensure that its information and referral service meets the following requirements bull establishes and maintains a comprehensive database on long-term care services (both

community and LTC home services) bull provides information to the client (and caregiver) on the health and related social services

provided or arranged by the CCAC (The service must provide people with the information necessary to make informed independent decisions)

bull informs people of other community resources that may be helpful to them provides information on key government funded programs and where appropriate directs persons to those other community resources that operate within the CCACrsquos designated geographic area (The CCAC may also provide information about services beyond its boundaries)

bull serves as an information resource to other health and community service providers so that they are equipped with the most current knowledge of long-term care services

bull informs the person accessing CCAC services about program requirements bull ensures that clients receive advice regarding their rights (including right to confidentiality

right to consent and right to make a complaint or appeal a decision affecting their care Consent to treatment is discussed in chapter 4 in this manual Complaints and appeals are discussed in chapter 10 in this manual) and are referred to appropriate resources Case managers must adhere to the Long-Term Care Act 1994 (LTCA) Ministry of Health and

September 2006 2

Long-Term Care (MOHLTC) policy and CCAC protocols with respect to clientsrsquo complaints and appeals (see chapter 10 in this manual)

bull ensures that clients are aware of the procedure for bringing forward issues and suggestions and the procedure to access their plan of service and personal health information and

bull advocates on behalf of their clients

September 2006 3

The information and referral function of the Community Care Access Centre (CCAC) must be comprehensive enough to reflect the needs of people who access CCAC services including children seniors caregivers and other interested individuals such as businesses other health and social service agencies and professionals The information and referral service must include the following features bull Services must be accessible The location of the CCAC and contact information such as

telephone number and e-mail address must be well publicized The CCAC must develop other methods to increase public awareness of its services (eg pamphlets posters andor information sessions) The CCAC must also investigate providing publicity in alternate formats such as Braille or large print

bull Telephone attendant(s) must be available during regular working hours as determined by the CCAC to address questions or concerns While the CCAC may use voice activated systems that enable people to access information these systems must not be viewed as a substitute for a telephone attendant during normal working hours Telephone technology must also meet the special needs of people with disabilities

bull French language services must be provided in areas designated under the French Language Services Act (FLSA) Once a clients language preference is determined during information and referral by the CCAC the CCAC must respect the clients wishes in accordance with the Act in providing or arranging services including communications for the purpose of the services When providing service or referring clients to external services the CCAC must take language preference into consideration and when possible inform clients of providers that can meet their needs

bull Services must be responsive to the ethno-cultural needs of the community Services must address the information access needs of the major linguistic groups served by the CCAC

521 Information and Referral Protocols

Each CCAC must develop protocols for the information and referral service to ensure that bull the information provided is current and accurate bull information is provided in a timely manner bull people are directed to a case manager where appropriate bull people are referred to the appropriate programs or services (including culturally and

linguistically appropriate) bull people with special needs receive assistance in understanding the information and bull processes are clearly explained so clients are able to understand what to expect of services

that are to be received The CCAC must develop these protocols in collaboration with community service agencies community health and social service providers and LTC home operators

September 2006 4

522 Inquiries that Should be Referred to Case Management Staff

Callers must be referred to case management staff when

bull the caller has complaints regarding CCAC services bull the caller requests a service arranged through the CCAC or bull the circumstances and needs of the caller are complex and require detailed clarification and

articulation 523 Emergency Calls

Either the CCAC or the caller must phone emergency services when bull the person needs emergency counselling or bull the person needs emergency intervention

September 2006 5

The CCAC must be able to provide inquirers with information about the following kinds of services bull services provided or arranged through the CCAC bull services provided by other approved agencies and bull other health and social service programs Services provided or arranged through the CCAC are

bull assessment and eligibility determination for professional personal support and

homemaking bull providing or arranging for the following services

bull professional services (nursing occupational therapy physiotherapy social work speech-language pathology dietetics)

bull personal support services (personal hygiene routine personal activities of living) bull homemaking services (housecleaning doing laundry shopping banking paying bills

planning menus preparing meals caring for children) and bull providing equipment supplies and other goods within their legislated authority

bull providing information and referral for community services and bull admission to long-term care (LTC) homes The 15 key community support services (as per the 20012002 Planning Funding and Accountability Policies and Procedures Manual for Long-Term Care Community Services) are bull meal services bull transportation services bull caregiver support services (these services include counselling information and education to

consultants) bull friendly visiting services

September 2006 6

bull security checks bull social or recreational services (including services delivered by both elderly persons centres

with physical disabilities including attendant outreach direct funding and special services for the blind and hearing impaired This also includes foot care aphasia and homemaking and personal support services)

All of the above services may not be available within each CCACrsquos catchment area

For each of the above services staff providing information and referrals must be knowledgeable about bull actual services provided (hours of service whether fees apply and other significant

information) bull eligibility determination process and criteria bull intended target population for community services bull service capacity and waiting lists if applicable and bull consumer rights including the right to appeal Other health and social service programs (including government programs or other programs provided by community agencies) include but are not limited to

bull services to First Nations (see subsection 311 in this manual) bull mental health programs and services (eg psychiatric hospitalsunits addictions services

programs psychiatric assessment and treatment crisis response supports for housing consumersurvivor and family initiatives) (see subsection 55 in this manual)

bull Ontario Health Insurance Plan (OHIP) bull Ontario Drug Benefit (ODB) Program bull Assistive Devices Program (ADP) bull hospital inpatient and community services (eg outpatient clinics and day hospitals) bull service agencies providing services to specific groups (eg Canadian Hearing Society

cancer care programs independent living centres) bull seniors centres bull voluntary service agencies that provide information outreach and advocacy services for

specific client groups bull ethno-cultural services and resources bull womenrsquos shelters and transition houses bull abuse preventionintervention services bull child welfare services children and family intervention services child treatment services

and child care resources

September 2006 7

bull other housing options (eg retirement homes) bull other personal support worker services and bull other homemakers and nurses services

Staff providing information and referral services should be able to provide a general description of the health and social service programs listed above and how to access them Staff may contact the program on the personrsquos behalf if the person is not capable of contacting the outside service directly

531 Collaboration with Other Information Providers

The CCAC must develop and maintain its information service in collaboration with other community service agencies and service providers within the geographic area it serves

532 CCAC Not Responsible for Other General Community Information

The CCAC is not required to provide information related to consumercommercial inquiries education labour market information (eg employment) environment or financial counselling

September 2006 8

The Community Care Access Centre (CCAC) must monitor the quality of the information and referral service and collect the following information bull source of call (eg client caregiver member of the public other CCAC staff other service

provider or other) bull type of inquiry bull action taken (eg appointment publication sent information provided information and

referral to another agency follow-up or contact agencyservice) and bull number and duration of calls

At regular intervals staff of the CCAC must analyze the collected data in order to bull determine basic statistics (eg numbers of calls by type source action response the

average length of each call) bull compare records from different time periods to show trends over time if any bull identify patterns (Are the numbers of calls higher at certain times of the day or week Is the

service being used disproportionately by one source Is the response time getting longer or shorter Is the CCAC able to respond to the queries for information)

bull identify gaps and address them accordingly (Are there repeated calls for a service that does not currently exist)

bull evaluate the information (Is the CCAC getting a high number of calls that are referred to the case manager and if so why Could non-case management staff who are properly trained handle the calls) and

bull consider alternatives (If the service is answering the same question repeatedly is there a way to disseminate the answer to the community by other means such as media coverage or inclusion in CCAC brochures)

The CCAC must conduct a survey of callers periodically to measure caller satisfaction with information and referral services Responses should be analyzed for indicators of

bull accessibility bull continuity bull safety bull timeliness and bull quality of information provided

September 2006 9

551 Persons Who Require Mental Health Services

Mental health programs and services for persons over the age of 16 are the responsibility of the Ministry of Health and Long-Term Care (MOHLTC) These programs are delivered by community mental health programs Schedule 1 hospitals and mental health facilities Most mental health programs and services for childrenyouths under the age of 16 are the responsibility of the Ministry of Community and Social Services (MCSS) and the Ministry of Children and Youth Services (MCYS) These programs are delivered by childrenrsquos mental health programs and some Schedule 1 hospitals Some mental health programs are delivered by the MOHLTC If a person of any age has a severe physical disability or illness in addition to a mental illness he or she may be assessed as eligible for services provided by a Community Care Access Centre (CCAC) (eg service for post-operative care) The CCAC should not provide services to individuals to monitor their medications assist in routine personal activities of daily living or provide homemaking services when these services are required solely due to a mental illness Case managers should refer individuals to community mental health services or other resources that support persons with mental illnesses to live successfully in a community setting

CCAC Client Services Policy Manual Chapter 6 CCAC Case Management

September 2006 1

CCAC Case Management

The Long-Term Care Act 1994 (LTCA) assigns specific duties to agencies approved to provide community services In regulation 3302 under the Community Care Access Corporations Act 2001 (CCACA) a Community Care Access Centre (CCAC) is deemed to be an approved agency under the LTCA and is approved to provide the community services set out in this regulation Two key CCAC responsibilities are provision of home care and managing the placement process into long-term care (LTC) homes The CCAC manages these key activities through case management services a core service of the CCAC Case management in the CCAC is vested in case managers who must assess and review requirements determine eligibility and develop and evaluate the plans of service for CCAC services and authorize the expenditures of funds for services in accordance with sections 22 and 23 of the LTCA and authorize admissions to LTC homes in accordance with subsection 201 of the Nursing Homes Act (NHA) section 18 of the Homes for the Aged and Rest Homes Act (HARHA) and subsection 96 of the Charitable Institutions Act (CIA) (The admission to LTC care homes is discussed in chapter 11 in this manual)

611 CCAC Case Management The LTCA sets out the case management function of the CCAC for community services Plan of service s 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges the agency shall (a) assess the personrsquos requirements (b) determine the personrsquos eligibility for the services that the person requires and (c) for each person who is determined to be eligible develop a plan of service that sets out the amount of each service to be provided to the person Revision of plan of service s 22(2) If a person is receiving a community service provided or arranged by an approved agency the agency shall

September 2006 2

(a) review the personrsquos requirements when appropriate depending on the personrsquos condition and circumstances and (b) evaluate the personrsquos plan of service and revise it as necessary when the personrsquos requirements change Co-ordination of services s 22(3) If a person is receiving more than one community service provided or arranged by an approved agency the agency shall assist the person in co-ordinating the services he or she receives in accordance with the personrsquos wishes Participation in plan of service s 22(4) An approved agency shall provide an opportunity to participate fully in the development evaluation and revision of a plan of service to (a) the person who is the subject of the plan of service (b) if the person who is the subject of the plan of service is mentally incapable the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service and (c) the person if any designated by the persons referred to in clauses (a) and (b) Other assessments to be considered s 22(5) In assessing a personrsquos requirements under clause (1) (a) and in reviewing a personrsquos requirements under clause (2) (a) an approved agency shall take into account all assessments and information that are provided to it relating to the personrsquos capacity the personrsquos impairment or the personrsquos requirements for health care or community services Personrsquos preferences to be considered s 22(6) In developing evaluating and revising a personrsquos plan of service an approved agency shall take into account the personrsquos preferences including preferences based on ethnic spiritual linguistic familial and cultural factors Compliance with regulations s 22(7) An approved agency shall apply the prescribed criteria follow the prescribed procedures and comply with the prescribed rules and standards in assessing a personrsquos requirements determining a personrsquos eligibility and developing evaluating and revising a plan of service Provision of services s 23(1) An approved agency shall ensure that the services outlined in a personrsquos plan of service are provided to the person within a time that is reasonable in the circumstances Waiting list s 23(2) If a community service outlined in a personrsquos plan of service is not immediately available the approved agency shall place the person on the waiting list for that service and shall advise the person when the service becomes available

September 2006 3

Case management is a core service provided by the CCAC and the mechanism through which individuals access a range of services The interactive involvement and relationship between a case manager and clients must be supportive and assist clients to live independently and make their own health choices In addition to being a service to individual clients CCAC case management also serves a system-level function promoting service consistency co-ordination quality and accountability while maximizing client independence and optimizing resource utilization

Case management is knowledge-based and incorporates skills abilities and experience to successfully carry out the processes of collecting and analyzing information and developing and managing a plan of service that is mutually agreed to by the client andor substitute decision-maker (SDM) Communication and client education are key elements in linking the processes with the client and linking the client with the CCAC and other parts of the health care system The CCAC must comply with the LTCA when providing case management and be guided by the following principles bull respect for the personrsquos rights dignity values and preferences bull promotion of the highest level of independence possible for the person within the personrsquos

capacity by focusing on the personrsquos strengths needs and preferences bull promotion of quality improvement in all aspects of service management bull promotion of a collaborative and co-ordinated approach to service delivery and bull promotion of efficient effective and equitable use of resources Case management is available to persons requesting in-home services school services and admission to LTC homes Case management intensity may vary according to the needs and goals of the individual client Some clients may benefit from care pathways while others may require intensive case management

September 2006 4

Case managers must co-ordinate service delivery provided by the Community Care Access Centre (CCAC) their contracted service providers and informal caregivers and link clients to appropriate volunteer and community resources Case managers must collaborate with clients and service providers to determine the nature intensity and duration of services required to address the clientrsquos needs and ensure the most effective use of resources A case manager must authorize each CCAC service provided to a client The case manager must have the knowledge and skills to work with clients and local community resources to provide efficient and effective services to clients Community services can supplement those provided through the CCAC to complement and strengthen the individuals plan of service Case managers must ensure that their practices use quality improvement risk management and best practice principles that strengthen service delivery As a primary objective the CCAC case manager must ensure that the right services are provided to the right clients at the right time The primary objective is achieved by bull assessing client needs (see subsection 621 in this manual) bull determining eligibility for services (see subsection 622 in this manual) bull developing plans of service for eligible clients in collaboration with clientcaregivers (see

subsection 623 in this manual) bull co-ordinating services to help clients meet the goals of optimal health and independence

(see subsection 624 in this manual) bull conducting regular reassessments of clients (see subsection 625 in this manual) bull adjusting CCAC services when client requirements change (see subsection 626 in this

manual) bull discharging clients as soon as the services are no longer required the client is no longer

eligible for services the client withdraws consent to receive services or the client is no longer available (see subsection 627 in this manual) and

bull supporting clients through the health and social support systems Case managers must assess needs determine eligibility based on eligibility criteria and develop authorize monitor and evaluate plans of service These plans of service may include professional services personal support services homemaking services and school services as well as supplies equipment or other goods within their legislated authority

Case managers must provide other supports to the client and the caregiver by bull counselling clients and families that are adapting to change or are in crisis and having

difficulty coping making decisions and problem solving bull assisting persons to develop the knowledge skills and ability to make choices that enhance

their health and well being

September 2006 5

bull developing appropriate strategies for clients who may be resistant to services and who live at risk in the community

bull assisting and supporting family caregivers or substitute decision-makers (SDMs) that must act on behalf of family members who are no longer capable and

bull monitoring clients who are at risk including clients with medical conditions that have the potential to deteriorate at any time clients who may have an urgent requirement for 24-hour seven-day supervision clients who may need crisis placement clients with cognitive disabilities and an inadequate support system caregivers at risk of burn out and clients who may be subject to abuse neglect or self-neglect

Under the Long-Term Care Act 1994 (LTCA) case managers are responsible for the following functions

Function Reference in this Manual

assessment 621

eligibility determination 622

service planning (plan of service development and resource allocation) 623

service co-ordination 624

reassessment 625

monitoring and revision of plan of service 626

service termination (discharge) 627

(See case managersrsquo functions with respect to long-term care (LTC) home admissions in chapter 11 in this manual)

621 Assessment

The assessment process is set out in the LTCA

Plan of service s 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges the agency shall (a) assess the personrsquos requirements hellip Other assessments to be considered s 22(5) In assessing a personrsquos requirements under clause (1)(a) and in reviewing a personrsquos requirements under clause (2) (a) an approved agency shall take into account all assessments and information that are provided to it relating to the personrsquos capacity the personrsquos impairment or the personrsquos requirements for health care or community services

September 2006 6

Compliance with regulations s 22(7) An approved agency shall apply the prescribed criteria follow the prescribed procedures and comply with the prescribed rules and standards in assessing a personrsquos requirements determining a personrsquos eligibility and developing evaluating and revising a plan of service

There are currently no regulations relating to the assessment of a personrsquos requirements Assessment is a dynamic and collaborative process that actively involves the client and others The CCAC case manager must collect and analyze relevant information in order to understand and identify an individualrsquos requirements for care This process serves as the foundation for consistent service planning across the CCAC The CCAC case manager must ensure that the clientrsquos values functional and cognitive capacity strengths impairments abilities preferences non-financial resources supports and needs are identified and documented consistently and accurately in a timely manner and that client needs are well understood Service providers and external community resources provide valuable information that contribute to the CCAC case management function Client assessment is the foundation for many other functions Assessment must be completed before the CCAC can determine eligibility for CCAC services or referral to other services It is also important for goal setting service planning service authorization and client outcome evaluation In addition to standardized client assessment data the CCAC requires significant additional client information These items are collected by other methods and may include other types of information or assessments such as physician orders the Health Report form for LTC homes consent and capacity evaluations and identification of a SDM (For information on health assessment see chapter 11 in this manual For information on consent and capacity evaluation and SDM see chapter 4 in this manual) The CCAC may have agreements to provide assessment on behalf of community service agencies such as adult day services (see subsection 39 in this manual) or programs funded by the Ministry of Children and Youth Services (MCYS) The RAI-HC Assessment Instrument The Resident Assessment Instrument-Home Care (RAI-HC) has been adopted as the comprehensive standardized instrument for evaluating the needs strengths and preferences of adult long-stay individuals in the community including individuals requesting admission to LTC homes The RAI-HC has been implemented in all 42 CCACs The longer-term objective is to implement a standardized assessment process which will include all CCAC client populations Standard assessment instruments for intake and short-stay palliative and other specialized client groups are under development

September 2006 7

Policies and guidelines have been drafted to assist the CCAC in the introduction of the RAI-HC The policies and guidelines described below will be reviewed and if necessary modified based on past experience Policies for Assessment of the Adult Long-Stay Client in the Community

All RAI-HC1 assessments must be administered by CCAC case managers who are regulated health or social work professionals and have been trained (two-day education program) to administer the tool This includes but is not limited to a registered nurse physiotherapist occupational therapist speech-language pathologist social worker dietitian and psychologist These professionals are required to be members in good standing of their regulatory body The CCAC case manager must

bull Use the RAI-HC assessment tool and related assessment process to assess and reassess

all CCAC adult long-stay clients for both CCAC services and LTC home placement An adult long-stay client is defined as an adult who requires more than 60 uninterrupted days of service through a CCAC or a client who requires admission to a LTC home including crisis situations

bull Conduct all RAI-HC assessments in face-to-face interviews with the client bull Complete all sections of the RAI-HC assessment tool bull Complete the RAI-HC assessment within 14 calendar days following the date that the

client is identified as long-stay according to the priority for assessment parameters This refers to the time frame that is allowed for the initiation of the face-to-face assessment

bull Complete the RAI-HC at the time of the initial visit In exceptional circumstances only when the RAI-HC assessment cannot be completed on a single visit the CCAC case manager must complete the assessment within three days of the initial visit If on the second visit the case manager determines that the clientrsquos condition has changed significantly the CCAC case manager must complete a new RAI-HC

bull Maintain proficiency in administering the RAI-HC by completing an average of eight to 10 assessmentsreassessments per month

bull If this level of activity is not maintained the CCAC must develop and implement protocols to ensure that assessors who have not been using the tool for a significant period of time are proficient

Policies for Assessment of the Adult Long-Stay Client in the Hospital

The CCAC case manager must conduct the RAI-HC assessment at home according to the priority for assessment parameters or within 14 days following hospital discharge according to the professional judgement of the case manager

1 See RAI-HC guidelines provided to CCACs by the MOHLTC Priority Project

September 2006 8

Note A long-stay client may be discharged home from hospital with a short-term plan of service following initial triage in the hospital setting

The CCAC case manager must conduct the Minimum Data Set for Home Care (MDS-HC) (hospital version) in the hospital setting for a client who is ineligible for home care services and unable to return to the community and is therefore applying for admission to a LTC home

622 Eligibility Determination

Eligibility determination requirements are set out in the LTCA

There are regulations under the LTCA relating to eligibility for homemaking personal support and school services and regulations under the Health Insurance Act (HIA) relating to eligibility for professional services (see chapter 3 in this manual)

The CCAC case manager must determine and document a clientrsquos eligibility for CCAC services andor for admission to a LTC home based on the regulated eligibility criteria (see chapter 3 in this manual) The CCAC has no authority to provide services to clients who do not meet these eligibility criteria

The CCAC case manager must ensure that services are provided to eligible persons in keeping with their assessed needs and the resources available and in accordance with the Bill of Rights (see subsection 221 in this manual) The case manager must also consider the respite care needs of the clientrsquos caregiver

The CCAC case manager must also refer persons to the appropriate health social service or community resources that can address their needs These persons would include for example persons determined ineligible for CCAC services persons whose CCAC services have terminated and persons who do not consent to CCAC services The case managerrsquos judgement will determine the duration of the provision of case management service to the individual (eg

September 2006 9

families requiring ongoing assistance with end of life care to a loved one who does not have Ontario Health Insurance Plan (OHIP) coverage may receive case management services)

623 Service Planning

The requirements relating to the development of a plan of service are set out in the LTCA Plan of service s 22(1) When a person applies to an approved agency for any of the community services that the agency provides or arranges the agency shall (a) assess the personrsquos requirements (b) determine the personrsquos eligibility for the services that the person requires and (c) for each person who is determined to be eligible develop a plan of service that sets out the

amount of each service to be provided to the person Participation in plan of service s 22(4) An approved agency shall provide an opportunity to participate fully in the development evaluation and revision of a plan of service to (a) the person who is the subject of the plan of service (b) if the person who is the subject of the plan of service is mentally incapable the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service and (c) the person if any designated by the persons referred to in clauses (a) and (b) Personrsquos preferences to be considered s 22(6) In developing evaluating and revising a personrsquos plan of service an approved agency shall take into account the personrsquos preferences including preferences based on ethnic spiritual linguistic familial and cultural factors Compliance with regulations s 22(7) An approved agency shall apply the prescribed criteria follow the prescribed procedures and comply with the prescribed rules and standards in assessing a personrsquos requirements determining a personrsquos eligibility and developing evaluating and revising a plan of service

There are currently no regulations relating to the development evaluation and revising of a plan of service Service planning involves the following processes bull determine and authorize the services to be provided to eligible clients based on assessed

requirements bull determine the frequency and duration of the services bull set out in the plan of service the services to be provided to the client bull determine whether the services are immediately available

September 2006 10

bull discuss the proposed plan of service with the client including the need if any to be placed on any waiting list

bull if any of the CCAC services are not immediately available place the client on a waiting list for these services based on priority of need2 as determined according to local policy

bull provide or ensure the provision of services in the plan of service that are available bull monitor the waiting list and provide or ensure the provision of services in the plan of

service once they become available and bull co-ordinate these services The CCAC case manager must develop and authorize a plan of service for each person who is determined eligible for CCAC services The plan of service must set out the amount of each service to be provided to the person by the CCAC Some elements of the plan of service may be short-term and others long-term The plan of service should also refer to the community services to which the client has been referred by the CCAC as well as other supports and services including family support or self-paid or privately insured services

The CCAC case manager must work closely with clients and others on the care team and take into account the personrsquos preferences including preferences based on ethnic spiritual linguistic familial and cultural factors when developing the plan of service Provision of Services The LTCA states Provision of services s 23(1) An approved agency shall ensure that the services outlined in a personrsquos plan of service are provided to the person within a time that is reasonable in the circumstances Waiting list s 23(2) If a community service outlined in a personrsquos plan of service is not immediately available the approved agency shall place the person on the waiting list for that service and shall advise the person when the service becomes available

Under section 23(1) of the LTCA the CCAC must provide the services set out in the clientrsquos plan of services ldquowithin a time that is reasonable in the circumstancesrdquo These circumstances could include for example the financial circumstances of the CCAC as well as availability of contracted service providers If services set out in the clientrsquos plan of service are not immediately available the CCAC must place the person on a waiting list With respect to the financial circumstances of the CCAC the CCAC must optimize the use of CCAC services by using a resource allocation methodology Case managers who carry a caseload must have a service envelope This envelope must be made up of service units based on the allocation by the CCAC of approved service units (ie for personal support and homemaking and shift nursing one unit is one hour for nursing and therapy services one unit

2 Priority of need must be re-established and kept current

September 2006 11

is one visit) Case managers who have a service envelope must be accountable for their service envelope and receive timely regular reports about the availability of CCAC resources In addition to each case managerrsquos envelope the CCAC must also develop a type of ldquoteamrdquo envelope for exceptional circumstances

624 Service Co-ordination

The CCACrsquos responsibility to co-ordinate services is set out in the LTCA

Co-ordination of services s 23(3) If a person is receiving more than one community service provided or arranged by an approved agency the agency shall assist the person in co-ordinating the services he or she receives in accordance with the personrsquos wishes

Case managers must provide support to the client and the caregiver by bull coordinating services provided by the CCAC and bull working collaboratively with the client staff of other approved agencies (eg attendant

outreach services community support services assisted living services in supportive housing) the family physician and contracted service providers to bull develop integrated plans of service for persons whose needs transcend the service

mandates of any one approved agency or service provider and bull develop area-wide service delivery strategies for persons who are vulnerable at risk of

abuse or being abused or living at risk in the community or persons who are at risk of not being served by the existing system (eg outreach services specifically designed for persons with mental illnesses or cognitive impairments the socially isolated and those who may experience cultural and language barriers to service)

Service co-ordination involves co-ordinating all elements of client care including CCAC services with other services and resources supporting the client Effective co-ordination includes regular and ongoing communication with clients family members physicians caregivers and contracted service providers and discussions with community services and community health care partners relating to provision of service It may also involve planning for future health care needs and establishing linkages to other services to help ensure continuity of care for the client The case manager must bull co-ordinate all CCAC services identified in the plan of service bull ensure that individual clients receive services within available resources and bull co-ordinate services from a number of contracted service providers and community

agencies in order to meet the individual clientrsquos needs and respect the clientrsquos preferences for service delivery

September 2006 12

625 Reassessment

The CCACrsquos responsibility to reassess clientsrsquo requirements is set out in the LTCA

Revision of plan of service s 22(2) If a person is receiving a community service provided or arranged by an approved agency the agency shall (a) review the personrsquos requirements when appropriate depending on the personrsquos condition and circumstances and (b) evaluate the personrsquos plan of service and revise it as necessary when the personrsquos

requirements change Participation in plan of service s 22(4) An approved agency shall provide an opportunity to participate fully in the development evaluation and revision of a plan of service to (a) the person who is the subject of the plan of service (b) if the person who is the subject of the plan of service is mentally incapable the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service and (c) the person if any designated by the persons referred to in clauses (a) and (b) Other assessments to be considered s 22(5) In assessing a personrsquos requirements under clause (1) (a) and in reviewing a personrsquos requirements under clause (2) (a) an approved agency shall take into account all assessments and information that are provided to it relating to the personrsquos capacity the personrsquos impairment or the personrsquos requirements for health care or community services Personrsquos preferences to be considered s 22(6) In developing evaluating and revising a personrsquos plan of service an approved agency shall take into account the personrsquos preferences including preferences based on ethnic spiritual linguistic familial and cultural factors Compliance with regulations s 22(7) An approved agency shall apply the prescribed criteria follow the prescribed procedures and comply with the prescribed rules and standards in assessing a personrsquos requirements determining a personrsquos eligibility and developing evaluating and revising a plan of service There are currently no regulations relating to the reassessment of clientsrsquo requirements The CCAC must reassess client needs to bull determine the clientrsquos continuing eligibility and need for CCAC services bull monitor types and levels of services required and appropriateness of supplies and

equipment used bull adjust service levels if client requirements change

September 2006 13

bull adjust goals and bull as necessary arrange for new services or the termination of service The CCAC must reassess adult long-stay clients using the RAI-HC as follows

bull at a minimum of every six months or bull when there is a significant change in a clientrsquos clinical condition functional level or living

circumstances This may include the following new diagnosis progression of the disease process functional decline or improvement return from a stay in hospital change in caregiver status andor change in the plan of service

The CCAC must reassess pediatric long-stay clients palliative clients and rehabilitation clients as follows bull at a minimum of every six months and bull when there is a significant change in a clientrsquos clinical condition functional level or living

The CCAC must reassess short-stay clients when there is a significant change in a clientrsquos clinical condition functional level or living circumstances This may include the following new diagnosis progression of the disease process functional decline or improvement return from a stay in hospital change in caregiver status andor change in the plan of service

626 Monitoring and Revision of Plan of Service

The CCACrsquos responsibility to revise the plan of service is set out in the LTCA Revision of plan of service s 22(2) If a person is receiving a community service provided or arranged by an approved agency the agency shall (a) review the personrsquos requirements when appropriate depending on the personrsquos condition and circumstances and (c) evaluate the personrsquos plan of service and revise it as necessary when the personrsquos

requirements change Participation in plan of service s 22(4) An approved agency shall provide an opportunity to participate fully in the development evaluation and revision of a plan of service to (a) the person who is the subject of the plan of service (b) if the person who is the subject of the plan of service is mentally incapable the person or persons who are lawfully authorized to make a decision on his or her behalf concerning the community services in the plan of service and (c) the person if any designated by the persons referred to in clauses (a) and (b)

September 2006 14

Personrsquos preferences to be considered s 22(6) In developing evaluating and revising a personrsquos plan of service an approved agency shall take into account the personrsquos preferences including preferences based on ethnic spiritual linguistic familial and cultural factors Compliance with regulations s 22(7) An approved agency shall apply the prescribed criteria follow the prescribed procedures and comply with the prescribed rules and standards in assessing a personrsquos requirements determining a personrsquos eligibility and developing evaluating and revising a plan of service There are currently no regulations relating to the evaluation and revision of a plan of service However the plan of service can only be changed if the clientrsquos requirementrsquos change Service monitoring like service planning is a dynamic process Depending on the personrsquos condition or circumstances the client andor caregiver the case manager and contracted service providers and physicians as appropriate must bull interactively and regularly review the clientrsquos requirements bull evaluate the plan of service in consideration of the changing needs of the client and bull measure client outcomes against previously agreed upon goals and commitments

The case manager must monitor and revise the plan of service as necessary when the clientrsquos requirements change The CCAC does not have the authority to revise a clientrsquos plan of service unless the clientrsquos requirements change To monitor service allocation for each client the case manager must solicit and review information including the following

bull contracted service provider reports bull client andor caregiver and physician input bull client andor caregiver contracted service provider and case manager conferences and

telephone calls and bull case manager reassessment of client needs

627 Service Termination

The CCAC case manager must begin service termination planning when the client is admitted and continue the process throughout the time services are being provided Service termination planning may focus on terminating all services or on terminating a single service among the range of services the client is receiving

September 2006 15

The case manager must bull work with the client to plan for service termination when planning goals developing a plan

of service to meet these goals and monitoring the clientrsquos progress towards the goals bull collaborate with the client caregivers and contracted service providers throughout the

clientrsquos service to identify and link the client with ongoing supports that may be required by the client when the CCAC services are no longer required or appropriate to meet the clientrsquos service needs and

bull determine when to discharge a client The CCAC must terminate services when the client no longer requires services the client is no longer eligible for services the client withdraws his or her consent or the client is no longer available to receive services For example bull The client has reached the service and treatment care goals and no longer requires service bull The client andor caregiver have been trained to provide the necessary care and can carry

out the care without further supervision and support bull Other available resources outside the home setting may meet the clientrsquos care requirements bull The clientrsquos needs cannot be met in the home setting

September 2006 16

63 Case Management Staff Qualifications 631 Position Requirements for the Case Manager

CCAC clients often have health conditions that require multi-dimensional assessments to be provided by a health or social work professional whose scope of practice includes comprehensive assessments A case manager must be qualified to undertake the core functions of assessment eligibility determination service planning (plan of service development and resource allocation) service co-ordination reassessment monitoring and revision of plan of service and service termination (discharge) The minimum qualification for persons that undertake these core functions in a CCAC is that the person be a registered health or social work professional This includes but is not limited to a registered nurse physiotherapist occupational therapist speech-language pathologist social worker dietitian and psychologist These professionals are required to be members in good standing of their regulatory body Case managers should be trained as capacity evaluators to assess a personrsquos capacity to consent to admission to a long-term care (LTC) home Not all health and social work professionals may act as evaluators of capacity to consent to admission to a LTC home For example dietitians are not evaluators of capacity for this purpose

September 2006 17

The Community Care Access Centre (CCAC) must ensure that an efficient and cost effective staffing model is in place to support the case management functions Staff who do not have professional qualifications to carry out core case management functions may support the case management process by performing administrative tasks however these staff will still require decision-making skills and a sound understanding of the case manager role Examples of activities that may be undertaken by other staff include but are not limited to bull directing calls received to the appropriate case manager or contracted service provider bull obtaining basic information on intake to assist case managers to determine eligibility and

facilitate access to program and community resources bull ordering prescribed services equipment and supplies approved by the case manager bull scheduling services bull cancelling drug benefit authorizations bull notifying contracted service providers of changes to plans of service bull handling communications of a non-urgent non-case management nature bull documenting receipt of reports bull flagging reports requiring review by the case manager bull assisting to maintain the clientrsquos record bull undertaking follow-up calls to identified persons at the request of the case manager and bull researching community options on request

The above are examples of tasks that the CCAC may reasonably delegate to other staff and should not be considered responsibilities that must be undertaken by staff with professional qualifications The delegation of these tasks will enable case managers to concentrate on activities that require their professional expertise

CCAC Client Services Policy Manual Chapter 7 CCAC Home Care Services

September 2006 1

CCAC Home Care Services

This chapter describes the community services available to Community Care Access Centre (CCAC) clients including professional personal support and homemaking services

The Long-Term Care Act 1994 (LTCA) states s 2(7) For the purpose of this Act the following are professional services 1 Nursing services 2 Occupational therapy services 3 Physiotherapy services 4 Social work services 5 Speech-language pathology services 6 Dietetics services 7 Training a person to provide any of the services referred to in paragraphs 1 to 6 8 Providing prescribed equipment supplies or other goods 9 Services prescribed as professional services Professional services includes the direct provision of the listed professional services as well as where appropriate the training of a person to provide any of these professional services There are currently no regulations relating to equipment supplies or goods prescribed under paragraph 8 and no additional services prescribed under paragraph 9 of subsection 2(7)

711 Eligibility for Professional Services

Regulation 552 of the Health Insurance Act (HIA) states s 13 (1) In this section home care facility means (a) a local board of health of a municipality or a health unit or (b) an agency approved by the Minister to provide home care services

September 2006 2

home care services means (a) the services that are provided on a visitation basis by a nurse or a nursing assistant (b) the services provided on a visiting basis by a physiotherapist occupational therapist speech therapist social worker or nutritionist (c) the provision of dressings and medical supplies (d) the provision of diagnostic and laboratory services (e) the provision of hospital and sickroom equipment (f) the provision of transportation services to and from the home to a hospital health facility or the attending physicians office as the case may be nurse means a nurse who holds a certificate of registration under Part IV of the Health Disciplines Act nursing assistant means a nursing assistant who holds a certificate of registration under Part IV of the Health Disciplines Act professional service means nursing physiotherapy occupational therapy and speech therapy services (2) Each home care facility is prescribed as a health facility under the Act and is designated as a health facility for the purpose of section 34 (3) Home care services provided by a home care facility to an insured person in his or her home are prescribed as insured services (4) It is a condition of payment for insured services under subsection (3) that (a) Revoked (b) the services are necessary to enable the insured person to remain in his or her home or to make possible the insured persons return to his or her home from a hospital or other institution (c) the needs of the insured person cannot be met on an out-patient basis (d) the insured person is in need of at least one professional service if the service for which payment is sought is described in clause (c) (d) (e) or (f) of the definition of home care services in subsection (1) (e) the services are provided in the insured persons home where such has been approved by the Minister as being suitable to enable the required care to be given (f) the services are available in the area where the insured person resides and (g) the services are reasonably expected to result in progress towards rehabilitation (5) Physiotherapy occupational therapy and speech therapy provided by a home care facility to an insured person who (a) is a resident in a nursing home (b) is a resident in a home for the aged established and maintained under the Homes for the Aged and Rest Homes Act or (c) is a resident in a charitable institution approved under the Charitable Institutions Act

September 2006 3

are prescribed as insured services (6) It is a condition of payment for insured services under subsection (5) that (a) Revoked (b) Revoked (c) the needs of the insured person cannot be met on an out-patient basis (d) the services are available in the area of the facility in which the insured person is a resident and (e) the services are reasonably expected to result in progress toward rehabilitation

Pursuant to the above provisions the CCAC only has authority to provide professional services to persons who are insured under the Health Insurance Act (HIA) (ie have Ontario Health Insurance Plan (OHIP) coverage) and meet the criteria set out above in subsection 13(4) The CCAC must provide these services on a visitation basis in the personrsquos home including group homes supportive housing settings and retirement homes The CCAC only has authority to provide the supplies diagnostic and laboratory services equipment and transportation as set out in the definition of ldquohome care servicesrdquo above if the person also needs at least one professional in-home service (ie nursing physiotherapy occupational therapy and speech therapy Note that social workers and dieticians are excluded from the definition of professional services for this purpose)

In addition the CCAC only has authority to provide physiotherapy occupational therapy and speech therapy to residents in a long-term care (LTC) home who meet the eligibility criteria set out in subsection 13(6) above The CCAC has no authority to provide LTC home residents with nursing social work or nutrition services

(See section 75 in this manual for information on drug benefits for CCAC clients) 712 Service Maximums for the Provision of Nursing Services

Regulation 38699 of the LTCA states s 4(1) A community care access centre shall not provide a person with more than the lesser of the following amounts of nursing services 1 28 visits from a registered nurse or a registered practical nurse in a seven-day period 2 The following number of hours of service in a seven-day period

i if services are provided by registered nurses 43 hours of service ii if services are provided by registered practical nurses 53 hours of service or iii if the services are provided by both registered nurses and registered practical nurses 48 hours of service

Note There are no regulated service maximums for the other professional health services provided by the CCAC

September 2006 4

713 Description of Professional Services

bull All regulated health professions governed under the Regulated Health Professions Act

1991 (RHPA) have a scope of practice statement within their profession specific act that broadly defines the practice of the profession While the RHPA sets out activities that are authorized to certain professions there is an exemption that will allow anyone to perform these activities if they are provided in the course of assisting a person with routine activities of living

bull Social work is regulated under the Social Work and Social Services Work Act 1998 (SWSSWA) and not by the RHPA The SWSSWA provides for a self-governing and self-funding regulatory college to govern both social workers and social service workers College membership is required from any person in Ontario who uses the titles of social worker or social service worker

bull Further information on each professional service can be found in the service schedule in the provincial CCAC procurement documents (posted on the Ontario Association of Community Care Access Centres (OACCAC) web site)

Nursing The scope of practice for nursing is the promotion of health and the assessment of the provision of care for and the treatment of health conditions by supportive preventive therapeutic palliative and rehabilitative means in order to attain or maintain optimal function Dietetics The scope of practice of dietetics is the assessment of nutrition and nutritional conditions and the treatment and prevention of nutrition-related disorders by nutritional means Occupational Therapy The scope of practice of occupational therapy is the assessment of function and adaptive behaviour and the treatment and prevention of disorders that affect function or adaptive behaviour to develop maintain rehabilitate or augment function in the areas of self-care productivity and leisure

Physiotherapy The scope of practice of physiotherapy is the assessment of physical function and the treatment rehabilitation and prevention of physical dysfunction injury or pain to develop maintain rehabilitate or augment function or to relieve pain Social Work Services The social work profession enables individuals families and communities to develop the skills and abilities necessary to optimize their functioning and thus reduce the risk of psychosocial breakdown Social work services arranged or provided through the CCAC may include but are not limited to the following situations bull adjustment to altered health or social status bull support and counselling to care providers

September 2006 5

bull crisis intervention bull behaviour problems and bull domestic elder abuse Speech-Language Pathology The scope of practice of speech-language pathology is the assessment of speech and language functions and the treatment and prevention of speech and language dysfunctions or disorders to develop maintain rehabilitate or augment oral motor or communicative functions The provision of speech-language pathology services for children in publicly funded schools is a shared responsibility with the Board of Education (See subsection 91 in this manual for an overview of CCAC school services)

Note The scope of practice of each professional service includes training a person to provide any of those services

September 2006 6

72 Personal Support and Homemaking Services 721 Personal Support Services

The Long-Term Care Act 1994 (LTCA) states s 2(6) For the purpose of this Act the following are personal support services 1 Personal hygiene activities 2 Routine personal activities of living 3 Assisting a person with any of the activities referred to in paragraphs 1 and 2 4 Training a person to carry out or assist with any of the activities referred to in paragraphs 1 and 2 5 Providing prescribed equipment supplies or other goods 6 Services prescribed as personal support services There are currently no equipment supplies or other goods prescribed under paragraph 5 and no additional services prescribed under paragraph 6 of subsection 2(6) Description of Personal Support Services Personal Hygiene Activities

Personal hygiene activities include but are not limited to bull washingbathingshoweringbed bath bull dressingundressing bull assistance with grooming bull mouth care bull hair care bull preventive skin care bull changing simple dry dressings and bull routine handfoot care Note Routine foot care consists of the non-invasive procedures of clipping and filing nails bathing and massaging the feet and monitoring the condition of the feet Only attendants or personal support workers with the appropriate training may undertake this function Advanced foot care (eg scaling calluses or surgical procedures) is not provided as a personal support service but only as a professional service

Routine Personal Activities of Living

Routine personal activities of living include but are not limited to

September 2006 7

bull assistance with eating bull assistance with mobility bull transferringpositioningturning bull assistance with toileting bull supervisionbedside care and monitoring bull bladder routines (including emptychange leg bag clean intermittent catheterization) bull bowel routines bull assisting the person to take pre-measured medications bull exercising bull tracheostomy care (eg shallow suctioning) where the needs of the person are stable

and bull assisting with essential communication for example Bliss boards augmentative

communication

A procedure is considered to be a routine personal activity of living when the need for the procedure the response to the procedure and the outcome of performing the procedure are established over time and as a result are predictable The same procedure may be a routine activity of living in one set of circumstances and part of a therapeutic plan of care in another1

The following procedures are considered routine personal activities of living Each client situation must be reviewed by a health professional to determine if it is appropriate for a personal support worker to perform any of the following tasks The personal support worker must be trained to carry out the procedure for the specific client regardless of how straightforward it appears to be2 bull shallow suctioning bull medications bull oxygen bull clean intermittent catheterization bull enemas and suppositories bull G GJ tube feedings bull changing simple dry dressings and bull augmentative communication

Note The Community Care Access Centre (CCAC) and the professional contracted service provider must develop local guidelines for transferring routine activities of living to personal support workers Guidelines must comply with the requirements of the health professional regulatory colleges and be included in the contractual agreement between the CCAC and the contracted service provider

1 Utilization of Unregulated Care Providers (UCPs) A Guide to Making Decisions College of Nurses March 2001 p 4 2 Guidelines for RNs and RPNs Working with Unregulated Care Providers College of Nurses of Ontario May 1996 p 5

September 2006 8

Further information on personal support and homemaking services can be found in the service schedule in the provincial CCAC procurement documents (posted on the Ontario Association of Community Care Access Centres (OACCAC) web site)

Eligibility for Personal Support Services Regulation 39699 of the LTCA states s 21 A community care access centre shall not provide personal support services to a person unless the community care access centre determines that the person is an insured person under the Health Insurance Act A CCAC does not have the authority to provide personal support services to a person unless the person is an insured person under the Health Insurance Act (HIA) (ie has an Ontario health card) The CCAC is required to provide personal support services to retirement home residents beyond what the operator provides through his or her agreement with the resident The CCAC must assess whether persons residing in supportive housing require these services if assisted living services in supportive housing (ALSSH) are available 3 Service Maximums for Homemaking and Personal Support Services Regulation 38699 of the LTCA states s 3(1) A community care access centre shall not provide a person with more than the following number of hours of homemaking and personal support services 1 80 hours in the first 30 days that follow the first day of service 2 60 hours in any subsequent 30-day period (2) The maximum amounts referred to in subsection (1) apply only with respect to homemaking services and personal support services that (a) are provided by or arranged by a community care access centre and (b) are provided to a person at his or her place of residence

Provision of Additional Personal Support and Homemaking Services in Extraordinary Circumstances Regulation 38699 of the LTCA states s 3(3) Despite subsection (1) a community care access centre may provide more than the maximum number of hours of homemaking and personal support services set out in that subsection for a period of up to 30 days if the community care access centre determines that there exists extraordinary circumstances that justify the provision of additional services

3 A CCAC case manager cannot assume that all clients living at a particular address would be assisted living services in supportive housing clients

September 2006 9

A situation is deemed to be extraordinary when the clientrsquos service requirements exceed the allowable service maximums all other service options have been exhausted and the higher level of service is necessary to support the person until alternative arrangements are made Situations where this might apply include but are not limited to the following bull palliative care clients who require a more intensive level of service to support them to

remain at home for end of life care bull clients who require additional services on a short-term basis until they are stabilized or

alternative arrangements for care can be made bull clients awaiting an emergency admission into a long-term care home and bull crisis situations where the clientrsquos caregiver is ill and the client cannot be left alone

722 Homemaking Services The LTCA states s 2(5) For the purpose of this Act the following are homemaking services 1 Housecleaning 2 Doing laundry 3 Ironing 4 Mending 5 Shopping 6 Banking 7 Paying bills 8 Planning menus 9 Preparing meals 10 Caring for children 11 Assisting a person with any of the activities referred to in paragraphs 1 to 10 12 Training a person to carry out or assist with any of the activities referred to in paragraphs 1 to 10 13 Providing prescribed equipment supplies or other goods 14 Services prescribed as homemaking services Note Regulation 3302 of the Community Care Access Corporations Act 2001 (CCACA) provides that the CCAC no longer has the authority to provide ironing and mending There are currently no equipment supplies or other goods prescribed under subsection 2(5)13 and no additional homemaking services prescribed under subsection 2(5)14

September 2006 10

Description of Homemaking Services3 bull Housecleaning Housecleaning refers to light cleaning only Heavy housecleaning may be

provided only in exceptional situations where conditions in the personrsquos setting pose a severe risk to health or safety (eg where months of neglect have resulted in the presence of animalhuman waste or physically unsafe surroundings) In cases in which the required cleaning and disinfecting are beyond the scope of services provided by homemaking agencies the services of a company that specializes in industrialresidential cleaning may be required In these situations a preliminary heavy cleaning may be required prior to initiating homemaking services The CCAC must only provide heavy cleaning in exceptional circumstances

bull Banking paying bills planning menus and preparing meals In situations where the client or caregiver cannot perform these services the CCAC may arrange for these services to encourage the independence of the client

bull Caring for children Caring for children refers to the support and assistance provided to a child when the parentguardian cannot undertake the physical care associated with the child because of the parentrsquosguardianrsquos health care requirements (eg due to the parentrsquos physical disability illness or specific post-surgical condition) The parentguardian may be at home and capable of directing the childrsquos care or the parentguardian may be absent from the home for a medical reason or because of an emergency of a short-term duration4 Short-term in this context means a period not exceeding 12 hours However the time period may be extended in crisis situations and in accordance with service maximums (See service maximums in subsection 721 in this manual) The parentguardian does not have to be receiving other services through a CCAC in order to be eligible for child care services in the home In general caring for children as a homemaking service involves the tasks that parentsguardians would undertake on a day-to-day basis if they were physically able to do so It does not involve carrying out the early childhood education activities Child care services include but are not confined to the following tasks bull infant care bull bathing dressing and feeding (toileting transferring) bull assisting the children to get ready for school and bull preparing school lunches

3 While there are no regulations relating to these matters this section provides policy direction on these services 4 If the parentguardian leaves the home he or she must designate a substitute decision-maker

September 2006 11

Child care services in this context should not be confused with a service to a child who is ill or disabled and who may require direct service in his or her own right Child care services provided or arranged by the CCAC may not be used as a substitute for private child minding or professional day care or child care services All other options must be exhausted before providing child care services (eg partner spouse or other relative is not able to provide child care no other child care service is available in the community nursing infant must be close to the ailing parent)

Eligibility for Homemaking Services When determining eligibility for homemaking services the CCAC must comply with the regulations under the LTCA The LTCA states s 2(2) A person is eligible to receive homemaking services if (a) the person requires personal support services along with the homemaking services (b) the person receives personal support and homemaking services from a caregiver who requires assistance with the homemaking services in order to continue providing the person with all the required care or (c) the person requires constant supervision as a result of a cognitive impairment or acquired brain injury and the persons caregiver requires assistance with the homemaking services (3) In this section caregiver means a family member friend or other person who (a) has primary responsibility for the care of an applicant for homemaking or personal support services or of a person who receives such services and (b) provides that care without remuneration Personal Support Required for Homemaking Services A person who is assessed to require assistance with personal support will be eligible to receive homemaking services if

bull the CCAC provides the personal support services or bull the personrsquos caregiver provides the personal support services or bull another agency provides the personal support services or bull despite having been assessed as eligible for personal support services and despite

experiencing great difficulty in doing so the person insists on managing his or her own personal support This recognizes that some CCAC clients may decline assistance with personal support because of concerns about loss of control dignity or privacy

September 2006 12

Limitations on Eligibility A person receiving homemaking services must have an Ontario health card in order to prove that he or she is insured under the Ontario Health Insurance Plan (OHIP) Regulation 38699 of the LTCA states

Eligibility for homemaking services s 2(1) A community care access centre shall not provide homemaking services to a person unless the community care access centre determines that the person is an insured person under the Health Insurance Act and is eligible under this section to receive homemaking services (See chapter 3 in this manual for OHIP eligibility criteria) Persons residing in some settings are not eligible for homemaking services Regulation 38699 of the LTCA states s 2(4) A person is not eligible to receive homemaking services if the person is a tenant in a care home within the meaning of the Tenant Protection Act 1997 or is a resident in a nursing home under the Nursing Homes Act an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act This provision ensures that the CCAC does not replicate services that a care home or long-term care (LTC) home provides as part of their agreement with the tenant or resident A CCAC has no authority to provide homemaking services to residents in retirement homes or tenants in supportive housing sites

September 2006 13

The Long-Term Care Act 1994 (LTCA) states Provision of services s 23(1) An approved agency shall ensure that the services outlined in a personrsquos plan of service are provided to the person within a time that is reasonable in the circumstances Waiting list s 23(2) If a community service outlined in a personrsquos plan of service is not immediately available the approved agency shall place the person on the waiting list for that service and shall advise the person when the service becomes available Waiting lists are a method of allocating resources in a prioritized manner when resources are not immediately available to a client that has been assessed to require the service(s) The Community Care Access Centre (CCAC) must establish and maintain waiting lists for the services they provide in accordance with section 23 of the LTCA The CCAC must also establish and maintain waiting lists for long-term care (LTC) homes admission based on priorities established in legislation (See chapter 12 in this manual for management of waiting lists for LTC homes) The CCAC must prioritize clients on the waiting list based on the following bull the clientrsquos condition bull the clientrsquos support system bull the availability of other community resources and bull the CCACrsquos prioritization system The CCAC must maintain a separate waiting list for each service and monitor the waiting list to address changes in priority needs

September 2006 14

74 Ambulance Services for CCAC Clients 741 Eligibility Criteria

Ambulance services are insured services under section 15 of Regulation 552 made under the Health Insurance Act (HIA) where the following conditions are met bull the person to whom the ambulance services are provided is an insured person under the

Health Insurance Act bull the services are medically necessary bull the services are provided by an ambulance service operator listed in Schedule 7 of

Regulation 552 which includes a number of ambulance service operators in communities throughout Ontario

bull the hospital to or from which the services are required is listed in Schedule 1 of 4 of Regulation 552 or is graded under the Public Hospitals Act as a Group A B C E F G J or R hospital which categories include many hospitals throughout Ontario and

bull the person to whom the services are provided pays the applicable co-payment for the service set out in Regulation 552 if any (the exceptions are described in section 15(6))

Notes bull Ambulance service is not an insured service if it is not medically necessary as determined

by a physician bull In emergency situations the choice of the destination health care facility is determined by

the ambulance communications officer (dispatcher) in accordance with the needs of the patient In the absence of such a determination by dispatch the patient will be transported to the closest health care facility that can provide the care apparently required by the patient

bull While the primary purpose and function of ambulances are to respond to emergencies ambulances are also used for non-emergency purposes eg transportation to and from scheduled hospital appointmentslong term care homes for a patient who needs a stretcher There are many private medical transportation services in the province that are used by patients for non-emergency transfers on a fee for service basis

742 Role of the CCAC Case Manager

The case manager must assess the clientrsquos transportation needs and if the client requires ambulance transportation the case manager must determine if the client meets the ambulance eligibility criteria authorize the ambulance transport and ensure the service is ordered If the client does not require ambulance transportation the case manager must discuss with the client other modes of transportation (eg accessible taxis stretcher-capable private medical transport service and medical transportation services operated by volunteer agencies) and payment options

September 2006 15

The Community Care Access Centre (CCAC) must develop local procedures for authorizing and ordering ambulances The procedures must include emergency measures

743 Co-payment Exemption

A number of people are exempt from the co-payment (ie invoice) for ambulance services including people who are bull CCAC clients (receiving home care services) bull transferred from a hospital to another hospital bull transferred from a hospital to a medical laboratory or public health laboratory bull transferred from a hospital to a facility registered under the Healing Arts Radiation

Protection Act (HARPA) for the purpose of radiological examination or treatment bull transferred from a hospital to a centre (as per the HIA) bull receiving provincial social assistance and bull residents in a long-term care (LTC) home

744 Important Information for the CCAC

The Medical Air Transport Centre for air ambulance will determine whether clients should travel on chartered services or scheduled airlines For up-to-date telephone number and fax number for the Medical Air Transport Centre see the Ministry of Health and Long-Term Care (MOHLTC) website at [httpwwwgovoncaMOHenglishprogramambulairambhtml] For further details on criteria for selection of air versus land transport see the document entitled A Guide to Choosing Appropriate Patient Transportation available through the Emergency Health Services Branch of the MOHLTC and through the ambulance transition website at [httpwwwambulance-transitioncom]

745 Criteria for Selecting Air Rather than Land Ambulance

Air ambulance may be selected when one or more of the following criteria are met bull the transfer involves a one way travel distance greater than 240 kilometres (150 miles) bull all land alternatives have been exhausted and it is not feasible to assign a land ambulance

andor bull specialized equipment andor escorts or paramedical staff are required

September 2006 16

Persons receiving home care services which are insured under the Health Insurance Act (HIA) are eligible to receive drug benefits under the Ontario Drug Benefit (ODB) Program The ODB Program covers over 3200 quality-assured drug products which are listed in the Ontario Drug Benefit FormularyComparative Drug Index (FormularyCDI) which can be accessed at [httpwwwhealthgovoncaenglishprovidersprogramdrugsodbf_eformularyhtml] Community Care Access Centre (CCAC) clients are only required to pay a $2 co-payment charge for prescription drug products covered under the ODB Program

751 Role of the Case Manager

The role of the case manager is to explain the ODB Program to appropriate clients determine eligibility authorize ODB coverage if the client is eligible and terminate coverage when the client is no longer eligible The case manager may also explore payment options for drugs not listed in the FormularyCDI for ODB-eligible persons under the individual review mechanism provided for in section 8 of the Ontario Drug Benefit Act (ODBA)

752 Benefit Coverage

A person must need at least one professional service in the home in order to be eligible for a drug card Drug coverage remains in place for the duration of the treatment period Coverage may be renewed if the client is still receiving professional services after the original coverage expires and it is terminated when eligibilityassessed need for the professional service ends The CCAC case manager completes the Drug Benefit Eligibility card (form 2654-87(9710)) in triplicate bull Copy 1 is provided to the client and retained by the pharmacy bull Copy 2 is forwarded by the CCAC to the Ministry of Health and Long-Term Care

(MOHLTC) bull Copy 3 is attached to the clientrsquos file

All hard copies of drug cards are numbered sequentially and must be accounted for by the CCAC A record should be kept of the numbers on drug cards received from the ODB Program and of every card issued The CCAC should also provide regular updates to local pharmacies regarding clientsrsquo ODB status (ie inform pharmacies of drug card expiries) Pharmacies must keep the Drug Benefit Eligibility card on file for a period of two years Another way of authorizing coverage is through the CCACrsquos local automated system Through the local automated system the pharmacy receives notification by autofax

September 2006 17

The CCAC must inform the clientrsquos pharmacy as soon as coverage is discontinued This is particularly important when the termination occurs prior to the expiry date of the benefit period

753 Ontario Residents Aged 65 Years and Over

All Ontario residents who have a valid Ontario health card are eligible for ODB coverage on the first day of the month following their 65th birthday The ODB Program uses the Health Network System an online information system which links all Ontario pharmacies and dispensaries to the MOHLTC for the real-time processing and adjudication of claims

754 Senior Co-payment

Seniors aged 65 years and over may pay a $2 or a $611 co-payment The co-payment amount is based on the individualrsquos or couplersquos net income which is based on the most recent taxation year If a person aged 65 years and older has an annual net income of less than $1601800 or if the combined income of the eligible person and his or her spouse or partner is less than $2417500 they may be charged a co-payment of up to $2 per prescription

Notes bull The minimum co-payment is not automatic for low-income seniors or senior couples

Seniors with incomes below the income threshold must apply to become eligible for the $2 co-payment by submitting a co-payment form to the MOHLTC

bull A person residing in a long-term care (LTC) home or home for special care (defined in the Homes for Special Care Act (HSCA)) automatically qualifies for the $2 co-payment

Seniors who have an income greater than the above income thresholds pay the first $100 of the cost of prescription drugs (combined total of the cost of the drug product and the dispensing fee) in every 12-month period commencing August 1 of each year Only allowable drug expenses can count towards the $100 deductible namely prescriptions for drug products listed in Part III of the FormularyCDI prescriptions for nutrition products and diabetic testing agents approved as benefits under the ODB Program as well as extemporaneous products that are designated pharmaceutical products under the ODBA regulations The ODB deductible and co-payment are tracked through the Health Network System according to the ODB benefit year For the balance of the ODB benefit year these seniors pay a maximum of $611 toward the ODB dispensing fee on each prescription

September 2006 18

755 Requests Under Section 8 of the Ontario Drug Benefit Act

Requests from ODB eligible persons for coverage of drug products that are not listed in the FormularyCDI may be considered by the MOHLTC under the individual clinical review mechanism provided for in section 8 of the ODBA The CCAC case manager will inform the referring physician that the clientrsquos drugs are not listed in the FormularyCDI and discuss options (eg the physician could provide alternate medication or if appropriate the physician could apply for coverage under section 8 of the ODBA) The individual clinical review (or section 8) mechanism of the ODBA is reserved for situations where bull the drug is not covered under another government program and bull there are no FormularyCDI alternatives to treat severe life-threatening organ-threatening

conditions or diseases that would otherwise cause severe debilitating effects The individual clinical review (or section 8) mechanism of the ODBA is not intended to be used bull to request drugs that treat self-limiting conditionssymptoms bull for patient ldquoconveniencerdquo or bull to continue clients previously enrolled in clinical trials of new drugs once these drugs are

approved for marketing To apply for special coverage under section 8 of the ODBA the clientrsquos physician must send a written request to the Drug Programs Branch including a concise clinical description and therapeutic plan

756 Trillium Drug Program CCAC clients who are not eligible for the ODB Program (eg children only receiving CCAC school services) but who have high drug expenses in relation to their income may be eligible for coverage under the Trillium Drug Program Each year starting August 1 drug costs must be paid up to the deductible level before eligibility for coverage begins The Trillium Drug Program recipients may pay up to a $2 co-payment towards the dispensing fee of an ODB-covered drug product once the deductible has been met Additional information about the Trillium Drug Program is available at 1-800-575-5386

September 2006 19

Community Care Access Centres (CCACs) may provide influenza vaccinations to a current CCAC client who has a physicians prescription In addition the CCAC may pay for on-site vaccinations of staff

September 2006 20

In October 2005 the government announced Ontariorsquos End-of-Life (EOL) Care Strategy to improve end-of-life care services at home and in the community One objective of the EOL Care Strategy is to shift care of the dying from the acute setting to appropriate alternate settings of individual choice Although many individuals would prefer to receive end-of-life care at home for some this is not possible Therefore the EOL Care Strategy includes funding support for residential hospices in over 30 communities by 2007-2008 The approved hospices and communities were identified in the Residential Hospice Backgrounder of the Ministry of Health and Long-Term Care (MOHLTC) News Release for the End-of-Life Care Strategy October 4 2005 at [httpwwwhealthgovoncaenglishmedianews_releasesarchivesnr_05bg_100405bpdf]

A residential hospice is a home-like environment where adults and children with life-threatening illnesses receive end-of-life care services The current priority is given to free standing residential hospices and does not include beds in long-term care (LTC) homes supportive housing homeless shelters or hospitals

The funding support for residential hospices approved by the MOHLTC is being provided through the Community Care Access Centres (CCACs) Residential hospices have the option of either 1 receiving a funding envelope to independently employ nursing and personal support

services with an accountability agreement through the CCAC or 2 receiving enhanced hours of service of nursing and personal support through the CCAC Access to all other CCAC services is based on the individualrsquos needs and are outside of any direct funding relationship with the residential hospice Services provided through the CCAC are governed under the Long-Term Care Act 1994 (LTCA)

If the residential hospice chooses the first option of receiving the funding envelope bull The CCAC must negotiate an accountability agreement with the residential hospice using the

template developed by the Ontario Association of Community Care Access Centres (OACCAC) and provide the designated funding envelope from the MOHLTC to the residential hospice

bull The funding can only be used for nursing and personal support services to support clients in residential hospice beds Staffing must include 247 Registered Nursing (RN) coverage

bull The purchase of nursing and personal support services is exempt from the Client Services Procurement Policy for Community Care Access Centres July 2003

bull Residential hospice resident days and expenditures are reconciled annually The residential hospice is permitted to retain 100 of the funding provided the hospice maintains a minimum of 80 occupancy

bull When the hospice initially begins admitting clients the need to maintain a minimum occupancy level of 80 is waived for the first three months

September 2006 21

bull The equivalency of one and a half months of funding is available prior to admitting clients to support recruiting hiring and training of nursing and personal support staff

bull If occupancy is less than 80 the amount of subsidy the residential hospice is permitted to retain is reconciled based on actual bed resident days

If the residential hospice chooses the second option bull The CCAC must use the designated funding from the MOHLTC to provide nursing and

personal support services in the residential hospice through CCAC contracted service provider(s)

CCAC Client Services Policy Manual Chapter 8 Supplementary Services

September 2006 1

Supplementary Services

The Assistive Devices Program (ADP) of the Ministry of Health and Long-Term Care (MOHLTC) administers the Home Oxygen Program (HOP) Oxygen is not included as a benefit under the Ontario Drug Benefit (ODB) Program The Community Care Access Centre (CCAC) is not responsible for the provision of oxygen and related equipment

The CCAC case manager may help CCAC clients to access information about HOP may assist clients to obtain the application forms and to complete necessary documentation to apply for the program

812 Eligibility

The HOP pays for oxygen and related equipment for eligible Ontario residents Residents who have an illness resulting in the need for oxygen therapy may apply Applicants must have a valid Ontario health card and meet the medical criteria (see subsection 814 in this manual) Eligibility for Long-Term Oxygen Funding The personrsquos medical condition must be stabilized and treatment regimen optimized before long-term oxygen therapy is considered The person must have chronic hypoxemia on room air at rest ndash PaO2 of 55mmHg or less or SaO2 of 88 or less Some applicants with a persistent PaO2 in the range of 56 to 60mmHg may be considered candidates for long-term oxygen therapy if the following medical conditions are present bull cor pulmonale bull pulmonary hypertension or bull persistent erthrocytosis

September 2006 2

Also some persons with a persistent PaO2 in the range of 56 to 60mmHg may be candidates for long-term oxygen if the following occurs bull exercise limited by hypoxemia and documented to improve with supplemental oxygen or bull nocturnal hypoxemia Eligibility for Funding for Oxygen for Palliative Care Special consideration is given to persons at the end stage of a terminal disease receiving palliative care who do not meet the medical criteria Persons who are identified as receiving palliative care may receive funding assistance for a maximum of 90 days If oxygen is required after the 90-day period the medical criteria must be met In this instance oximetry tests are acceptable The vendor bills the MOHLTC

813 Persons Not Eligible

The following are not eligible for funding assistance from the HOP bull people who require oxygen due to work related injuries or bull people who are eligible for benefits through the Department of Veteran Affairs (DVA)

Group ldquoArdquo or bull people who are in acute chronic or rehabilitation hospitals

814 Funding

For eligible Ontario residents the HOP may fund 100 of the monthly cost of a basic oxygen system Vendors can supply a liquid system or concentrator andor cylinders The ADP pays a flat monthly rate regardless of the system supplied except for cylinders which get a per cylinder rate according to the personrsquos oxygen needs To qualify for 100 coverage a person must meet the medical criteria and be bull receiving in-home professional services through the CCAC or bull 65 years or older or bull a social assistance recipient or bull a resident in a long-term care (LTC) home The HOP may fund 75 of the monthly cost of a basic oxygen system according to the personrsquos oxygen needs To qualify for 75 coverage a person must be 64 years or younger and must meet the medical criteria and should not fall into any of the categories listed immediately above

September 2006 3

815 Application Procedure for Home Oxygen Program Funding

The HOP application form is available from oxygen vendors and must be completed by the physician and a registered oxygen vendor New HOP applicants must submit arterial blood gas results with the first application Applicants who meet medical eligibility criteria receive approval for 90 days To continue HOP funding an oximetry test must be submitted at the end of the 90-day period HOP clients who continue to meet the medical eligibility criteria receive funding for an additional 12 months A final oximetry test must be submitted at the end of the 12-month period confirming eligibility At that time ongoing funding is approved and continues until HOP is notified that oxygen therapy has been discontinued

816 Registered Vendor

A registered oxygen vendor supplies and monitors the oxygen equipment A list of registered vendors can be obtained from the HOP Registered vendors agree to follow HOP policies and must not charge more than the program-approved price for oxygen and approved equipment They may charge less if they choose

817 Hospital Replacement Program Pilot Project ndash Short Term Oxygen Therapy

Effective August 1 2005 the ADP introduced the Hospital Replacement Program (HRP) Pilot Project which will be part of the HOP The pilot project will run for two years beginning in 2005 and concluding in 2007 The intent of the HRP is to prevent a person with an acute respiratory condition from being admitted to hospital or in the case of hospitalization allows the individual to be discharged earlier by providing funding assistance for short term oxygen therapy To receive funding assistance through the HRP the individualrsquos condition must be such that early discharge from hospital or avoiding hospitalization with short-term home oxygen therapy and other appropriate support services is recommended by the prescribing physician An applicant with an acute respiratory condition such as but not restricted to an acute exacerbation of COPD pneumonia pulmonary emboli or post-operative lung surgery is eligible to apply for funding assistance if the individual exhibits hypoxemia at rest For the HRP hypoxemia at rest is defined as PaO2 less than or equal to 60mmHg If the individual meets the general and medical eligibility criteria funding assistance is provided for up to 60 days Access to the HRP occurs through one of four methods 1 Emergency room physicians who have diagnosed their patient with an acute respiratory

condition and have determined that the use of short-term home oxygen therapy along with appropriate support services will result in an early discharge from the hospital or avoid hospitalization

September 2006 4

2 Attending physicians who have diagnosed their patient with an acute respiratory condition and have determined that the use of short-term home oxygen therapy along with appropriate support services will result in an early discharge from the hospital

3 CCAC case managers located in the hospital or discharge planners who have identified a

patient with an acute respiratory condition that could potentially be discharged from the hospital The attending physician would then determine if short-term home oxygen therapy along with appropriate support services would result in an early discharge from the hospital

4 Family physicians who have diagnosed their patient with an acute respiratory condition

and have determined that the use of short-term oxygen therapy along with appropriate support services will avoid hospitalization

818 HRP Application Process

1 Applicants to the HRP use the regular HOP application form that is used by all HOP clients

2 The prescribing physician must complete section 2 of the HOP application form clearly

indicating in section 2 that the applicant is applying to the HRP The physician can do this by recording the phrase ldquoHospital Replacement Programrdquo directly on the application form The home oxygen service provider cannot complete this section

3 When applying to the HRP arterial blood gas results must be provided The arterial blood

gas results must be within one day of the physicianrsquos prescription date 4 A separate HRP questionnaire must be completed for all applicants to the HRP The

questionnaire can be completed by the health care professional from the home oxygen service provider Data collected from the questionnaire will be used to evaluate the program at the end of the two-year period Copies of the Hospital Replacement Program Questionnaire have been provided to all ADP registered home oxygen service providers and can be printed from the MOHLTC website at [httpwwwhealthgovoncaenglishprovidersprogramadphrpquestionnairepdf]

5 The completed questionnaire should be attached to the application and submitted to the

ADP 6 Funding assistance is provided for up to 60 days If funding assistance is required beyond

the 60-day funding period the client must apply to the regular HOP and must meet the general and medical eligibility criteria and submit arterial blood gases

CCACs will be notified when the pilot project is completed

September 2006 5

The Ministry of Health and Long-Term Care (MOHLTC) provides travel grants to help defray the cost of transportation for eligible residents of northern Ontario who must travel a long distance to receive medical specialist services that are not available locally Unless advance funding is provided through Northern Health Travel Grant Program designated third party agencies the person incurs the cost of transportation and is later reimbursed if eligible Travel grants are paid based on the two-way road distance a client travels less a 100 kilometre deductible The grants do not cover all of the clientrsquos travel costs such as meals or accommodation In the event a designated third party agency advances funds to an eligible client the third party agency claims the grant on behalf of the client

The Community Care Access Centre (CCAC) case manager may help CCAC clients to access information about the Northern Health Travel Grant Program and may assist clients to obtain the application forms The case manager may refer clients to social workers when clients require assistance to complete the forms

822 Eligibility

A person is eligible for the Northern Health Travel Grant if bull the person lives in the territorial Districts of Algoma Cochrane Kenora Manitoulin

Nipissing Parry Sound Rainy River Sudbury Thunder Bay or Timiskaming bull the person has a valid Ontario health card bull the person is referred for specialty health care that is an insured service under the Health

Insurance Act (HIA) bull a northern Ontario physician dentist optometrist chiropractor midwife or nurse

practitioner has referred the person before the travel takes place bull the person has been referred to a dental or medical specialist who is certified by the Royal

College of Physicians and Surgeons of Canada or to a designated health facility and bull the nearest specialist or designated health facility in Ontario or Manitoba is at least 100

kilometres from the personrsquos area of residence 823 Additional Conditions

The amount of the grant is based on the two-way road distance to the nearest specialist or health facility that can provide the required service and not necessarily the one the person chooses to visit A deductible of 100 kilometres on the trip is applied If it is necessary to travel to a specialist other than the nearest one the referring practitioner must provide written information on the application explaining why this is medically necessary

September 2006 6

A companion grant may be paid if bull the applicant is under 16 years of age or bull the referring health care practitioner indicates in section 3 of the grant application form

before the travel takes place that a companion for the individual is necessary because the individual is under 16 years old or for health and safety reasons (eg the person is in a wheelchair or is cognitively impaired)

If the individual is transported one way by ambulance the person is eligible for a one-way grant If travel is by plane train or bus and both the person and the escort have paid a fare both the person and the escort may receive a grant If travel is by car the person and the escort can apply for an equal share of one grant

824 Exclusions

An individual does not qualify for the grant if bull the care is related to a Workplace Safety and Insurance Board claim bull another government program or organization pays for the individualrsquos travel bull the service is covered by an insurance company bull the person travels round trip by ambulance bull the services are not provided by a certified medical or dental specialist or bull the nearest specialist is within 100 kilometres of the personrsquos area of residence

825 Obtaining Application Forms

The MOHLTC Application for Northern Health Travel Grant form (014-0327-88) can be printed from the MOHLTC website at [httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailopenformampENV=WWEampNO=014-0327-88] Northern Ontario general practitioners specialists dentists optometrists chiropractors and the CCAC or local MOHLTC office may also have printed versions of the application form

826 Completing the Application Forms and Deadline for Submission

The application form must be completed by bull the applicant bull the referring health practitioner specialist or technician if a procedure is performed within

a health care facility bull a third party agency if applicable and bull a travelling companion if involved

September 2006 7

Applications must be received by the MOHLTC office within 12 months from the date the person receives health care services from the specialist or designated health care facility For more information visit the MOHLTC website at [httpwwwhealthgovoncaenglishpublicpubpub_menuspub_ohiphtml] or contact the Northern Health Travel Grant Program at 1-800-461-4006 (English) or 1-800-461-1149 (French)

CCAC Client Services Policy Manual Chapter 9 CCAC School Services

Note Current regulations under the Long-Term Care Act 1994 distinguish between ldquoschool servicesrdquo (which are professional services (ie nursing therapies etc) and ldquopersonal support school servicesrdquo To provide clarity in this manual ldquoschool servicesrdquo are referred to as ldquoprofessional school servicesrdquo and ldquopersonal support school servicesrdquo are referred to as ldquopersonal support school servicesrdquo When referring to both these services the term ldquoschool servicesrdquo is used September 2006 1

CCAC School Services

Community Care Access Centre (CCAC) school services are provided to childrenyouths in publicly funded and private schools and to childrenyouths who are being home schooled to assist them in pursuing their education The student must require the services in order to be able to attend school participate in school routines and receive instruction including receiving satisfactory instruction at home In other words in the absence of school services the childrsquosyouthrsquos school attendance instruction or participation would be significantly disrupted CCAC school services include professional school services and personal support school services Professional school services are provided to childrenyouths in publicly funded and private schools and to childrenyouths who are being home schooled CCAC personal support school services are only provided to childrenyouths in private schools and to childrenyouths who are being home schooled

911 ChildrenYouths in Publicly Funded Schools

Childrenyouths enrolled in publicly funded schools have access to a range of professional school services nursing physiotherapy occupational therapy speech-language pathology and dietetics These services are provided through CCAC contracted service providers and include the training of school personnel and provision of necessary medical supplies dressings and treatment equipment

The CCAC provides access to these professional school services for childrenyouths with medical andor rehabilitation needs to enable them to attend school participate in school routines and receive instruction Personal support school services are not provided by the CCAC to students in publicly funded schools School boards are responsible for accommodating the needs of public school students for assistance with routine personal activities of living Social work services are not provided through the CCAC in publicly funded school settings Public school resources deal with psycho-social needs of students that need to be addressed while attending public school

CCAC professional school services are provided in publicly funded schools by the Ministry of Health and Long-Term Care (MOHLTC) the Ministry of Education and Training (EDU) and the Ministry of Community and Social Services (MCSS) pursuant to the following 1 PolicyProgram Memorandum No 81 (PPM81) July 19 1984 available at

[httpwwwedugovoncaextraengppm81html] This policy memorandum sets out the responsibility of the MOHLTC for funding the provision of health services for childrenyouths with special needs who would have difficulty attending school if at all were they not to receive these services The policy also addresses joint responsibilities of the MOHLTC and school boards for medications lifting positioning general maintenance exercises feeding and toileting

2 Memorandum regarding Catheterization and Suctioning August 14 1989 Clarification of

PolicyProgram Memorandum No 81 This memorandum was issued in response to questions raised about PPM81 in order to clarify the responsibilities for different types of catheterization and suctioning as follows bull Clean catheterization and shallow surface suctioning are recognized as part of a childrsquos

normal toileting and oral hygiene needs and can be administered by the child or school board staff Training and direction for these procedures may be provided by the parent or the CCAC

bull Sterile intermittent catheterization and deep suctioning are administered by a health professional provided by the CCAC

3 Interministerial Guidelines for the Provision of Speech and Language Services 1988

(MCYS EDU MOHLTC) available at [httpwwwedugovoncaextraengppm81html] This memorandum clarifies the shared responsibilities of CCACs and school boards relating to the provision of speech therapy as follows bull The school board is responsible for the initial assessment to determine if the primary

concern is speech production or a language disorder bull The CCAC is responsible for childrenyouths who have problems because speech

production is difficult bull The Interministerial Guidelines for the Provision of Speech and Language Services

were developed in 1985 and revised in 1988 to provide direction to public schools and home care programs1about their responsibilities in the provision of speech and language services This 1988 version also supercedes references to speech and speech pathologytherapy in PPM81

1 Precursors to the CCAC

bull Medical disorders that the CCAC manages fall primarily under the following diagnostic areas

bull articulationspeech sound production problems caused by motor speech disorders

including dyspraxias and dysarthrias bull non-speech communication (assessment for and prescription of and orientation to

augmentative and alternative methods of communication) bull fluency disorders such as stuttering bull voice disorders (eg hoarseness andor nasal speech due to vocal nodules and cleft

lip palate) and bull swallowing disorders

bull CCACs do not provide speech therapy for childrenyouths who primarily have a language disorder School boards are responsible for providing these services to childrenyouths who have a language disorder (ie do not have the ability to translate thoughts into verbal expression and to understand others and do not have reading and spelling skills that are prerequisite for acquiring literacy skills)

CCACs must provide professional school services in accordance with PPM81 and all other relevant memoranda and guidelines CCACs must not assume any of the responsibilities of school boards as outlined in PPM81 and all other relevant memoranda and guidelines

912 ChildrenYouths in Private Schools and Home Schooling Situations

Childrenyouths enrolled in private schools or receiving instruction at home have access to a range of professional school services and personal support school services nursing physiotherapy occupational therapy speech-language pathology dietetics and personal support services such as personal hygiene activities and routine activities of living These school services can be purchased directly2 or accessed through CCAC contracted service providers Social work services are not provided through the CCAC in private schools and home schooling situations

The CCAC provides access to these professional school services and personal support school services to childrenyouths with medical andor rehabilitation needs to enable them to attend school participate in school routines and receive satisfactory instruction at home In other

2 Purchased services means that the CCAC provides funding directly to a transfer payment agency The agency in turn provides funding to the private school or the parentguardian in home schooling situations who is then responsible for locating and hiring the service provider

words in the absence of school services the childrsquosyouthrsquos school attendance instruction or participation would be significantly disrupted

CCACs are required to provide the initial assessment for speech-language pathology for childrenyouths in private schools or receiving home schooling The CCAC funds private schools and parentsguardians providing home schooling (through an agency) for the treatment of speech disorders primarily in the diagnostic areas listed above in subsection 911 point ldquo3rdquo in this manual

Community Care Access Centre (CCAC) school services are governed by the Long-Term Care Act 1994 (LTCA) The regulations under the LTCA refer to the terms ldquoschoolrdquo and ldquoprivate schoolrdquo as they are defined under the Education Act (EA) The following are the definitions of these terms under the EA s 1(1)ldquoschoolrdquo means (a) the body of elementary school pupils or secondary school pupils that is organized as a unit for educational purposes under the jurisdiction of the appropriate board or (b) the body of pupils enrolled in any of the elementary or secondary school courses of study in an educational institution operated by the Government of Ontario and includes the teachers and other staff members associated with the unit or institution and the lands and premises used in connection with the unit or institution ldquoprivate schoolrdquo means an institution at which instruction is provided at any time between the hours of 9 am and 4 pm on any school day for five or more pupils who are of or over compulsory school age in any of the subjects of the elementary or secondary school courses of study and that is not a school as defined in this section In addition the regulations under the LTCA refer to subsection 21(1)(a) of the EA relating to home schooling Subsection 21(1)(a) of the EA states s 2(2) A child is excused from attendance at school if (a) the child is receiving satisfactory instruction at home or elsewhere hellip

921 Eligibility for Professional School Services Section 5 of regulation 38699 of the LTCA states s 5(1) ldquoschoolrdquo means a school as defined in subsection 1 (1) of the Education Act and includes a private school as defined in subsection 1 (1) of that Act ldquoschool servicesrdquo means the following professional services that are provided to a person who is enrolled as a pupil at a school on the school premises or while the pupil is being transported to or from the school on a school bus or other school vehicle or participating in a school trip or activity outside the school premises or that are provided to a person who is receiving satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act and are necessary in order for the person to be able to receive instruction

1 Nursing services 2 Occupational therapy services 3 Physiotherapy services 4 Speech-language pathology services 5 Dietetics services 6 Training of school personnel to provide the services referred to in paragraphs 1 to 5 to persons enrolled as a pupil at the school 7 The provision of medical supplies dressings and treatment equipment necessary to the provision of the services referred to in paragraphs 1 to 5 Clarification Professional school services are defined in regulation 38699 of the LTCA as nursing services occupational therapy services physiotherapy services speech-language services and dietetics services These services include the training of school personnel and provision of necessary medical supplies dressings and treatment equipment s 5(2) A community care access centre shall not provide school services to a person unless the person meets the following eligibility criteria Clarification A CCAC does not have the authority to provide professional school services to a person unless the person meets the following eligibility criteria s 5(2)1 The person must be enrolled as a pupil at a school or be receiving satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act Clarification A childyouth up to the age of 21 must be either enrolled in a publicly funded school or private school or receiving satisfactory instruction at home in order to be eligible for these professional school services More information is available on the Ministry of Education and Training (EDU) website at [httpwwwedugovoncaengfunding] s 5(2)2 The person must require the services i in order to be able to attend school participate in school routines and receive instruction or ii in order to be able to receive satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act

Clarifications

bull The CCAC may provide professional school services at the school or while the pupil is

being transported to or from publicly funded school or private school or participating in publicly funded school or private school related activities (see subsection 95 in this manual for additional information) in other locations3 The professional school services

3 For example early screening may be done in a clinic setting

must be necessary in order for the childyouth to be able to attend publicly funded school or private school participate in publicly funded school or private school routines and receive instruction In other words in the absence of professional school services the childrsquosyouthrsquos publicly funded school or private school attendance instruction or participation would be significantly disrupted

bull The CCAC must not assume responsibility for determining what constitutes ldquosatisfactory instruction at homerdquo In order for a childyouth who is receiving home schooling to be eligible for professional school services the parentguardian must provide the CCAC with a letter from the relevant school board indicating that the childyouth is excused from attendance at school because he or she is receiving ldquosatisfactory instruction at homerdquo PolicyProgram Memorandum No 131 (PPM131) dated June 17 2002 addresses the services offered by the MOHTLC and sets out the process a parentguardian should follow in order to obtain the appropriate documentation including a sample letter PPM131 and the sample letter are available on the EDU website at [httpwwwedugovoncaextraengppm131html]

s 5(2)3 The person must be an insured person under the Health Insurance Act (See chapter 3 in this manual for Ontario Health Insurance Program (OHIP) eligibility criteria)

s 5(2)4 The school or home in which the service is to be provided must have the physical features necessary to enable the service to be provided

Clarifications bull The setting in which the professional school services are to be provided must be conducive

to providing the service such as having enough space to allow the use of necessary equipment and supplies and privacy to allow appropriate treatment to be given

bull The CCAC must use their best efforts to adapt their service provision to the available surroundings However when such adaptations cannot be made the CCAC must discuss alternative courses of action with the childyouthparentguardian andor publicly funded or private school in order to avoid declaring a childyouth ineligible for professional school services on this basis

s 5(2)5 The risk that a service provider who provides the school service to the person who requires the service will suffer serious physical harm while providing the service i must not be significant or ii if it is significant the service provider must be able to take reasonable steps to reduce the risk so that it is no longer significant

Clarification The CCAC must use their best efforts to mitigate any risk to the point where it is no longer a serious risk to the contracted service provider in order to avoid declaring a childyouth ineligible for professional school services on this basis

922 Eligibility for Personal Support School Services

Section 7 of regulation 38699 of the LTCA states

s 7(1) ldquoschoolrdquo means a private school as defined in subsection 1 (1) of the Education Act s 7(1) ldquopersonal support school servicesrdquo means the following personal support services that are provided to a person who is enrolled as a pupil at a school on the school premises or during a school trip or activity outside the school premises or that are provided to a person who is receiving satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act and are necessary in order for the person to be able to receive instruction 1 Personal hygiene activities 2 Routine personal activities of living 3 Training of school personnel to provide the services referred to in paragraphs 1 and 2 to persons enrolled as pupils at the school and assisting the personnel in providing them 4 The provision of medical and personal equipment necessary to the provision of the services referred to in paragraphs 1 and 2

Clarification Personal support school services are defined in regulation 38699 as personal hygiene activities and routine personal activities of living These services include the training of school personnel and provision of treatment equipment necessary to the provision of the services Personal hygiene activities and routine personal activities of living in the context of private and home schools include assistance with eating dressing and toileting (including clean catheterization) personal hygiene (including shallow suctioning) mobility transferring positioning and routine exercises taught by a therapist (physiotherapist occupational therapist speech-language pathologist)4 s 7(2) A community care access centre shall not provide personal support school services to a person unless the person meets the following eligibility criteria Clarification A CCAC does not have the authority to provide personal support school services to a person unless the person meets the following eligibility criteria

s 7(2)1 The person must be enrolled as a pupil at a school or be receiving satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act

4 MOHLTC Memorandum regarding Personal Support Services and Equipment in Private and Home Schools January 8 2001

Clarification A childyouth up to the age of 21 must be either enrolled in a private school or receiving satisfactory instruction at home in order to be eligible for these personal support school services More information is available on the EDU website at [httpwwwedugovoncaengfunding] s 7(2)2 The person must require the services i in order to be able to attend school participate in school routines and receive instruction or ii in order to be able to receive satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act

Clarifications

bull The CCAC may provide personal support school services at the private school or while the

pupil is being transported to or from private school or participating in private school related activities (see subsection 95 in this manual for additional information) in other locations5 The personal support school services must be necessary in order for the childyouth to be able to attend private school participate in private school routines and receive instruction In other words in the absence of personal support school services the childrsquosyouthrsquos private school attendance instruction or participation would be significantly disrupted

bull The CCAC must not assume responsibility for determining what constitutes ldquosatisfactory instruction at homerdquo In order for a childyouth who is receiving home schooling to be eligible for personal support school services the parentguardian must provide the CCAC with a letter from the relevant school board indicating that the childyouth is excused from attendance at school because he or she is receiving ldquosatisfactory instruction at homerdquo PolicyProgram Memorandum No 131 (PPM131) dated June 17 2002 addresses the services offered by the MOHTLC and sets out the process a parentguardian should follow in order to obtain the appropriate documentation including a sample letter PPM131 and the sample letter are available on the EDU website at [httpwwwedugovoncaextraengppm131html]

s 7(2)3 The person must be an insured person under the Health Insurance Act (See chapter 3 in this manual for Ontario Health Insurance Program (OHIP) eligibility criteria) s 7(2)4 The school or home in which the service is to be provided must have the physical features necessary to enable the service to be provided

Clarifications bull The setting in which the personal support school services are to be provided must be

conducive to providing the service such as having enough space to allow the use of necessary equipment and supplies and privacy to allow appropriate treatment to be given

bull The CCAC must use their best efforts to adapt their service provision to the available surroundings However when such adaptations cannot be made the CCAC must discuss alternative courses of action with the childyouthparentguardian andor private school in order to avoid declaring a childyouth ineligible for personal support school services on this basis

s 7(2)5 The risk that a service provider who provides the service to the person who requires it will suffer serious physical harm while providing the service i must not be significant or ii if it is significant the service provider must be able to take reasonable steps to reduce the risk so that it is no longer significant Clarification The CCAC must use their best efforts to mitigate any risk to the point where it is no longer a serious risk to the contracted service provider in order to avoid declaring a childyouth ineligible for personal support school services on this basis

923 Overview of Services Offered by CCAC

Publicly Funded Schools Private Schools Home Schooling

Situations

Nursing physiotherapy occupational therapy specified speech-language pathology after school board provides initial assessment dietetics

Nursing physiotherapy occupational therapy specified speech-language pathology (including initial assessment) dietetics

Personal support services Personal support services

Training of school personnel Training of school personnel Training of parentguardian

The provision of medical supplies dressings and treatment equipment relating to professional school services

The provision of medical supplies dressings and treatment equipment relating to professional school services as well as the provision of medical and personal

The provision of medical supplies dressings and treatment equipment relating to professional school services as well as the provision of medical

Publicly Funded Schools Private Schools Home Schooling Situations

equipment relating to personal support school services

and personal equipment relating to personal support school services

93 Service Maximums

Service maximums for CCAC school services are regulated under the Long-Term Care Act 1994 (LTCA)

931 Private and Publicly Funded Schools ndash No Service Maximums

There are no service maximums for Community Care Access Centre (CCAC) school services provided in public and private schools However subsection 4(3) of regulation 38699 of the LTCA states

s 4(3) In determining the maximum amount of nursing services that may be provided to a person under this section a community care access centre shall not include any nursing services that are provided as school services under sections 5 and 6

Clarification Subsection 4(3) of regulation 38699 provides that the CCAC must not include the hours of nursing services provided to a childyouth in a publicly funded school private school or in a home schooling situation through CCAC school services when determining the maximum amount of nursing services that can be provided to a childyouth as part of in-home nursing services Childrenyouths who receive CCAC school services may also receive professional services at home

932 Home Schooling Situations ndash Service Maximums

There are service maximums for childrenyouths receiving professional school services and personal support school services while being home schooled regulation 38699 of the LTCA states

s 6 A community care access centre that provides school services to a person who is receiving satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act shall not provide more than six hours of school services a day to that person five days a week s 7(3) A community care access centre that provides personal support school services under this section to a person who is receiving satisfactory instruction at home in accordance with clause 21 (2) (a) of the Education Act shall not provide more than six hours of those services a day to that person five days a week

Clarification The CCAC must not provide more than six hours of professional school services or personal support school services a day five days a week to a childyouth who receives home schooling However regulation 38699 of the LTCA states

s 3(4) In determining the maximum amount of personal support services that may be provided to a person under this section a community care access centre shall not include any personal support school services provided under section 7 Clarification Subsection 3(4) of regulation 38699 provides that the CCAC must not include the hours of personal support school services provided to a childyouth in a private school or in a home schooling situation through CCAC school services when determining the maximum amount of personal support services that can be provided to a childyouth as part of in-home personal support services

941 Medical Supplies Dressings and Treatment Equipment Relating to

Professional School Services

Professional school services include the provision of medical supplies dressings and treatment equipment necessary to the provision of nursing services occupational therapy services physiotherapy services speech-language pathology services and dietetics services to eligible childrenyouths Subsection 5(1)7 of regulation 38699 of the Long-Term Care Act 1994 (LTCA) states that ldquoschool servicesrdquo include ldquothe provision of medical supplies dressings and treatment equipment necessary to the provision of the services referred to in paragraphs 1 to 5rdquo The eligibility criteria and case management functions set out in subsection 921 in this manual apply to these medical supplies dressings and treatment equipment

Clarification The childyouth or his or her parentguardian is responsible for the provision and transportation of any specialized long-term treatment equipment required for the childyouth to participate in school which is not related to the provision of school services for example a wheelchair6 The Community Care Access Centre (CCAC) case manager may authorize the provision of treatment equipment to an eligible childyouth through the CCAC school services when one of the following conditions applies

bull the treatment equipment is required for a trial period prior to purchase and requires

monitoring and evaluation by an Assistive Devices Program (ADP) authorizing professional

bull the treatment equipment is not available through ADP and is essential to support the childrsquosyouthrsquos medical treatmentrehabilitation needs (as opposed to education related needs such as a communication device or customized desk which is the responsibility of the school board) or

bull the childyouth has a short-term need for the treatment equipment Note The CCAC does not provide Ontario Drug Benefits (ODBs) to children who are only

receiving school services

Treatment Equipment Selection To facilitate the provision of treatment equipment the CCAC case manager must

6 A childyouth may be eligible to receive assistance to obtain equipment for long-term use from the Ministry of Health and Long-Term Care (MOHLTC) as per Assistive Devices Program (ADP) requirements

bull assess a childrsquosyouthrsquos need for equipment or request a therapist to do the assessment for

this equipment bull select the most cost effective equipment bull authorize the price of equipment which may include applicable taxes and delivery charges

or monthly rental charges and bull reassess the childyouth if different equipment is subsequently required

Purchase Maintenance and Disposal of Treatment Equipment

The purchase disposal and maintenance of treatment equipment are the responsibility of the school or the home schooling parent When the childyouth no longer requires the treatment equipment it is the responsibility of the school or parent to determine the best use of the equipment (eg donate to charity)

942 Medical and Personal Equipment Relating to Personal Support School Services

Personal support school services include the provision of medical and personal equipment necessary to the provision of routine hygiene activities and routine personal activities of daily living Subsection 7(1)4 of regulation 38699 of the LTCA states that ldquopersonal support school servicesrdquo include ldquothe provision of medical and personal equipment necessary to the provision of the services referred to in paragraphs 1 and 2rdquo The eligibility criteria and case management functions set out in subsections 921 and 922 in this manual respectively apply to these medical supplies dressings and treatment equipment The medical and personal equipment required must be necessary to the provision of personal support school services Examples include standers grab bars lifts adaptive seating equipment (eg wedges wrist weights and weighted vests) commode chairs change tables suction machines adaptive feeding equipment lifts and wheelchair tables The CCAC case manager must authorize the purchase of the following medical and personal equipment bull equipment that is covered by the Ministry of Health and Long-Term Care (MOHLTC) ADP

required for the home and the school setting and problematic to transport (eg suction machine)7 and

7 In this case a second piece of equipment may be necessary The second piece of equipment does not have to be identical to the original piece but must be functionally appropriate for the purpose for which it is required eg more conducive to travel or accommodated to functioning in a smaller space

bull equipment that is not covered by the ADP but is needed to support the provision of personal support school services as determined by a professional assessment (eg transfer boards)

Medical and Personal Equipment Not Provided The CCAC does not provide the following medical and personal equipment

bull educational equipment that allows the childyouth to access the curriculum (eg frequency

modulation (FM) systems for childrenyouths who are hard of hearing Braille printers and custom designed desks) and

bull equipment associated with modifying the school or home infrastructure This may include elevators stair glides special toilets handrails for stairs ramps locked medication cupboard and cardio-pulmonary equipment

Medical and Personal Equipment Selection

To facilitate the provision of medical and personal equipment the case manager must bull assess a childrsquos need for equipment or request a therapist to do the assessment for

equipment bull select the most cost effective equipment bull authorize the price of equipment which may include applicable taxes and delivery charges

or monthly rental charges and bull reassess the childyouth if different equipment is subsequently required Purchase Disposal and Maintenance of Medical and Personal Equipment

The purchase disposal and maintenance of medical and personal equipment are the responsibility of the school or the home schooling parentguardian When the childyouth no longer requires the equipment it is the responsibility of the school or parentguardian to determine the best use of the equipment (eg donate to charity)

It is the not the responsibility of the Community Care Access Centre (CCAC) to transport childrenyouths to publicly funded or private school The CCAC provides school services to eligible childrenyouths while they are being transported to or from school on a school bus or other school vehicle or are participating in a school trip or activity outside the school premises The CCAC may only provide school services when the childyouth being transported bull is at risk of significant physical injury during transportation and bull the skills of a nursing professional are required within scope of practice

A childyouth who is home schooled is also eligible for nursing services while being transported in a private vehicle to attend an organized activity directly related to the education of the childyouth as long as the childyouth meets the above criteria The CCAC does not provide school services in relation to casual activities that are not related to the childrsquosyouthrsquos education

96 Case Management Function Relating to the Provision of

CCAC School Services The Community Care Access Centre (CCAC) case manager must assess the childrsquosyouthrsquos requirements determine eligibility for school services and for each eligible childyouth develop and authorize a plan of service that sets out the amount of service to be provided in accordance with the Long-Term Care Act 1994 (LTCA) When required by the school board the CCAC is responsible to ensure that case managers have police clearancecriminal checks in order to be able to access schoolsschool property The CCAC case manager must manage the plan of service between the childyouth the parentguardian the school and the contracted service provider as well as bull interpret CCAC school service policies and guidelines bull collaborate in planning for the integration of school services to complement existing school

programs bull make recommendations about specific supplies and dressings and facilitate access to certain

specialized equipment to meet the program goals bull track units of service for these services as required by the Management Information System

(MIS) and bull facilitate harmonious relationships among the parties

The CCAC case manager must review the childrsquosyouthrsquos requirements when appropriate Depending on the childrsquos condition and circumstances the review can be in consultation with the contracted service provider parentguardian and school personnel as appropriate It is recommended that the CCAC conduct a review at least once a year During the course of the review the CCAC must evaluate the childrsquosyouthrsquos plan of service (outcomes goals and timeframes) and revise the plan of service as necessary when the childrsquosyouthrsquos requirements change

961 Specific Processes Relating to Provision of CCAC Professional School

Services to ChildrenYouths Enrolled in Publicly Funded Schools

bull For a childyouth enrolled in a publicly funded school the childrsquosyouthrsquos parent andor an outside health care professional if one is involved should first discuss any need for professional school services with the principal of the school

bull If it is agreed that CCAC professional school services would be appropriate in the situation the parties should designate one person to contact the CCAC

bull The CCAC case manager must contact the school for an appointment to see and assess the child with the parentrsquos consent

bull The CCAC must then assess the childrsquosyouthrsquos needs determine whether the childyouth is eligible for professional school services and if so develop and authorize a plan of service

bull The CCAC provides the professional school services to childrenyouths in publicly funded schools through their service providers

962 Specific Processes Relating to the Provision of CCAC Professional School

Services and Personal Support School Services to ChildrenYouths Enrolled in Private Schools bull For a childyouth enrolled in a private school the parentguardian should first discuss with

the principal of the school bull the need for professional school services or personal support school services and bull the request for a referral

bull If it is agreed that CCAC professional school services or personal support school services would be appropriate in the situation the principal or parent should then contact the CCAC

bull The principal must provide express permission to the CCAC to provide service on school property

bull The CCAC must then assess the childrsquosyouthrsquos needs determine whether the childyouth is eligible for either professional school services or personal support school services or both and if so develop and authorize a plan of service

bull The private school may bull receive funding directly from the CCAC and hire the service provider itself or bull request in writing that the CCAC arrange the professional school services or personal

support school services on the schoolrsquos behalf The CCAC then refers the matter to the appropriate contracted service provider

Where the private school receives funding directly from the CCAC the following responsibilities arise The CCAC case manager must

bull enter into a memorandum of understanding with the principalchief administrator of the

private school bull receive quarterly reports from the private schools and include this information in the

quarterly reports submitted to the Ministry of Health and Long-Term Care (MOHLTC)

bull ensure the private schoolrsquos quarterly reports identify all expenditures related to the provision of professional school services and personal support school services (Private schools may charge the CCAC up to 3 as an administration fee)

bull receive annual reconciliation reports from the private schools and provide this information in the annual reconciliation reports (ARRs) submitted to the MOHLTC (When the amount of funding is limited the CCAC may use its discretion regarding the requirement for an ARR In these cases the submission of invoices with the quarterly report may be a less expensive and a more reasonable accountability mechanism) and

bull monitor and be satisfied based on the claims and reports submitted by the CCAC that the private school has spent the funding provided by the CCAC for approved services including the purchase of services and equipment in accordance with the plans of service for the childrenyouths enrolled in the private school

The private school must bull enter into a memorandum of understanding with the CCAC bull use the funding provided by CCAC only for approved services including the purchase of

services and equipment in accordance with the plans of service for the childrenyouths enrolled in the private school

bull assume all liability related to the provision of services bull hire service providers (When the private school hires staff to provide the approved services

the private school must use a standard job description and have policies for screening and supervision of staff Any staff hired must comply with the requirements set in the Regulated Health Professions Act 1991 (RHPA))

bull provide a quarterly report to the CCAC bull provide an annual audited reconciliation report at year-end that indicates how their funding

was spent for the provision of approved services in accordance with the plans of service for the eligible childrenyouths and

bull return any unspent funds to the CCAC

963 Specific Processes Relating to the Provision of CCAC Professional School Services and Personal Support School Services to ChildrenYouths in Home Schooling Situations

bull For a childyouth in home schooling the parentguardian should contact the CCAC directly bull Once the CCAC has assessed a childrsquosyouthrsquos needs determined his or her eligibility and

developed and authorized a plan of service the CCAC must flow funds for childrenyouths schooled at home through a local community agency that is a transfer payment agency of either the MOHLTC or Ministry of Community and Social Services (MCSS) The CCAC must flow funding directly to the agency and the agency must agree to act as a banker and

flow funds to the parentguardian who will then purchase the approved services The CCAC is responsible for the reconciliation process

Where the parentguardian receives funding from the agency the following responsibilities arise The CCAC case manager must

bull enter into a memorandum of understanding with the parentguardian bull enter into a memorandum of understanding with the agency bull receive quarterly receipts from the parentguardian and include this information in the

quarterly reports submitted to the MOHLTC bull ensure the quarterly reports identify all expenditures related to the provision of professional

school services and personal support school services approved by the CCAC (Parentsguardians are not permitted to charge an administration fee) and

bull monitor and be satisfied based on the claims and reports submitted by the parentguardian that the parentguardian has spent the funding provided by the agency for professional school services or personal support school services approved by the CCAC including the purchase of services and equipment in accordance with the plan of service for the childrenyouths being home schooled

The parentguardian must bull enter into a memorandum of understanding with the CCAC bull use the funding provided by the agency only for professional school services and personal

support school services approved by the CCAC including the purchase of services and equipment in accordance with the plan of service for the childyouth being home schooled

bull assume all liability related to the provision of services bull directly hire appropriate and competent service providers (non-family members only) or

contract with an appropriate service provider bull provide quarterly reports identifying all expenditures related to the provision of

professional school services and personal support school services approved by the CCAC for the childyouth being home schooled and

bull return any unspent funds to the CCAC The agency must

bull flow the funds provided to the agency by the CCAC to the parentguardian

Since the introduction of Community Care Access Centre (CCAC) school services there has been a dramatic increase in the demand for these services School childrenyouths are a unique client group because of the settings in which they receive school services and the need for their treatment and care to be integrated into their academic program These factors have prompted each CCAC to pursue different approaches to service delivery in order to efficiently serve as many childrenyouths as possible Regardless of the method of intervention or the type of therapist employed the CCAC must ensure that

bull all procedures are within the scope of practice outlined under the Regulated Health

Professions Act 1991 (RHPA) bull all contracted service providers are trained and competent in the procedures used and bull the procedures offered are in keeping with any site restrictions

971 Acceptable Approaches to Service Delivery

The following approaches are acceptable only when deemed to be appropriate by the CCAC and the school principal (where applicable)

1 Mediator Training involves demonstrating and teaching tasks to school staff and

volunteers (including the home schooling instructor) Teachers can assist in the supervision of students in regards to tasks that support the learning process 8(The role or involvement of school staff may depend on school policies)

2 Group Treatment involves treating childrenyouths with similar therapy needs in a group

For example childrenyouths requiring life skills teaching can be taught in a group setting by therapists Childrenyouths with similar difficulties may benefit from intensive treatment programs such as a writing program held in the summer months or a dysfluency treatment group

3 Block TreatmentCycling Model involves use of a scheduling model based on a cycle of

time when therapy is provided and not provided Lengths of the interval can also be varied by cycling the variations (staggering cycle blocks or staggering the length of blocks or intervals) After the initial block of treatments teachers and parentsguardians are trained on a remedial program for the childyouth The model can be used for individual or group treatments

8 For example the CCAC may agree to provide some training to teachers so that they would become more adept in recognizing the level of handwritingprinting difficulties which would benefit from a therapistrsquos assessment

4 Periodic Sessions involve scheduling of individual treatments at appropriate intervals

(eg monthly every three months) Treatment programs are designed for use at school and home

5 Direct Service involves treatment on a one-to-one basis 6 Consultation to exchange knowledge or information in a general informative way

between the CCAC and the school staffinstructor as appropriate ie a service care plan cannot be developed solely based on consultations

7 Sharing ResourcesCost Sharing Staffing where the health professional and educational

assistant are working with the same childyouth and it is possible for one person to provide all the assistance in cases where appropriate This promotes continuity of care for the childyouth

Once the CCAC and the school principal have agreed on the split responsibilities the cost

of providing both services by one staff person must be shared between the CCAC and the public or private school For example a medically fragile childyouth with gastric tube feeds who has an educational assistant for educational needs and a nurse for tube feeds could have one dually-trained professional to provide both services

8 Conferences where case managers andor contracted service providers may be required to

attend case conferences or meetings to develop or explain plans of service This is a normal expectation for the effective delivery of service The case manager authorizes who attends case conferences especially if the CCAC is paying for a contracted service provider to attend these meetings Attendance at case conferences may be a service provider contractual obligation

9 Service Sites where the primary service site for the childyouth attending a public or

private school is the school the childyouth receiving instruction at home has home visits Occasionally a contracted service provider may need to visit a childyouth in locations

other than the school setting For example a contracted service provider may be required to

bull participate in school day trips bull attend case conferences and meetings not on school property bull attend a specialized assessment requiring the presence of the studentrsquos CCAC therapist

or other contracted service provider bull access specialized equipment not available in the school

bull provide specialized support during the studentrsquos transportation to and from school or a school-related activity

bull attend co-op placement sites andor bull conduct assessments in the childrsquosyouthrsquos home Off-site service would be provided in accordance with the goals of CCAC professional school services and personal support school services

10 General Training while not a primary function of CCAC school services the CCAC may

authorize training and consultation to parentsguardians and groups of school staff regarding provision of school services for eligible childrenyouths Examples are training sessions on proper body mechanics for lifting positioning and transferring

Many children have fine motor difficulties that affect their printing skills CCACs could provide information to teachers on their professional development days or CCACs could approach school boards to ask whether they would like information sessions on professional activity days While school services may include training on some occasions schools have the primary responsibility to teach printinghandwriting skills to their students The CCAC may agree to provide some training to teachers so that they would become more adept in recognizing the level of handwritingprinting difficulties which would benefit from a therapistrsquos assessment

The Community Care Access Centre (CCAC) may terminate a childrsquos professional school services or personal support school services if

bull the childyouth andor parentguardian are repeatedly not available for scheduled

appointments or bull the provision of continued therapy will not further clinical progress The CCAC must terminate professional school services and personal support school services if bull the childyouth moves from Ontario bull any of the eligibility criteria cease to be met (for example if the childyouth receiving

services is no longer an insured person under the Health Insurance Act (HIA) bull the child is not enrolled in a publicly funded school or private school or is not being home

schooled or bull the childyouth has reached the age of 21

The Community Care Access Centre (CCAC) must liaise with publicly funded schools private schools and community service agencies to ensure that these groups are fully informed about the professional school services and personal support school services provided by the CCAC During the course of these liaison activities the CCAC must ensure that they comply with the laws governing the confidentiality of personal health information

991 Publicly Funded Schools and Private Schools

The CCAC schools and contracted service providers should have regular meetings to discuss the roles of CCAC staff school staff and contracted service providers relating to the provision of services to pupils in schools (eg private treatment space record keeping and information sharing) and other issues of mutual concern Note Every publicly funded school board must establish a Special Education Advisory Committee (SEAC) that advises the school board on special education issues It is important for the CCAC case manager to liaise with this Committee for information sharing and planning purposes School principals should be aware of service issues and the needs of childrenyouths in order to be partners in the provision of CCAC school services and personal support school services Parentsguardians and teachers must be aware of these issues as there may be times when they are directlyindirectly involved with service provision or act as mediators on behalf of the pupil

992 Agencies Providing Service to Preschoolers

Preschool-aged children with special needs may be clients of early intervention programs Easter Seal Society day care centres public health units specialty clinics hospitals or others The CCAC and their contracted service providers must liaise with these organizations in order to ensure a smooth transition from the pre-school agency to CCAC school services when the child becomes school-aged and to avoid duplication of services Note Children attending day care or nursery schools are not eligible for the provision of CCAC school services in the day care or nursery school settings as these are not ldquoschoolsrdquo as defined under the Education Act (EA)

Community Groups

CCAC staff must liaise with community groups in order to promote a comprehensive range of school services For example the CCAC in conjunction with local school boards childrenrsquos services planning bodies and parent groups could work together to ensure that available resources are being efficiently utilized and services are working well together as well as to develop service priorities and plans based on local needs

Childrenyouths with health needs may also receive services in the school setting from four other agencies

9101 Childrenrsquos Care and Treatment Facilities and Correctional Facilities

Some childrenyouths are unable to attend school because of their need for treatment or the fact that they are incarcerated Services in childrenrsquos mental health treatment programs and correctional service programs for young offenders are provided by the Ministry of Children and Youth Services (MCYS) Where the childyouth resident in any of these types of facilities are unable to attend school the facilities provide space for an education program to be provided by a local school board Childrenyouths in these facilities are not eligible for Community Care Access Centre (CCAC) professional school services or personal support school services

9102 Childrenrsquos Treatment Centres

There are six childrenrsquos treatment centres (CTCs) with school boards attached in Ontario These centres have their own volunteer school boards and provide education programs for the children who attend the centres The CCAC may provide specialized nursing services in these settings Other health services are provided by the CTC

9103 First Nations Schools

The federal government through Indian and Inuit Affairs Canada funds special education programs for First Nations childrenyouths living on reserves Health Canada may fund the provision of health services in school for childrenyouths attending schools on First Nations reserves Childrenyouths residing in First Nations communities are eligible for CCAC services The CCAC must first assess whether these individuals require CCAC services if similar services are provided through the First Nations community CCAC services should co-ordinate with and complement services available in the First Nations community rather than duplicate those services To achieve this goal CCAC staff need to be aware of the services available in First Nations communities within their service area First Nations may purchase services from the CCAC or contracted service providers In remote northern areas First Nations may also purchase services from Integrated Services for Northern Children (ISNC) a program administered by the MCYS

Note First Nations childrenyouths attending public schools off reserves may receive CCAC school services if they meet the eligibility criteria The CCAC must assess requirements and determine eligibility for services on the same basis as any other Ontario resident The MOHLTC provides funding to some aboriginal organizations to provide home and community care services to aboriginal people both on and off reserve The types and availability of services vary across the province

9104 Integrated Services for Northern Children (ISNC)

The ISNC program is a commitment made by the MCYS the MOHLTC the Ministry of Education and Training (EDU) and the Ministry of Northern Development and Mines to provide a range of health mental health and education services to childrenyouths living in rural and remote areas across northern Ontario Since ISNC provides services similar to CCAC professional school services and personal support school services the CCAC and ISNC must negotiate roles and responsibilities locally For additional information visit the ISNC website at [httpwwwchildrengovoncaCSenprogramsSpecialNeedsintegratedServicesforNorthernChildrenhtm] or call (705) 474-3540 ext 218 or (705) 564-8153 ext 341

As the management of an emergency situation while a childyouth is attending school or a school-related activity is the responsibility of the school or home school instructor it is the responsibility of the school or home school instructor to arrange any required ambulance service or any other response to an emergency In regards to the payment of ambulance service a childyouth receiving in-home services as well as school services is eligible for a fee waiver relating to ambulance services A childyouth receiving school services only is not eligible for a fee waiver

CCAC Client Services Policy Manual Chapter 10 Complaints and Appeals

September 2006 1

Complaints and Appeals

This section describes the complaint and appeal processes to be followed by the Community Care Access Centre (CCAC) with respect to decisions regarding the provision of community services and admission to a long-term care (LTC) home

101 Complaint Resolution ndash Community Services

The Long Term Care Act 1994 (LTCA) provides that the CCAC must establish a process for reviewing complaints regarding the provision of community services Section 39 of the LTCA states s 39(1) An approved agency shall establish a process for reviewing complaints made to it by a person about any of the following matters 1 A decision by the approved agency that the person is not eligible to receive a particular community service 2 A decision by the approved agency to exclude a particular community service from the personrsquos plan of service 3 A decision by the approved agency respecting the amount of any particular community service to be included in the personrsquos plan of service 4 A decision by the approved agency to terminate the provision of a community service to the person 5 The quality of a community service provided to the person or arranged for the person by the approved agency 6 An alleged violation by the approved agency of any of the personrsquos rights set out in subsection 3 (1)

Complaint under par 5 or 6 of subs (1) s 39(2) Within 60 days after a complaint is made to an approved agency about a matter referred to in paragraph 5 or 6 of subsection (1) the approved agency shall review the complaint and respond to the person who made the complaint Complaint under par 1 2 3 or 4 of subs (1) s 39(3) Within 60 days after a complaint is made to an approved agency about a decision referred to in paragraph 1 2 3 or 4 of subsection (1) the approved agency shall (a) affirm the decision and give a written notice of the affirmation to the persons referred to in subsection (4)

September 2006 2

(b) rescind the decision and give a written notice of the rescission to the persons referred to in subsection (4) or (c) rescind the decision substitute a new decision in its place and give a copy of the new decision to the persons referred to in subsection (4)

Who must be given notice s 39(4) A notice under clause (3) (a) or (b) or a copy of a decision under clause (3) (c) shall be given (a) to the person to whom the decision relates and (b) if the person to whom the decision relates is mentally incapable to the person who is lawfully authorized to make a decision on his or her behalf concerning the community service

The CCAC must have a formal written process approved by the board of directors for receiving reviewing and responding to complaints regarding community The CCAC must review all complaints in accordance with section 39 of the LTCA A complaint may be made to the CCAC by the person affected by the CCACrsquos decision or their substitute decision-maker Complaints may also be made regarding CCAC services directly to the Ministry of Health and Long-Term Care (MOHLTC)

1011 Decisions for Which the CCAC Must Have a Complaint Review Process

Pursuant to subsection 39(1) of the LTCA the CCAC must establish a process for reviewing complaints made to it by a person about any of the following matters bull a decision by the CCAC that the person is not eligible to receive a particular community

service bull a decision by the CCAC to exclude a particular community service from the persons plan

of service bull a decision by the CCAC respecting the amount of any particular community service to be

included in the persons plan of service bull a decision by the CCAC to terminate the provision of a community service to the person bull the quality of a community service provided to the person or arranged for the person by the

CCAC or bull an alleged violation by the CCAC of any of the persons rights set out in subsection 3(1) (See the Bill of Rights for people receiving community services in subsection 3(1) of the LTCA or subsection 221 in this manual)

1012 Documentation Relating to Complaints

The CCAC must maintain a written record of all complaints concerning the above matters including the following information bull name of the person who is the subject of the complaint

September 2006 3

bull name of the person who is making the complaint if it is different than the person who is the subject of the complaint

bull date of the complaint bull substance of the complaint bull review taken bull outcome of the review bull decision made andor action taken bull date of the decision andor action taken bull date feedback was provided to the person or his or her substitute decision-maker bull reaction to the feedback bull any follow-up action required and bull monitoring plan if required

1013 Steps to Review a Complaint

The CCAC must implement a complaint review process which includes but is not limited to the following steps Clarifying the Complaint The CCAC must listen to the personrsquos concerns asking questions to obtain details (What happened When and where did it happen Who was involved) and attempt to bring all parties to a consensus on the exact identification of the problem

Early Resolution Through Information Exchange

It is possible that a complaint has been made as one or both parties have not clearly understood a particular situation In addition the complainant or the CCAC may have additional information that may affect the outcome of the complaint The CCAC must attempt to solicit all relevant and appropriate information that may result in the resolution of the complaint Clarifying the Process If the complaint is not resolved at an early stage the CCAC must bull determine whether the complainant wishes to pursue the complaint further bull explain the next steps in the complaints process and bull advise the complainant when he or she may expect a response Information Gathering The CCAC must interview staff and the affected person (where appropriate) the contracted service provider (where appropriate) and review documentation about the situation such as application forms client files daily logs and incident reports The CCAC must also review relevant legislation and agencygovernment policies

September 2006 4

Action Based on the above information the CCAC must decide whether or not to support the CCACrsquos original decision or action If any complaint suggests there is a systemic rather than an individual problem relating to the provision of community service by the CCAC the CCAC must review its policies and procedures and determine whether any changes are necessary Where system changes are necessary the CCAC must make the changes and communicate them to staff to prevent reoccurrences and if required the CCAC must monitor to ensure that new policies andor procedures are fully implemented in a timely fashion Feedback Pursuant to subsection 39(2) of the LTCA the CCAC must review any complaint relating to quality of service or alleged violation of the Bill of Rights and respond within 60 days to the person who made the complaint Pursuant to subsections 39(3) and (4) of the LTCA within 60 days after a complaint is made relating to eligibility exclusion of a particular community service from the plan of service amount of service or termination of service CCAC must do one of the following

bull affirm the decision and give a written notice of the affirmation bull rescind the decision and give a written notice of the rescission or bull rescind the decision substitute a new decision and provide a copy of the new decision The CCAC must provide the notice or copy of the decision to the person to whom the decision relates or his or her substitute decision-maker

1014 Reporting Complaints to the MOHLTC

The MOHLTC has implemented a complaint reporting policy for the CCAC The CCAC must report all client complaints to the MOHLTCrsquos regional offices at the time the CCAC submits its Annual Performance Report The CCAC must report client complaints based on two categories bull client complaints about CCAC decisions (see subsection 1011 in this manual) and bull client complaints about the quality of service by the CCAC and contracted service provider

agencies For the purpose of reporting a complaint is defined as any concern brought forward by a client or caregiver (or substitute decision-maker) concerning the services provided by the CCAC or any contracted service provider agency that is not resolved at the level of the case manager (ie the clientcaregiver is referred to the managerexecutive director for follow up) A complaint

September 2006 5

can relate to any component of the services provided through the CCAC (eg placement in-home services medical supplies and equipment)

September 2006 6

102 Appeal of CCAC Decisions ndash Community Services

Appeal of original decision s 40(1) A person to whom a decision referred to in paragraph 1 2 3 or 4 of subsection 39 (1) relates and who has made a complaint to the approved agency about the decision may appeal the decision to the Appeal Board if (a) either of the persons referred to in subsection 39 (4) receives a notice of the affirmation of the decision under clause 39 (3) (a) or (b) neither of the persons referred to in subsection 39 (4) receives a notice under clause 39 (3) (a) or (b) or a copy of a decision under clause 39 (3) (c) within 60 days after the complaint is made Appeal of new decision s 40(2) A person to whom a decision referred to in paragraph 1 2 3 or 4 of subsection 39 (1) relates and who has made a complaint to the approved agency about the decision may if either of the persons referred to in subsection 39 (4) receives a copy of the approved agencyrsquos new decision under clause 39 (3) (c) appeal the new decision to the Appeal Board Notice s 40(3) To appeal the decision of the approved agency to the Appeal Board under subsection (1) or (2) the person shall give the Appeal Board a notice requiring a hearing Only decisions concerning matters referred to in paragraphs 1 2 3 and 4 of section 39 (1) of the LTCA can be appealed These decisions are

bull a decision by the CCAC that the person is not eligible to receive a particular community

service bull a decision by the CCAC to exclude a particular community service from the personrsquos plan

included in the personrsquos plan of service and bull a decision by the CCAC to terminate the provision of a community service to the person

1021 Right to Appeal

Pursuant to section 40 of the LTCA a complainant or the complainantrsquos substitute decision-maker has the right to appeal to the Health Services Appeal and Review Board (HSARB) a decision made by the CCAC in response to a complaint if bull the decision of the CCAC affirms the original decision and the complainant or substitute

decision-maker continues to disagree with that decision

September 2006 7

bull the complainant or substitute decision-maker has not had a written notice of a response to his or her complaint within 60 days or

bull the complaint has resulted in a new CCAC decision with which the complainant or the substitute decision-maker disagrees

In order to commence the appeal the complainant or substitute decision-maker must give a notice to the HSARB requiring a hearing The HSARB is created under the Ministry of Health Appeal and Review Boards Act 1998 (MHARBA) Pursuant to subsection 6(1) of this legislation the HSARB has the duty to conduct hearings under amongst others the LTCA The HSARB is required to interpret and apply all laws including the LTCA The HSARB has no jurisdiction to override the provisions of the LTCA including its regulations For example eligibility criteria and service maximums have been established in the regulations under the LTCA The HSARB has no authority to require a CCAC to provide more services than permitted under the regulations The HSARB is not bound by Ministry of Health and Long-Term Care (MOHLTC) or CCAC policies or guidelines

1022 The Appeal Process

Step 1 Notice by Complainant As referred to above pursuant to subsection 40(3) of the LTCA the complainant or complainantrsquos substitute decision-maker must provide a notice to the HSARB requiring the hearing The request for an appeal must be submitted in writing to

Health Services Appeal and Review Board Health Boards Secretariat 151 Bloor Street West 9th floor Toronto ON M5S 2T5 Fax (416) 327-8524 Step 2 Arranging a Time and a Place for a Hearing Subsections 41(1) and (2) of the LTCA state

Hearing s 41(1) If a person appeals a decision of an approved agency to the Appeal Board in accordance with section 40 the Appeal Board shall promptly appoint a time and place for a hearing

September 2006 8

When hearing to begin s 41(2) The hearing shall begin within 30 days after the day the Appeal Board receives the notice requiring the hearing unless the parties agree to a postponement The HSARB usually conducts pre-hearings prior to the hearing and these pre-hearings are scheduled within 30 days after the HSARB receives notice of the appeal Step 3 Notice of Hearing Subsection 41(3) of the LTCA states Notice of hearing s 41(3) The Appeal Board shall give each of the parties and the Minister at least seven days notice of the time and place of the hearing Step 4 The Hearing Parties to the Hearing

Sections 42 and 43 of the LTCA state Parties s 42 The parties to a proceeding before the Appeal Board under this Act are the person appealing the approved agencyrsquos decision the approved agency whose decision is being appealed and any other persons specified by the Appeal Board Minister entitled to be heard s 43 The Minister is entitled to be heard by counsel or otherwise in a proceeding before the Appeal Board under this Act

The parties to an HSARB hearing are

bull the person appealing the CCAC decision bull the CCAC bull any other persons specified by the HSARB and bull the Minister of Health and Long-Term Care if the minister makes a decision to

intervene

Other Procedural Matters

Sections 46 and 47 of the LTCA state Evidence of person unable to attend s 46(1) If a party to a proceeding before the Appeal Board under this Act wishes to give evidence in the proceeding or wishes to call another person as a witness to give evidence in the proceeding but the party or other person is unable to attend the hearing by reason of

September 2006 9

age infirmity or physical disability the Appeal Board members holding the hearing may at the request of the party attend upon the party or the other person as the case may be and take his or her evidence Medical report proves inability s 46(2) A medical report signed by a legally qualified medical practitioner stating that the practitioner believes that the person is unable to attend the hearing by reason of age infirmity or physical disability is proof in the absence of evidence to the contrary of the inability of the person to attend the hearing Notice to all parties s46(3) No Appeal Board member shall take evidence from anyone under subsection (1) unless reasonable notice of the time and place for taking the evidence is given to all parties to the proceeding and each party attending is given an opportunity to examine or cross-examine the person giving the evidence Health Insurance Act applies s 47 Subsections 23 (1) (2) (4) and (6) of the Health Insurance Act apply to the proceedings and decisions of the Appeal Board under this Act Subsections 23 (1) (2) (4) and (6) of the Health Insurance Act (HIA) state Examination of documentary evidence s 23(1) A person who is a party to proceedings before the Appeal Board shall be afforded an opportunity to examine before the hearing any written or documentary evidence that will be produced or any report the contents of which will be given in evidence at the hearing Board members not to have investigated prior to hearing s 23(2) Members of the Appeal Board holding a hearing shall not have taken part before the hearing in any investigation or consideration of the subject-matter of the hearing and shall not communicate directly or indirectly in relation to the subject-matter of the hearing with any person or with any party or representative of the party except upon notice to and with opportunity for all parties to participate but the Appeal Board may seek legal advice from an adviser independent from the parties and in such case the nature of the advice should be made known to the parties in order that they may make submissions as to the law Findings of fact s 23(4) The findings of fact of the Appeal Board pursuant to a hearing shall be based exclusively on evidence admissible or matters that may be noticed under section 15 or 16 of the Statutory Powers Procedure Act

September 2006 10

Release of documents etc s 23(6) Documents and things put in evidence at the hearing shall upon the request of the person who produced them be released to the person by the Appeal Board within a reasonable time after the matter in issue has been finally determined

Step 5 Decision of the HSARB Section 48 of the LTCA states Decision of Appeal Board s 48(1) After a hearing by the Appeal Board under this Act the Appeal Board may (a) affirm the decision of the approved agency (b) rescind the decision of the approved agency and refer the matter back to the approved agency for a new decision in accordance with such directions as the Appeal Board considers appropriate or (c) rescind the decision of the approved agency substitute its opinion for that of the approved agency and direct the approved agency to implement the decision of the Appeal Board in accordance with such directions as the Appeal Board considers appropriate (2) Repealed

Decision and reasons s 48(3) The Appeal Board shall render its decision within three days after the end of the hearing and shall provide written reasons to the parties as soon as possible after rendering the decision Decision to Minister s 48(4) The Appeal Board shall give the Minister a copy of its decision and reasons

Decision final s 48(5) A decision of the Appeal Board under this Act is final and binding and is not subject to appeal Pursuant to subsection 48(1) after a hearing the HSARB may do one of the following bull affirm the decision of the CCAC bull rescind the decision of the CCAC and refer the matter back to the CCAC for a new decision

in accordance with the HSARBrsquos directions or bull rescind the decision of the CCAC substitute its own decision and direct the CCAC to

implement the decision in accordance with the HSARBrsquos directions Pursuant to subsection 48(5) the decision of the HSARB is final and not subject to appeal However this provision does not preclude any party including the Attorney General from bringing an application for a judicial review to the Divisional Court of Ontario (see subsection 1034 in this manual)

September 2006 11

103 Appeal Process Relating to Admission to a Long-Term

Care Home

A person may apply for admission to a long-term care (LTC) home as a long-stay resident or a short-stay resident (respite or supportive care) The applicant for admission has the right to appeal determination of the Community Care Access Centre (CCAC) that the person is ineligible for admission Although the CCAC should attempt to resolve any complaints relating to these types of determinations through an internal complaints process the applicant may commence the appeal as soon as the determination is made The applicant may appeal the decision to the Health Services Appeal and Review Board (HSARB) If the applicant is not satisfied with the decision of the HSARB the applicant has a further right of appeal to the Divisional Court of Ontario The following long-term care home legislation governs the appeal process relating to admission to homes bull The Nursing Homes Act (NHA) bull The Charitable Institutions Act (CIA) and bull The Homes for the Aged and Rest Homes Act (HARHA) The provisions in these statutes are similar and therefore only the provisions of the NHA will be incorporated into this section The equivalent sections in the CIA and HARHA will be cross-referenced

1031 Decisions that Can be Appealed

Section 205 of the NHA (see also section 910 of the CIA and section 191 of the HARHA) states

Notice of determination s 205(1) If a placement co-ordinator determines that an applicant for a determination respecting eligibility for admission to a nursing home is not eligible the placement co-ordinator shall ensure that the applicant and the person if any who applied for the determination on behalf of the applicant are notified of (a) the determination of ineligibility (b) the reasons for the determination and (c) the applicantrsquos right to apply to the Appeal Board for a review of the determination Application to Appeal Board s 205(2) The applicant may apply to the Appeal Board for a review of the determination of ineligibility made by the placement co-ordinator

September 2006 12

Pursuant to the above provisions a person or substitute decision-maker may appeal a decision of the CCAC that the person has been determined ineligible for admission to a LTC home Other decisions relating to admission for example decisions relating to waiting list management are not subject to appeal The CCAC must advise the person of the determination the reasons for the determination and the right to appeal The term ldquoAppeal Boardrdquo is defined in the LTC home legislation as meaning the ldquoHealth Services Appeal and Review Board under the Ministry of Health Appeal and Review Boards Act 1998rdquo Pursuant to subsection 6(1) of this legislation the HSARB has the duty to conduct hearings under amongst others the NHA CIA and HARHA The HSARB is required to interpret and apply all laws including these statutes The HSARB has no jurisdiction to override the provisions of these statutes including their regulations For example eligibility criteria have been established in the regulations under these statutes The HSARB has no authority to require a CCAC to determine that a person is eligible for admission if the person does not meet the eligibility criteria established under the regulations The HSARB is not bound by Ministry of Health and Long-Term Care (MOHLTC) or CCAC policies or guidelines

1032 Further Determinations of Eligibility

The fact that a person has appealed a determination of ineligibility does not preclude the person from applying for a new eligibility determination or the CCAC from initiating a new assessment of eligibility For example there may be gap in time between the date of the original determination of ineligibility and the date of the hearing Depending on the circumstances the CCAC may wish to contact the person to ask whether the personrsquos condition has changed If the person indicates that his or her condition has changed and the person wants a further assessment of eligibility the CCAC may conduct the assessment If the person is determined eligible at this point in time it is likely that the person will withdraw the appeal If the person is still determined to be ineligible the person may appeal the second determination of ineligibility as well

Step 1 Notice by Applicant As referred to above pursuant to subsection 205(2) of the NHA (see also subsection 910(2) of the CIA and subsection 191(2) of the HARHA) the applicant or substitute decision-maker must provide a notice to the HSARB requiring the hearing The request for an appeal must be submitted in writing to Health Services Appeal and Review Board Health Boards Secretariat 151 Bloor Street West 9th floor Toronto ON M5S 2T5 Fax (416) 327-8524

September 2006 13

Step 2 Arranging a Time and a Place for a Hearing

Subsections 206(1) and (2) of the NHA (see also subsections 911(1) and (2) of the CIA and subsections 192(1) and (2) of the HARHA) state

Hearing s 206(1) When the Appeal Board receives an application for a review of a determination of ineligibility it shall promptly appoint a time and place for a hearing Same s 206(2) The hearing shall begin within twenty-one days after the day the Appeal Board receives the application for the hearing unless the parties agree to a postponement

The HSARB usually conducts pre-hearings prior to the hearing and these pre-hearings are scheduled within 21 days after the HSARB receives notice of the appeal Step 3 Notice of Hearing by the HSARB and CCAC Subsection 206(3) of the NHA (see also subsection 911(3) of the CIA and subsection 192(3) of the HARHA) states Notice to parties s 206(3) The Appeal Board shall notify each of the parties of the time and place of the hearing at least seven days before the hearing begins In addition subsection 206(5) of the NHA (see also subsection 911(5) of the CIA and subsection 192(5) of the HARHA) states Notice to Minister s 206(5) When a placement co-ordinator is notified by the Appeal Board of a hearing the placement co-ordinator shall promptly give the Minister written notice of the hearing together with written reasons for the determination of ineligibility made by the placement co-ordinator When the CCAC is notified by the HSARB of a hearing the CCAC must give the following to the Minister of Health and Long-Term Care bull notice of the hearing and bull the CCACrsquos written reasons for the determination of ineligibility Step 4 The Hearing

Parties to the hearing

Subsections 206(4) and (6) of the NHA (see also subsection 911(4) and (6) of the CIA and subsection 192(4) and (6) of the HARHA) state

September 2006 14

Parties s 206(4) The parties to the proceeding before the Appeal Board are the applicant who was determined to be ineligible for admission the placement co-ordinator who made the determination and such other parties as the Appeal Board specifies Minister entitled to be heard s 206(6) The Minister is entitled to be heard by counsel or otherwise in a proceeding before the Appeal Board under this section Parties to the HSARB hearing are bull the person appealing the CCAC decision bull the CCAC bull any other persons specified by the Appeal Board and bull the Minister of Health and Long-Term Care if the minister makes a decision to

intervene

Subsections 206 (9 through 13) of the NHA (see also subsections 911 (9 through 13) of the CIA and subsections 192 (9 through 13) of the HARHA) state Evidence of disabled person s 206(9) If a party to a proceeding before the Appeal Board under this Act wishes to give evidence in the proceeding or wishes to call another person as a witness to give evidence in the proceeding but the party or other person is unable to attend the hearing by reason of age infirmity or physical disability the Appeal Board members holding the hearing may at the request of the party attend upon the party or the other person as the case may be and take his or her evidence Medical report proves inability s 206(10) A medical report signed by a legally qualified medical practitioner stating that the practitioner believes that the person is unable to attend the hearing by reason of age infirmity or physical disability is proof in the absence of evidence to the contrary of the inability of the person to attend the hearing Opportunity for all parties s 206(11) No Appeal Board member shall take evidence from a party or other person under subsection (9) unless reasonable notice of the time and place for taking the evidence is given to all parties to the proceeding and each party attending is given an opportunity to examine or cross-examine the party or other person as the case may be Recording of evidence s 206(12) The oral evidence taken before the Appeal Board at a hearing and the oral evidence taken from a party or other person under subsection (9) shall be recorded and if

September 2006 15

required copies of a transcript of the evidence shall be furnished on the same terms as in the Ontario Court (General Division) Health Insurance Act s 206(13) Subsections 23 (1) (2) (4) and (6) of the Health Insurance Act apply to the proceedings and decisions of the Appeal Board under this Act Subsections 23 (1) (2) (4) and (6) of the Health Insurance Act (HIA) state Examination of documentary evidence s 23(1) A person who is a party to proceedings before the Appeal Board shall be afforded an opportunity to examine before the hearing any written or documentary evidence that will be produced or any report the contents of which will be given in evidence at the hearing Board members not to have investigated prior to hearing s 23(2) Members of the Appeal Board holding a hearing shall not have taken part before the hearing in any investigation or consideration of the subject-matter of the hearing and shall not communicate directly or indirectly in relation to the subject-matter of the hearing with any person or with any party or representative of the party except upon notice to and with opportunity for all parties to participate but the Appeal Board may seek legal advice from an adviser independent from the parties and in such case the nature of the advice should be made known to the parties in order that they may make submissions as to the law Findings of fact s23(4) The findings of fact of the Appeal Board pursuant to a hearing shall be based exclusively on evidence admissible or matters that may be noticed under section 15 or 16 of the Statutory Powers Procedure Act Release of documents etc s 23(6) Documents and things put in evidence at the hearing shall upon the request of the person who produced them be released to the person by the Appeal Board within a reasonable time after the matter in issue has been finally determined

Step 5 Decision of the Appeal Board Subsections 206(14) through (16) of the NHA (see also subsections 911(14) through (16) of the CIA and subsections 192(14) through (16) of the HARHA) state

Powers of Appeal Board s 206(14) After a hearing by the Appeal Board the Appeal Board may (a) affirm the determination of ineligibility made by the placement co-ordinator (b) rescind the determination of ineligibility made by the placement co-ordinator and refer the matter back to the placement co-ordinator for re-determination in accordance with such directions as the Appeal Board considers proper or

September 2006 16

(c) rescind the determination of ineligibility made by the placement co-ordinator substitute its opinion for the opinion of the placement co-ordinator and direct the placement co-ordinator to determine that the applicant is eligible for admission to a nursing home Decision and reasons s 206(15) The Appeal Board shall render its decision within one day after the end of the hearing and shall provide written reasons to the parties within seven days after rendering the decision Decision to Minister s 206(16) The placement co-ordinator shall furnish the Minister with a copy of the decision and reasons of the Appeal Board After a hearing the HSARB may do one of the following bull affirm the determination of ineligibility bull rescind the determination of ineligibility made by the CCAC and refer the matter back to

the CCAC for re-determination in accordance with the HSARBrsquos directions or bull rescind the determination of ineligibility made by the CCAC substitute its own decision

and direct the CCAC to determine that the applicant is eligible for admission 1034 Appeal to the Divisional Court

Subsection 208(1) of the NHA (see also subsection 913(1) of the CIA and subsection 194(1) of the HARHA) states

Appeal to Divisional Court s 208(1) A party to a review of the determination of ineligibility by the Appeal Board may appeal its decision to the Divisional Court on a question of law or fact or both in accordance with the rules of court Any party to the HSARB appeal may appeal the decision of the HSARB to the Divisional Court on a question of fact or law or both The appellant may raise issues relating to the determination of fact or interpretation of the law or both made by the HSARB Subsection 208(2) of the NHA (see also subsection 913(2) of the CIA and subsection 194(2) of the HARHA) states

Record s 208(2) If a party appeals a decision of the Appeal Board to the Divisional Court under this section the Appeal Board shall promptly file with the Divisional Court the record of the proceeding before the Appeal Board and the transcript of the evidence taken before the Appeal Board which together constitute the record in the appeal Subsection 208(3) of the NHA (see also subsection 913 of the CIA and subsection 194(3) of the HARHA) states

September 2006 17

Minister to be heard s 208(3) The Minister is entitled to be heard by counsel or otherwise on the argument of an appeal under this section Subsection 208(4) of the NHA (see also subsection 1913(4) of the CIA and subsection 194(4) of the HARHA) states

Powers of court on appeal s 208(4) On an appeal under this section the Divisional Court (a) may affirm or rescind the decision of the Appeal Board (b) may refer the matter back to the Appeal Board for rehearing in whole or in part in accordance with such directions as the court considers proper (c) may refer the matter back to the placement co-ordinator for re-determination in accordance with such directions as the court considers proper (d) may substitute its opinion for that of the placement co-ordinator or the Appeal Board and (e) may direct the placement co-ordinator to determine that the applicant is eligible for admission to a nursing home

On an appeal the Divisional Court may do the following bull affirm or rescind the decision of the HSARB bull refer the matter back to the HSARB for rehearing in whole or in part in accordance with the

Divisional Courtrsquos directions bull refer the matter back to the CCAC for re-determination in accordance with the Divisional

Courtrsquos directions bull substitute its opinion for that of the CCAC or the HSARB and bull direct the CCAC to determine that the applicant is eligible for admission Subsection 208(5) of the NHA (see also subsection 913(5) of the CIA and subsection 194(5) of the HARHA) states

Decision to Minister s 208(5) The placement co-ordinator shall furnish the Minister with a copy of the decision and reasons of the Divisional Court

1035 Impact of Appeals on Waiting List Management ndash Date of Ranking

Subsection 150(3) of Regulation 832 under the NHA (see also subsection 81(3) of Regulation 69 under the CIA and subsection 1216(3) of Regulation 637 under the HARHA) states

s 150(3) If a person who was determined by a placement co-ordinator to be ineligible for admission to a nursing home as a long-stay resident is determined to be eligible for admission as a long-stay resident as a result of an application to the Appeal Board under subsection 205 (2) of the Act or an appeal to the Divisional Court under subsection 208 (1) of the Act and if the person then makes an application for authorization of his or her admission to one or more

September 2006 18

nursing homes homes under the Homes for the Aged and Rest Homes Act or approved charitable homes for the aged under the Charitable Institutions Act as a long-stay resident (a) that application for authorization shall for the purposes of Table 5 be deemed to have been made at the time that the placement co-ordinator determined that the person was ineligible for admission and (b) all additional applications for authorization of admission to one or more nursing homes as a long-stay resident made by the person within six weeks after making the first application and before being admitted to one of such facilities shall for the purpose of Table 5 be deemed to have been made at the time that the first application is deemed under clause (a) to have been made If a person who was originally determined by the CCAC to be ineligible for admission is later determined to be eligible as a result of an appeal before the HSARB or Divisional Court and the person applies for authorization of admission the application for authorization is deemed to have been made at the time the CCAC determined the person ineligible In addition all additional applications submitted by the person within six weeks after making the first application for authorization are deemed to have been made at the same time as the original application for authorization The date of the application for authorization has an impact on the ranking of the person within the waiting list category as set out in Table 5 in the NHA regulation at [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90n07_ehtm] Also see

bull Table 4 Ranking of Waiting List Categories (subsection 1281 in this manual) bull Table 5 Rules for Ranking within Categories (subsection 1282 in this manual) bull Table 6 in the CIA regulation at [httpwwwe-

lawsgovoncaDBLawsStatutesEnglish90c09_ehtm ]

CCAC Client Services Policy Manual Chapter 11 Admission to Long-Term Care Homes

September 2006 1

Admission to Long-Term Care Homes

111 Introduction Community Care Access Centres (CCACs) are the designated placement co-ordinators under the Nursing Homes Act (NHA) Charitable Institutions Act (CIA) and Homes for the Aged and Rest Homes Act (HARHA) and are therefore required to comply with the relevant provisions of these statutes and their regulations As placement co-ordinators management of admissions to long-term care (LTC) homes is one of the key functions of the CCAC In some CCACs case managers carry out placement co-ordination while other CCACs have dedicated placement co-ordinators The terms case manager and placement co-ordinator are often used interchangeably in reference to the persons carrying out the placement function The term placement co-ordinator is used throughout this chapter for purposes of consistency This chapter sets out the requirements that the CCAC must adhere to in order to determine a personrsquos eligibility for admission to a LTC home and for those determined eligible authorizing their admission to the LTC home of their choice The requirements for short-stay and long-stay clients are dealt with separately in this chapter (See prioritization criteria and waiting list management in chapter 12 in this manual) All legislative references in this chapter unless stated otherwise are to the NHA and regulation 832 of the NHA However similar provisions can be found in the CIA and HARHA and their regulations It should be noted that the CCAC does not determine eligibility or authorize admissions to group homes rest homes and retirement homes or to acute complex continuing care and psychiatric hospitals

1111 Responsibilities of the CCAC with Respect to LTC Home Admissions

All persons seeking admission to a LTC home must contact the placement co-ordination service (PCS) of the CCAC in the personrsquos area The CCAC through its placement function is responsible for bull determining eligibility for admission to LTC homes

September 2006 2

bull for those persons determined eligible requesting the LTC homersquos approval for admission to the home

bull determining priority for admission and placing all eligible applicants in the appropriate prioritization categories on the waiting lists when beds are not immediately available

bull keeping and managing the waiting lists for admission to LTC homes and bull authorizing admissions to LTC homes If an application is made for a LTC home in another area of the province the local CCAC where the person is living at the time of application is responsible for the determination of eligibility but will transfer the assessment and eligibility information to the out-of-area CCAC where the LTC home is located In this situation the two CCACs co-ordinate their activities and the local CCAC acts as liaison with the person When a person requests admission to a LTC home the CCAC will conduct an interview with the applicant or if the applicant is incapable of making the admission decision with his or her authorized substitute decision-maker (SDM) Here the CCAC will explain the assessment and admission processes and will gather information to determine the applicantrsquos needs and whether the needs can be met through CCAC in-home services or community services or whether the applicant requires LTC home admission The CCAC must have detailed information about the LTC homes publicly-funded community services retirement homes and other alternative services in its area The information for each home should include programming available unique features in-house staffing number of beds and compliance with standards policies criteria regulations and legislation This information is necessary because the placement co-ordinator must consider the following

bull whether the personrsquos care requirements can be met in a LTC home (rather than in the

personrsquos home or in the community) bull the personrsquos care expectations and personal preferences and bull the personrsquos ethnic spiritual linguistic familial and cultural preferences The placement co-ordinator must also assess the personrsquos ability to understand the service options that are available and appropriate to address the personrsquos needs and assist the person or if the person is incapable of making the admission decision the SDMrsquos ability to access these services

1112 History PCSs were initially pilot tested in Ontario in the1970s In 1993 the Long-Term Care Statute Law Amendment Act 1993 (LTCSLAA) made amendments to the NHA CIA and HARHA These amendments enabled the Ministry of Health and Long-Term Care (MOHLTC) to designate one or more persons classes of persons or other entities as placement co-ordinators By 1994 PCSs were fully implemented across the province Between 1996 and 1998 PCSs and Home Care Programs were consolidated to form the new CCACs with the purpose of providing simplified access for persons seeking in-home services or placement in LTC homes

September 2006 3

This manual supersedes the previous Placement Coordination Services Manual issued in 1994 and its subsequent updates Further information about MOHLTC policies with respect to LTC homes can be found in the Long-Term Care Facilities Program Manual 1993 Revisions 1995 1998 available from the MOHLTC Long-Term Care Homes Branch or any regional office of MOHLTC

September 2006 4

112 Eligibility Criteria 1121 Eligibility Criteria for Long-Stay Applicants

Section 130 of the Nursing Homes Act (NHA) regulation outlines eligibility criteria for a person seeking long-stay placement in a long-term care (LTC) home

s 130(1) An applicant shall be determined to be eligible for admission to a nursing home if and only if (a) the applicant is at least 18 years old (b) the applicant is an insured person under the Health Insurance Act (c) the applicant meets at least one of the conditions set out in subsection (2) (d) the applicant meets at least one of the conditions set out in subsection (3) and (e) the applicants care requirements can be met in a nursing home (2) The following are the conditions referred to in clause (1) (c) 1 The applicant requires that nursing care be available on-site 24 hours a day 2 The applicant requires assistance each day with activities of daily living 3 The applicant requires at frequent intervals throughout the day on-site supervision or on-site monitoring to ensure his or her safety or well-being 4 The applicant is at risk of being financially emotionally or physically harmed if the applicant lives in his or her residence 5 The applicant is at risk of suffering harm due to environmental conditions that cannot be resolved if the applicant lives in his or her residence 6 The applicant may harm someone if the applicant lives in his or her residence (3) The following are the conditions referred to in clause (1) (d) 1 None of the publicly-funded community-based services available to the applicant while the applicant lives in his or her residence and none of the other caregiving support or companionship arrangements available to the applicant while the applicant lives in his or her residence are sufficient in any combination to meet the applicants requirements 2 None of the publicly-funded community-based services available to the applicant in the area to which the applicant plans to move and none of the other caregiving support or companionship arrangements available to the applicant in the area to which the applicant plans to move are sufficient in any combination to meet the applicants requirements (4) Revoked O Reg 12102 s 7 (5) Revoked O Reg 12102 s 7 (6) This section does not apply to an applicant who is applying for a determination respecting his or her eligibility for admission to a nursing home as a short-stay resident in the respite care or supportive care program

1122 Discussion of the Eligibility Criteria for Long-Stay Applicants

As indicated in the regulatory provisions of the NHA referenced above the criteria for determining an applicantrsquos eligibility for admission to a LTC home are

September 2006 5

1 the applicant must be at least 18 years old 2 the applicant must be an insured person under the Health Insurance Act (HIA) 3 the applicant must meet at least one of the following criteria

bull requires nursing care be available on-site 24 hours a day bull requires assistance each day with activities of daily living bull requires at frequent intervals throughout the day on-site supervision and monitoring to

ensure his or her safety or well-being bull at risk of being financially emotionally or physically harmed if the applicant lives in his

or her residence bull at risk of suffering harm due to environmental conditions that cannot be resolved if the

applicant lives in his or her residence or bull applicant may harm someone if the applicant lives in his or her residence

4 publicly-funded community-based services available to the applicant and caregiving support or companionship arrangements available where the applicant lives or intends to live are insufficient to meet the applicantrsquos requirements and

5 applicantrsquos care requirements can be met in a LTC home For greater clarity additional information and discussion of each of these requirements is provided below 1 The applicant is at least 18 years old

Persons under the age of 18 years cannot be admitted to LTC homes on either a short or long-term basis Persons aged 18 years and over may be served in a LTC home Of course all community-based service options should be explored with all applicants Some younger persons may prefer community-based services over placement in a LTC home as the majority of persons who seek admission to LTC homes are seniors

2 The applicant is an insured person under the HIA

The Community Care Access Centre (CCAC) must ensure that the applicant has valid Ontario Health Insurance Plan (OHIP) coverage (For additional information on OHIP coverage see chapter 3 in this manual)

3 The applicant meets at least one of the following criteria

s 130(2)1 The applicant requires that nursing care be available on-site 24 hours a day

People seeking admission to LTC homes should not require the constant presence of registered nursing staff this level of care is only available in a hospital However the applicant who requires frequent intervention and monitoring of a condition by a nurse throughout the day which would be difficult to provide in a community-based setting would meet this criterion

s 130(2)2 The applicant requires assistance each day with activities of daily living

September 2006 6

The applicant requires assistance with some or all of the following activities each day that would be difficult to provide in a community-based setting These activities include but are not limited to the following

bull washingbathingshoweringbed bath bull mouth care bull hair care bull preventive skin care bull routine handfoot care bull menstrual care bull transferringpositioningturning bull exercises (rehabilitationambulation) bull dressingundressing bull assistance with eating bull toileting (including emptychange leg bag catheterization) bull bowel routines bull assistance with taking pre-measured medications bull changing non-sterile dressings and bull care and maintenance of equipment

In addition an applicant who is of such frailty that he or she requires ongoing assistance with a number of activities of daily living such as meal preparation ordinary housework managing finances managing medications and shopping on a daily basis may be in need of admission to a LTC home

s 130(2)3 The applicant requires at frequent intervals throughout the day on-site supervision and monitoring to ensure his or her safety or well-being

The need for a supervised safe physical environment is the reason for admission in this case as opposed to the applicantrsquos need for nursing or personal care The applicant requires frequent monitoring or on-site supervision to ensure his or her safety and well-being throughout the day For example a secure setting may be required to prevent wandering or for applicants who experience considerable agitation and distress living in an environment where they would be alone for long periods of time

s 130(2)4 The applicant is at risk of being financially emotionally or physically harmed if the applicant lives in his her residence

There is reason to believe that the applicant is at risk of harm or abuse if he or she is left in his or her existing living situation In the case of abuse it could be physical psychological

September 2006 7

or emotional financial abuse or exploitation sexual abuse medication abuse violation of civilhuman rights or neglectself-neglect1 Another example of where an individual may be at risk for financial or emotional harm occasionally occurs when a person is left on his or her own as a result of his or her spousersquospartnerrsquos admission to a LTC care home

s 130(2)5 The applicant is at risk of suffering harm due to environmental conditions that cannot be resolved if the applicant lives in his or her residence

The applicant may be living in a home that is no longer fit for habitation or living in a remote area where there are limited health and community services to assist the applicant to remain in his or her current setting

s 130(2)6 The applicant may harm someone if the applicant lives in his or her residence

Family members caregivers or neighbours may be at risk if the applicant is prone to assaultive behaviour because of an illness or a cognitive impairment

4 The community-based services caregiving support or companionship arrangements

available where the applicant lives or intends to live are insufficient to meet the applicantrsquos requirements

s 130(1)(d) The applicant meets at least one of the conditions set out in subsection (3) (3) 1 None of the publicly funded community-based services available to the applicant while the applicant lives in his or her residence and none of the other caregiving support or companionship arrangements available to the applicant while the applicant lives in his or her residence are sufficient in any combination to meet the applicantrsquos requirements 2 None of the publicly-funded community-based services available to the applicant in the area to which the applicant plans to move and none of the other caregiving support or companionship arrangements available to the applicant in the area to which the applicant plans to move are sufficient in any combination to meet the applicantrsquos requirements

If the applicantrsquos needs can be met through the community-based services described above the applicant is not eligible for admission to a LTC home The CCAC may declare an applicant ineligible if the CCAC placement co-ordinator believes that the community-based services the applicant is receiving or could receive are adequate to meet his or her needs The CCAC may not however declare an applicant ineligible on the grounds that the applicant has the financial resources to live in a retirement home or to make private care arrangements that exceed the amount of service available through publicly-funded or voluntary community-based services

1 British Columbia Coalition to Eliminate Abuse of Seniors Fact Sheet 1

September 2006 8

If an applicant refuses to accept community-based services that have been determined by the CCAC to be available and appropriate to meet the applicantrsquos needs the applicant is not eligible for LTC home admission

5 The applicantrsquos care requirements can be met in a LTC home

The CCAC must ensure that the applicantrsquos assessed care needs bull may be reasonably met within the LTC home bull are within the scope of what a LTC home provides or bull can be provided by a LTC home with the support and assistance of other institutional or

home resources in the community

1123 Determination of Ineligibility

Pursuant to LTC home legislation if an applicant is determined ineligible for admission to a LTC home the CCAC must provide the applicant and the person if any who applied for the determination on behalf of the applicant with written notice outlining

s 205(1)the determination of ineligibility the reasons for the determination and the applicantrsquos right to apply to the Health Services Appeal and Review Board (Appeal Board) for a review of the determination

The CCAC should advise applicants to contact the CCAC for a re-determination of eligibility should their condition or circumstances change If the applicant is a hospital inpatient the CCAC may advise the hospital of the CCACrsquos determination of ineligibility subject to the provisions of the Personal Health Information Protection Act 2004 (PHIPA)

1124 Other Alternatives

Subsection 201(16) of the NHA provides that the CCAC placement co-ordinator must suggest alternative services or make appropriate referrals on behalf of an applicant if it is determined that the applicant is either not eligible for admission to a LTC home or is determined eligible for admission to a LTC home but not authorized for immediate admission

1125 SpousalPartner Accompaniment by a ldquoWell SpousePartnerrdquo

A spousepartner who does not have care requirements of his or her own but who wishes to enter a LTC home to be with his or her spousepartner who has been determined eligible as a result of care needs or who is already residing in a LTC home may be admitted to a LTC home as long as he or she meets the following criteria

September 2006 9

s 132 Despite section 130 an applicant shall be determined to be eligible for admission to a nursing home as a long-stay resident if (a) the applicants spouse or partner is

(i) a long-stay resident or (ii) a person who has been determined by a placement co-ordinator to be eligible for admission to a nursing home as a long-stay resident

(b) the applicant is at least 18 years old (c) the applicant is an insured person under the Health Insurance Act and (d) the applicants care requirements can be met in a nursing home

bull The term spouse is defined in subsection 1(1) of the NHA regulation as

s 1(2) a person (a) to whom the person is married or (b) with whom the person is living or was living immediately before one of them was admitted to a nursing home in a conjugal relationship outside marriage if the two persons

bull The term partners is defined in subsection 1(2) of the NHA regulation as s 1(2) Two persons are partners for the purpose of this Regulation if they have lived together for at least one year and have a close personal relationship that is of primary importance in both persons lives

bull A spousepartner entering a LTC home to join his or her spousepartner must provide the same assessment and personal information required for any applicant

bull An accompanying spousepartner who is admitted to a LTC home may continue to reside in the LTC home after the death of his or her spousepartner even if the surviving person does not require LTC home services The rationale for allowing this person to remain in the home is that the survivor is unlikely to have a home in the community to which he or she can return

bull If the spousepartner in the LTC home dies while the accompanying person is on a waiting list the CCAC must reassess the eligibility of the person If the person does not meet the eligibility criteria for admission set out in section 130(1) of the NHA regulation the person must be removed from the waiting list The CCAC should explain this situation to prospective applicants who wish to join a spousepartner in a LTC home and are not eligible for home admission on the basis of their own care and support requirements

bull If there is a strong indication that a well spousepartner will want to accompany his or her spousepartner into a LTC home the CCAC should strongly encourage the well spousepartner to apply for admission at the same time as his or her spousepartner This will ensure the earliest possible date for ranking of the well spouse within prioritization category 2 of the waiting list (The spouse with the care needs will receive higher prioritization in category 1A1 See subsection 123 in this manual for additional information on prioritization criteria in category 1A1)

September 2006 10

1126 Eligibility of Individuals Already Resident in a LTC Home

Section 133 of the NHA regulation exempts existing residents of LTC homes from a re-determination of their eligibility for admission to another LTC home by stating

s 133 Despite section 130 the following applicants shall be determined to be eligible for admission to a nursing home as long-stay residents 1 A long-stay resident requesting a transfer to another nursing home as a long-stay resident 2 A long-stay resident under the Homes for the Aged and Rest Homes Act or the Charitable Institutions Act requesting a transfer to a nursing home as a long-stay resident Note This exemption extends only to the eligibility requirements in section 130 of the NHA regulation It does not exempt the CCAC from obtaining an applicantrsquos consent for admission to another LTC home which is required for authorization of admission The requirement for consent is contained in subsection 201(13) of the NHA (See subsection 114 in this manual for additional information on the requirement for consent) Although the eligibility for admission of a person who is seeking a transfer to another LTC home cannot be re-determined there may be situations where a transfer is being requested because the personrsquos needs can no longer be met in a LTC home In these cases it is imperative that the LTC homes to which the person is seeking a transfer receive comprehensive and up-to-date information about the personrsquos condition including physical and mental health functional status and behaviours in order to determine whether to grant or refuse admission In some instances new assessments may be appropriate when an applicant is transferring from one home to another

1127 Eligibility of Veterans

With the exception of the requirement that they be an insured person under the HIA veterans are also exempt from the eligibility criteria set out in section 130 of the NHA regulation Section 1331 provides for the eligibility of veterans as follows

s 1331 Despite section 130 an applicant who is a veteran shall be determined eligible for admission to a nursing home as a long-stay resident if the applicant is an insured person under the Health Insurance Act

September 2006 11

113 Application Process for Long-Stay Eligibility

Determination

Section 134 of the Nursing Homes Act (NHA) regulation sets out the application process for a determination of eligibility

s 134(1) To apply for a determination respecting his or her eligibility for admission to a nursing home a person shall establish that he or she is at least 18 years old and shall provide to a placement co-ordinator (a) a request by the person for a determination of his or her eligibility in the form provided by the Minister (b) proof that the person is an insured person under the Health Insurance Act (c) an up-to-date health assessment of the person in the form provided by the Minister signed by

(i) a member of the College of Physicians and Surgeons of Ontario or (ii) a registered nurse who holds a general certificate of registration or an extended certificate of registration in accordance with the regulations made under the Nursing Act 1991

(d) an up-to-date functional assessment of the person conducted by a health or social service provider approved by the placement co-ordinator and (e) such additional information and documentation as is necessary to enable the placement co-ordinator to determine whether the person meets the eligibility requirements set out in this Regulation

(11) Despite subsection (1) a veteran who wishes to apply for a determination of his or her eligibility for admission to a nursing home is not required to establish that he or she is 18 years old or to provide his or her request for a determination respecting his or her eligibility in the form provided by the Minister (2) Despite subsection (1) the following persons are not required to establish that they are at least 18 years old and are not required to comply with clauses (1) (b) (c) and (d)

1 A long-stay resident applying for a determination of eligibility for the purpose of transferring to another nursing home as a long-stay resident 2 A long-stay resident under the Homes for the Aged and Rest Homes Act or the Charitable Institutions Act applying for a determination of eligibility for the purpose of transferring to a nursing home as a long-stay resident

(3) Despite subsection (1) a person described in a paragraph of subsection (2) who is applying for a determination of eligibility for the purpose of transferring to a related temporary nursing home a re-opened nursing home or a replacement nursing home as a long-stay resident is not required to provide his or her request for a determination respecting his or her eligibility in the form provided by the Minister if he or she is a long-stay resident of the original nursing home or was a long-stay resident of the original nursing home immediately before the closure of his or her bed in the home

September 2006 12

(4) If a person applying for a determination of eligibility is going to be placed in category 1A under section 143 the person is not required to comply with clauses (1) (c) and (d) if there is insufficient time to comply with them (5) The placement co-ordinator shall assist the person in obtaining the information and documentation that the person is required to provide to the placement co-ordinator under this section

1131 Discussion of the Application Process for Determination of Eligibility

The application process begins when a person requests admission to a long-term care (LTC) home The placement co-ordinator conducts an interview with the applicant or if the applicant is incapable of the admission decision with his or her authorized substitute decision-maker (SDM) (For information on identifying the SDM see subsection 453 in this manual) In the interview the placement co-ordinator will explain the assessment and admission processes and will gather information to determine the applicantrsquos needs whether the needs can be met through Community Care Access Centre (CCAC) in-home services or community services If the clientrsquos needs cannot be met by in-home services or community services then the assessment continues to determine whether the clientrsquos needs can be met by LTC home services The placement co-ordinator will review the following information with the applicant or the SDM bull the criteria for determining eligibility bull the type of information that is collected during the eligibility determination process

including personal information bull the process for admission to a LTC home which includes authorizing admission to a LTC

home and the LTC homersquos ability to withhold approval for the personrsquos admission under certain circumstances (ie the home lacks the physical facilities or nursing expertise necessary to meet the personrsquos care requirements)

bull the process for determining a personrsquos priority for admission and what the waiting list involves

bull the personrsquos rights to appeal any determination of being incapable of making an admission decision and the right to appeal a determination of ineligibility for admission to a LTC home and

bull resident charges in a LTC home If the person agrees to proceed with the determination of eligibility the placement co-ordinator works with the person andor the personrsquos SDM in obtaining the information and documentation required by the regulation under subsection 134(5) of the NHA In all cases the outcome of this interview must be documented and retained for future reference

September 2006 13

Establishing that an Applicant is at Least 18 Years Old Subsection 134(1) of the NHA provides that to apply for admission to a LTC home a person must establish that he or she is at least 18 years old Since many individuals seeking admission to LTC homes are seniors specific verification of age through the provision of identification that includes a date of birth is generally not required If a situation arises where a placement co-ordinator is in doubt that a prospective applicant is at least 18 years old the placement co-ordinator must request proof of age This proof could include a birth certificate passport or any other government identification that provides date of birth Exemptions Under subsections 134 (11) (2) and (3) of the NHA regulation veterans and persons already resident in a LTC home who are transferring to another LTC home are not required to establish that they are at least 18 years old (For long-stay residents of a LTC home applying for a determination of eligibility in order to transfer to a related temporary re-opened or replacement LTC home see ldquoStreamlined Admission Processrdquo in subsection 1273 in this manual) A Written Request for Determination of Eligibility for Admission to a LTC Home A further requirement in subsection 134(1)(a) of the NHA is the provision of a written request for determination of eligibility for admission to a LTC home which is contained in the Ministry of Health and Long-Term Care (MOHLTC) consent form Consent for Placement Coordination Services to Collect Keep on File and Release Information form (014-2747-69) available at [httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailOpenFormampACT=RDRampTAB=PROFILEampENV=WWEampNO=014-2747-69] When completed and signed this form provides the written request for eligibility determination Exemptions bull Under subsections 134 (11) and (3) of the NHA regulation veterans and long-stay

residents of a LTC home applying for a determination of eligibility in order to transfer to a related temporary re-opened or replacement nursing home are not required to provide their requests for eligibility determination in the form provided by the MOHLTC (In the latter case see ldquoStreamlined Admission Processrdquo in subsection 1273 in this manual)

bull This does not mean that these applicants are exempt from making the request but rather that the request does not have to be in the form provided by the MOHLTC (ie the request can take another form such as an oral request)

September 2006 14

Proof that the Person is an Insured Person Under the Health Insurance Act A person seeking admission to a LTC home must provide proof that he or she is an insured person under the HIA The CCAC must ensure that the applicantrsquos Ontario Health Insurance Plan (OHIP) coverage is valid by verifying coverage through the OHIP validation systems (For information on the verification process see subsection 32 in this manual) Exemptions bull Under subsections 134(2) and (3) of the NHA regulation persons who are already residents

in a LTC home who are transferring to another LTC home are not required to provide proof of OHIP coverage (For long-stay residents of a LTC home applying for a determination of eligibility in order to transfer to a related temporary re-opened or replacement LTC home see ldquoStreamlined Admission Processrdquo in subsection 1273 in this manual)

bull Also see ldquoResidency Requirements for OHIP Coveragerdquo in subsection 33 in this manual Up-to-date Health and Functional Assessments A further requirement for a determination of eligibility for LTC home admission is the provision of an up-to-date health assessment and an up-to-date functional assessment of the applicant in all cases including crisis situations

Purpose of Assessments

The purpose of the assessments is to

bull identify and evaluate the personrsquos needs strengths and preferences bull identify potential risks bull determine the personrsquos eligibility and bull determine the most appropriate level of care to address the personrsquos requirements

Health Assessment

An up-to-date health assessment of the person is required in all cases including crisis situations The information for the health assessment is provided in the MOHLTC Health Report form (014-2734-69) which is available at [httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailOpenFormampACT=RDRampTAB=PROFILEampENV=WWEampNO=014-2734-69] This form seeks information about the personrsquos medical diagnosis health history special needs treatment and medication requirements The form must be signed by a member of the College of Physicians and Surgeons of Ontario or a registered nurse who holds a general certificate of registration or an extended certificate of registration as required by section 134(1)(c) of the NHA regulation

September 2006 15

Applicants cannot be charged for completion of this form by a physician if the completion of the form is a common element of an insured service provided by the physician (under the OHIP Schedule of Benefits)

Functional Assessment

Under subsection 134(1)(d) of the NHA regulation an up-to-date functional assessment carried out by a health or social services provider approved by the CCAC is required in all cases including crisis situations Since March 2004 functional assessments are carried out using the Resident Assessment Instrument-Home Care (RAI-HC) assessment tool the use of which the MOHLTC has mandated In the past functional assessments were frequently contracted out to hospitals and service providers however since the introduction of the RAI-HC in all CCACs these assessments are now carried out almost exclusively by CCAC case managers or placement co-ordinators who are either healthcare or social work professionals This assessment has become an activity internal to the CCAC as a result of the proficiency requirements associated with the assessment tool However there is nothing to preclude the CCAC from contracting out the provision of this assessment so long as the health or social service providers they select are and remain proficient in the use of the RAI-HC Note Subsection 134(1)(d) of the NHA regulation provides that although the functional assessment that contributes to the eligibility determination may be delegated to a health or social services professional in the employ of a service provider or service agency an applicantrsquos eligibility for admission to a LTC home shall be determined only by the CCAC as provided by subsection 201(9) of the NHA The RAI-HC provides for a standardized assessment process and terminology that is applicable throughout the province Standardized assessments ensure greater consistency in outcomes based on data collected from applicants It also ensures LTC homes throughout the province receive the same type of reports and information for consideration when deciding on admission of an applicant The RAI-HC assessment tool consists of the Minimum Data Set for Home Care (MDS-HC) and Client Assessment Protocols The MDS-HC is the screening component that enables a home care provider to assess multiple key areas of a clientrsquos function health social support and service use The RAI-HC report function known as the Personal Health Profile provides a standard summary document of the information generated by the RAI-HC tool that homes use to help decide whether to approve an application for admission Exemptions bull Under subsections 134(2) and (3) of the NHA regulation persons who are already long-

stay residents in a LTC home who are transferring to another LTC home are exempt from the requirements for an up-to-date health assessment and up-to-date functional assessment (For long-stay residents of a LTC home applying for a determination of

September 2006 16

eligibility in order to transfer to a related temporary re-opened or replacement nursing home see ldquoStreamlined Admission Processrdquo in subsection 1273 in this manual)

bull Additionally under subsection 134(4) of the NHA regulation applicants who are going to be placed in category 1A (crisis) of the waiting lists of their chosen LTC homes are not required to provide up-to-date health and functional assessments at this point of the admissions process if there is insufficient time to comply with these requirements

Any Additional Information Necessary for the CCAC to Determine Whether the Person Meets the Eligibility Requirements Set Out in the Regulations Additional information and documentation may be requested if required to enable the placement co-ordinator to determine whether an applicant meets the eligibility requirements in the regulations

September 2006 17

114 Consents Required for Long-Stay Placement 1141 Consent for Admission

People cannot be forced to go into a long-term care (LTC) home or to choose specific homes The Nursing Homes Act (NHA) states Applications to placement co-ordinator s 201(6) A person may apply for a determination by a placement co-ordinator respecting the personrsquos eligibility for admission to a nursing home and for authorization of admission with respect to such nursing home or homes as the person selects Conditions of authorization s 201(13) The placement co-ordinator designated for a nursing home under subsection (3) may authorize the admission of a person to the nursing home only if (a) the placement co-ordinator or another placement co-ordinator has determined within the six months preceding authorization that the person is eligible for admission to a nursing home (b) the licensee of the nursing home to which the personrsquos admission is to be authorized approves the personrsquos admission to the nursing home and (c) the person consents to being admitted to the nursing home While applicants can be encouraged they cannot be required to choose a specific number of LTC homes or homes with short waiting lists In addition they cannot be required to accept a first available bed that is not one of the personrsquos choices These consumer rights have been a well-established part of the placement co-ordination system since 1993 In addition the Health Care Consent Act 1996 (HCCA) sets out a comprehensive scheme for obtaining substitute decisions on behalf of persons who are incapable of making the decision about admission to a LTC home (For information on the provisions of the HCCA concerning consent to admission to a LTC home on behalf of an incapable person see chapter 4 in this manual)

1142 Consent to Release Personal Information 2

LTC home legislation also requires the placement co-ordinator to obtain a personrsquos consent to share information with the LTC home to which a person is to be admitted The NHA states Information to licensee s 202(1) A placement co-ordinator who authorizes a personrsquos admission to a nursing home shall give to the licensee of the nursing home the information mentioned in a paragraph of subsection (2) if

2 CCACs are health information custodians under the Personal Health Information Protection Act 2004 (PHIPA)

September 2006 18

(a) the placement co-ordinator has the information mentioned in the paragraph and (b) consent to the disclosure of the information to the licensee is given by

(i) the person whose admission is authorized or (ii) the person if any who was lawfully authorized to consent to admission to the nursing home on behalf of the person whose admission is authorized

Same s 202(2) The information referred to in subsection (1) is the following 1 Information about assessments of the person whose admission is authorized 2 Information about the personrsquos medical history 3 Information about the personrsquos social and other care requirements 4 The name and address of the person if any who was lawfully authorized to consent to admission to the nursing home on behalf of the person whose admission is authorized

Further requirements under the Personal Health Information Protection Act 2004 (PHIPA) impose additional obligations on the Community Care Access Centre (CCAC) regarding the maintenance of confidentiality of clientsrsquo personal health information and the sharing of such information Personal information gathered by the CCAC must be kept confidential The CCAC must obtain the consent of the applicant or the applicantrsquos substitute decision-maker (SDM) to collect use and disclose information In some instances PHIPA permits the CCAC to release information without consent The Ministry of Health and Long-Term Care (MOHLTC) form Consent for Placement Coordination Services to Collect Keep on File and Release Information form (014-2747-69) is used to obtain client consent for a number of purposes as described below The placement co-ordinator is responsible for discussing the contents of the form with the applicant and having the form signed and dated by the applicant or the applicantrsquos SDM before proceeding with the application process The Consent for Placement Coordination Services to Collect Keep on File and Release Information form (014-2747-69) is available at [httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailOpenFormampACT=RDRampTAB=PROFILEampENV=WWEampNO=014-2747-69]

1143 Types of Consent

Different situations require different types of consents to be given by the person or his or her SDM if the person is incapable The types of consent are outlined below

bull Consent for the CCAC to request and collect personal information including personal

information about the applicant from other organizations

Such personal information could include assessments by the applicantrsquos physicians community-based service providers or informal caregivers These assessments may provide

September 2006 19

information that is necessary to determine the personrsquos eligibility for admission to a LTC home

bull Consent for the CCAC to disclose personal information about an individual to another

Consent is required to share information with another CCAC when an individual wants to reside in a LTC home outside the catchment area of the CCAC The person must give consent to the CCAC that will undertake the eligibility determination to disclose personal information to the CCAC that will authorize the personrsquos admission to the LTC home in another area

bull Consent for the CCAC to disclose personal information to the LTC home(s) to which

the person has applied for admission

Information about the applicantrsquos medical history social health and functional status enables the LTC home to determine whether the home can meet the applicantrsquos care requirements

bull Consent for the CCAC to send information to the LTC homes to which a resident of a

LTC home wishes to transfer

Before transferring a person from one LTC home to another information from the sending LTC home must be sent by the CCAC to the receiving LTC home to obtain the approval of the receiving LTC home to admit the person

September 2006 20

If an applicant is declared eligible for admission to a long-term care (LTC) home the process continues with the selection of the personrsquos preferred LTC home(s) The person has the right to choose the LTC home in which he or she will seek to reside In order for the applicant to make an informed choice the applicant needs information about the homes

1151 General Information About Homes

The Community Care Access Centre (CCAC) can assist a person to make choices about a LTC home by providing information about the services and programs provided by a LTC home including whether the home has indoor smoking facilities (see 1161 below in this manual) and answering any questions he or she may have about possible choices The CCAC must inform the person about home waiting lists so he or she knows how long the wait may be for a specific LTC home The CCAC may also provide information to persons regarding the performance of the LTC home but should not attempt to influence the personrsquos decision The CCAC may share the following information with persons interested in different LTC homes

bull results of the Ministry of Health and Long-Term Care (MOHLTC) inspection of the LTC

home and bull corrective action plans if any that have been identified as part of the inspection

CCACs can also refer applicants to the public reporting website so applicants can review this information themselves (although the CCAC may have a more up-to-date inspection report than is posted on the website) Applicants should be advised if a LTC home has failed to take corrective actions and where sanctions have been applied If the applicant has additional questions he or she should be referred to staff of the MOHLTC regional office The CCAC is also required to maintain up-to-date information with a description of services and programs offered in each LTC home and inform applicants about those services

1152 Information About Accommodation Rates

The CCAC should provide the following information to persons who are considering choices of LTC homes

bull the accommodation charges that are required to be paid by the resident bull the premium for preferred accommodation

September 2006 21

bull that the applicant will be asked by the LTC home to which he or she is admitted to sign an agreement regarding payment of accommodation charges even though the legal requirement for payment is set out in the LTC homes legislation

bull the services for which the LTC home is responsible and cannot charge residents and any services the home may make available for which it does charge

bull income testing procedures for rate reduction (see subsection 1153 in this manual) and bull reasons for and costs associated with ldquobed holdingrdquo

1153 Information About Rate Reduction

Under subsection 116(1) of the Nursing Homes Act (NHA) regulation rate reduction is only available to long-stay residents in basic accommodation It is available when a person is unable to pay the full amount of the accommodation fees as a result of limited income A rate reduction is not available to residents contracting for preferred accommodation If a person applies for a rate reduction income testing will be undertaken by the LTC home at the time the person is admitted (or later if the application for rate reduction is made at a later time) A person applying for a rate reduction must provide a copy of their Notice of Assessment from the Canada Revenue Agency as proof of income for the immediately preceding year Under subsection 116(2) of the NHA regulation if the person is not required to file an income tax return with the Canada Revenue Agency alternative documentation provided by an independent third party may be accepted to prove income for the immediately preceding year (eg a confirmation letter from the Income Security Branch of Human Resources Development Canada or from the applicable social assistance program of the Ministry of Community and Social Services (MCSS)) For a description of the entire process for making an application for a reduction in the basic accommodation rate refer to section 116 of the NHA regulation

1154 Additional Rate Reduction in Basic LTC Home Accommodation Fees ndash Exceptional Circumstances Application

Effective July 1 1995 the regulations under the LTC home legislation were amended to allow residents living in long-stay basic accommodation to apply for an additional reduction to the basic accommodation rate in exceptional circumstances Section 1161 of the NHA regulation sets out the requirements related to this additional rate reduction

s 1161(1) An application may be made to the Director for a reduction in the fee payable by any of the following persons for basic accommodation 1 A long-stay resident for whom the maximum monthly amount is determined to be $96316 under section 116 2 A long-stay resident whose spouse lives outside a nursing home a home under the Homes for the Aged and Rest Homes Act an approved charitable home for the aged under the Charitable Institutions Act or a hospital or other facility that is government-funded

September 2006 22

Under subsection 1161(4) of the NHA regulation these applications are not processed by the LTC home but by the MOHLTC directly (ie the ldquoDirectorrdquo under the LTC homes legislation) Therefore when a rate reduction is sought under one of these two circumstances the application must be filed with the MOHLTC regional office for processing An application may only be filed under one of the above referenced circumstances even when both circumstances apply An application under the second circumstance referred to above may be made by either the resident or the residentrsquos spouse The exceptional circumstances application requires residents to provide proof of income for the immediately preceding year In the case of an application under the second circumstance proof of the income of the spouse of the resident for the immediately preceding year is also required Applicants may be requested to provide an explanation of any decrease in their current income from their previous yearrsquos income An applicant who has had a government benefit entitlement supplement or other financial assistance reduced due to income received or deemed received during the previous year would in most cases not qualify for the exceptional circumstances rate reduction MOHLTC regional offices will provide additional information upon request

1155 Visits to Homes

When circumstances allow the applicant or substitute decision-maker (SDM) andor family members should be encouraged to visit the LTC homes in which they have expressed interest before they provide the CCAC with their LTC home choices The visit to the LTC home provides an opportunity to assess the appropriateness of the LTC homersquos services and amenities and to pose questions to LTC home staff The CCAC is responsible for advising the applicant that when he or she visits the LTC home the applicant may request to see the following government documents or reports

bull the Residentsrsquo Bill of Rights along with information on the procedures for making

complaints about the maintenance or operation of the home the conduct of the staff of the home or the treatment or care received by a resident in the home

bull a copy of the service agreement between the LTC home and the MOHLTC bull a copy of the most recent inspection report relating to the LTC home (MOHLTC

inspections are conducted annually and the report should be dated within 12 months of the date of the visit) and

bull copies of the most recent year-end report and most recent auditorrsquos report for the home

LTC homes legislation requires these documentsreports to be posted in the LTC home or provided by written notice to each resident (or if the resident is incapable to the SDM)

September 2006 23

1156 Classes of Accommodation

Section 155 of the NHA regulation sets out the classes of accommodation for which an applicant may apply and be waitlisted

s 155(1) Subject to section 156 the placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act shall authorize the admission of a person to the home if and only if hellip (c) the home has available the class of accommodation for which the person is recorded to be waiting (d) there is no one on the waiting list for the home who is recorded to be waiting for the class of accommodation that is available who ranks ahead of the person and whose admission may be authorized under this section hellip

(2) For the purposes of clauses (1) (c) and (d) the following are the classes of accommodation for which a person may be recorded to be waiting 1 Accommodation for a woman in a respite care or supportive care program 2 Accommodation for a man in a respite care or supportive care program 3 Basic accommodation for a woman other than in a respite care or supportive care program 4 Basic accommodation for a man other than in a respite care or supportive care program 5 Semi-private accommodation for a woman other than in a respite care or supportive care program 6 Semi-private accommodation for a man other than in a respite care or supportive care program 7 Private accommodation for a woman other than in a respite care or supportive care program 8 Private accommodation for a man other than in a respite care or supportive care program

1157 Number of Home Choices

LTC home legislation allows a person to apply to as many LTC homes as he or she wishes However subject to two exceptions the regulations under LTC care home legislation restrict to three the number of ldquoapproval requestsrdquo that the CCAC can send at any one time to LTC home operators and the number of waiting lists upon which a CCAC may place a person at any one time Under subsection 1371(3) of the NHA regulation the two exceptions are persons who will be placed in category 1A (crisis) or the short-stay category on the waiting list for a LTC home An applicant has the right to have applications sent to three LTC homes in the same CCAC area or three LTC homes in different areas of the province or a combination of both as long as only three or less are issued and outstanding at any given point in time The applicant also has the right to select only one or two LTC homes if that is all the person is prepared to consider Once an applicant has made his or her choice(s) the CCAC will send up to a maximum of three approval requests to the LTC homes If the maximum of three requests is sent they must be the

September 2006 24

applicantrsquos top three choices If the applicant is approved by the three LTC home operators the CCAC must place the applicant on the waiting lists for these three LTC homes If any of the applications are refused by one or more of the LTC homes selected the CCAC may send a request to another LTC home selected by the applicant (or SDM) Under subsections 1371(1) and (2) of the NHA regulation the ldquothree LTC homerdquo rule which took effect on May 1 2002 applies to approval requests sent to LTC home operators and waiting lists for all applicants (both hospital and community-based) with the exception of those who are ranked in category 1A (crisis) and those who are applying for short-stay programs Under subsection 1371(3) persons who are ranked in category 1A (crisis) or applying for short-stay programs may apply to an unlimited number of homes Under subsections 1371(1) and (2) applicants who were placed on more than three waiting lists prior to May 1 2002 who are still awaiting placement may remain on the lists However a CCAC cannot send any approval requests or place the applicant on any additional waiting lists unless the applicant agrees to remove his or her name from other waiting lists so that the total number of waiting lists on which the person is placed does not exceed three Applicants should be encouraged to examine a range of potential LTC homes and should have their names placed only on the waiting lists of those LTC homes that they are prepared to accept

September 2006 25

116 Request for Approval of Admission and Response from the

LTC Home 1161 Application for Authorization of Admission

Once the applicant has been determined eligible for admission and made his or her selection(s) of long-term care (LTC) home(s) the applicant must apply for authorization of admission The Community Care Access Centre (CCAC) is obliged to assist applicants with the completion of the application Sections 135 and 136 of the Nursing Homes Act (NHA) regulation set out the requirements related to the application for authorization of admission

s 135 A person may apply for authorization of his or her admission to a nursing home only after the person has been determined by a placement co-ordinator to be eligible for admission s 136(1) To apply for authorization of his or her admission to a nursing home a person shall provide to the placement co-ordinator designated for the home under subsection 201 (3) of the Act (a) a written request by the person for authorization of his or her admission to the home (b) the items mentioned in clauses 134 (1) (c) and (d) if

(i) the person was not required to provide those items when the person applied for the determination of his or her eligibility and (ii) in the opinion of the placement co-ordinator the licensee of the home does not have sufficient other information about the person to determine whether to give or withhold approval for the personrsquos admission to the home and

(c) such additional information and documentation as is necessary to enable the placement co-ordinator to determine the category in which to place the person under sections 142 to 1484 (11) Despite clause (1) (a) a request for authorization of admission need not be in writing if it is a request for authorization of admission as a long-stay resident with respect to a related temporary nursing home a re-opened nursing home or a replacement nursing home made by a person who is a long-stay resident of the original nursing home or was a long-stay resident of the original nursing home immediately before the closure of his or her bed in the home (2) The placement co-ordinator shall assist the person in obtaining the information and documentation that the person is required to provide to the placement co-ordinator under this section

Applicants provide the written request for authorization of admission to the LTC home(s) of their choice by completing the selection form provided by the CCAC Each CCAC has developed its own forms for applicants to complete for selection of LTC homes As part of this application the person also indicates his or her preferences for accommodation (private semi-private or basic) An applicant may base his or her decision on many factors including ethnic spiritual linguistic familial and cultural preferences the location of the home whether the home has indoor smoking facilities or what he or she can afford to pay

September 2006 26

If an applicant is a smoker it is imperative that the CCAC advise the person that the provisions of the Smoke-Free Ontario Act prohibit smoking inside a LTC home other than in a controlled smoking area that complies with the requirements under that legislation Furthermore even where a LTC home has a controlled smoking area residents who wish to smoke in there must be able to smoke safely without assistance from an employee Employees are not required to enter a controlled smoking area to assist a resident to smoke If the person selects one or more LTC homes that do not have a controlled smoking area the CCAC must ensure that the person is aware of the LTC homersquos internal no smoking policy and agrees not to smoke inside the LTC home

If the applicant being advised that a LTC home is non-smoking indicates that he or she will continue to smoke indoors the operator may decide not to approve the admission on the basis that the LTC home lacks the physical facilities necessary to meet the applicantrsquos care requirements The applicant must be advised of this likelihood

As part of the process for authorization of admission CCACs must provide applicants who are smokers with the information referred above CCACs must document the provision of information to applicants and the applicantrsquos response and ensure that this information is provided to the LTC home(s) as part of the application for admission

As noted in the above referenced provision the written request for authorization of admission to a LTC home must be accompanied by the following documentation bull the functional and health assessment information if the applicant was not initially required

to provide this information to the CCAC when applying for the determination of eligibility and the CCAC is of the view that the LTC home needs it to provide approval for admission and

bull any additional information and documentation that the CCAC deems necessary to determine the applicantrsquos category on the waiting list

1162 Date of Application

The date and time when the CCAC received all the information for the application is considered the ldquotime at which the person applied for authorization of their admissionrdquo This date and time will be used to rank the person for admission within each category of the waiting list with some exceptions (For additional information on ranking of priority categories see subsection 128 in this manual)

1163 Request for Approval of Admission by LTC Home

Once the CCAC has determined that the applicant is eligible for admission to a LTC home and the applicant has applied for authorization of admission the CCAC must submit the application(s) to the LTC home(s) chosen by the applicant This requirement is set out in section 137 of the NHA regulation

September 2006 27

s 137 (1) Subject to sections 1371 and 1381 when a person who has been determined by a placement co-ordinator to be eligible for admission to a nursing home applies for authorization of his or her admission to a particular nursing home the placement co-ordinator designated for the home under subsection 201 (3) of the Act shall (a) give the licensee of the home the information possessed by the placement co-ordinator that is relevant to the licenseersquos determination of whether to give or withhold approval for the personrsquos admission to the home and (b) request the licensee to determine whether to give or withhold approval for the personrsquos admission to the home

With the consent of the applicant or where applicable the applicantrsquos substitute decision-maker (SDM) the CCAC must provide the LTC home(s) with information that is relevant for the operator to make the decision to give or withhold approval for the applicantrsquos admission to the LTC home This information includes bull the name and address of the applicant and the SDM if any who was lawfully authorized to

consent to the admission bull whether the person is requesting a long-stay or a short-stay respite care or supportive care

program bull assessments of the person who is seeking admission to the LTC home

bull information about the personrsquos medical history (The completed Ministry of Health and Long-Term Care (MOHLTC) Health Report form requests information about a medical diagnosis history current condition current treatments required prognosis and current medications and diet The Health Report form (014-2734-69) is available at [httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailOpenFormampACT=RDRampTAB=PROFILEampENV=WWEampNO=014-2734-69])

bull information about the personrsquos social and other care requirements including reports and assessments that may have been undertaken and could have a bearing on the personrsquos care requirements (eg a psychogeriatric assessment)

bull type of accommodation requested by the person and bull personal information such as

bull age bull gender bull ethnic spiritual linguistic cultural familial preferences bull relevant life-style factors (eg smoker) and bull names of relatives or other contacts

1164 Response from the LTC Home

The LTC home is required to provide a written response to both the CCAC and the applicant stating the applicant is either approved or not approved for admission to the home within five days after receiving the request for approval of admission This time frame does not include weekends or holidays The NHA states

s 137(2) A licensee of a nursing home shall within five days after receiving the request mentioned in subsection (1)

September 2006 28

(a) give the placement co-ordinator designated for the home and the person applying for authorization of admission to the home a written notice stating that the licensee approves the persons admission or (b) if the licensee is withholding approval for the persons admission give the written notice required under subsection 201 (15) of the Act to the persons mentioned in subsection 201 (15) of the Act (3) In counting five days for the purpose of subsection (2) holidays shall not be included (4) In this section holiday means (a) Saturday (b) Sunday (c) New Years Day (d) Good Friday (e) Victoria Day (f) Canada Day (g) Civic Holiday (h) Labour Day (i) Thanksgiving Day (j) Christmas Day (k) Boxing Day (l) any special holiday proclaimed by the Governor General or the Lieutenant Governor (m) if New Years Day or Canada Day falls on a Saturday or Sunday the following Monday (n) if Christmas Day falls on a Saturday or Sunday the following Monday and Tuesday and (o) if Christmas Day falls on a Friday the following Monday

LTC homes are not obliged to take the full five days to respond to an applicantrsquos request for approval of admission so the CCAC can try to negotiate to receive a response sooner

1165 LTC Home Approval of Admission

If a LTC home of the applicantrsquos choice approves admission and a bed is available for the person the CCAC may authorize the admission and the person may be admitted to the LTC home immediately If a bed is not immediately available the CCAC must place the person on the waiting list(s) of the personrsquos chosen LTC homes The CCAC must advise the person of his or her priority for admission (For information on management of LTC home waiting lists see chapter 12 in this manual)

1166 LTC Home Withholds Approval

LTC homes legislation sets out limited grounds for a LTC home to withhold approval of a personrsquos admission and the notification requirements in such situations The NHA states Approval s 201(14) A licensee of a nursing home shall approve a persons admission to the nursing home unless

September 2006 29

(a) the nursing home lacks the physical facilities necessary to meet the persons care requirements (b) the staff of the nursing home lack the nursing expertise necessary to meet the persons care requirements or (c) circumstances exist which are prescribed by the regulations as being a ground for withholding approval Written notice s 201(15) A licensee who withholds approval for the admission of a person to a nursing home shall give to the person the Director and the placement co- ordinator designated for the nursing home under subsection (3) a written notice setting out the ground or grounds on which the licensee is withholding approval and a detailed explanation of the supporting facts

A LTC home operator must approve the admission of an applicant unless the LTC home lacks the physical facilities necessary to meet the personrsquos care requirements or the staff of the home lack the nursing expertise necessary to meet the personrsquos care requirements Currently there are no additional circumstances prescribed by the regulations as being grounds for a LTC home to withhold approval under subsection 201(14)(c) of the NHA When admission is not approved the LTC home operator must provide a written notice to the Director (ie MOHLTC regional office) the CCAC and the applicant setting out the grounds on which the approval is withheld and a detailed explanation of the supporting facts The homersquos written notification should not simply reference the legislative provisions under which approval is denied but specify how the reason(s) for refusal relate specifically to the condition of the individual whose approval for admission is being refused Homes that do not provide this level of detail should be challenged on their refusal

1167 LTC Home Withdrawal of Approval

Section 138 of the NHA regulation sets out the conditions for the operatorrsquos withdrawal of approval for a personrsquos admission

s 138(1) Subject to section 1381 a licensee may withdraw an approval of a personrsquos admission to a nursing home before the personrsquos admission is authorized if as a result of a change in the personrsquos condition a ground for withholding approval mentioned in subsection 201 (14) of the Act exists (2) A licensee who withdraws an approval of a personrsquos admission to a nursing home under subsection (1) shall give to the person the Director and the placement co-ordinator designated for the home under subsection 201 (3) of the Act a written notice (a) stating that the licensee is withdrawing the approval of the personrsquos admission and (b) setting out the ground or grounds on which the licensee is withholding approval and a detailed explanation of the supporting facts

A LTC home may withdraw approval of a personrsquos admission to the LTC home prior to authorization of the personrsquos admission if a change in the personrsquos condition results in grounds for withholding approval Permitted grounds for withdrawing approval for admission are the

September 2006 30

same as those for withholding approval for admission (ie the LTC home lacks the physical facilities necessary to meet the personrsquos care requirements or the staff of the home lack the nursing expertise necessary to meet the personrsquos care requirements) Under subsections 138 (2)(a) and (b) of the NHA regulation when approval for admission is withdrawn the LTC home operator must provide a written notice to the Director (ie MOHLTC regional office) the CCAC and the applicant stating that approval of the personrsquos admission is withdrawn and setting out the grounds on which the approval is withheld and a detailed explanation of the supporting facts

The LTC homersquos written notification should not simply reference the legislative provisions under which approval is withdrawn but specify how the reason(s) for the withdrawal of approval relate specifically to the condition of the individual whose approval for admission is being withdrawn Exemptions Under subsection 1381(1) and (2) of the NHA regulation the applications of individuals applying to a related temporary LTC home a re-opened LTC home or a replacement LTC home are not subject to LTC home approval In the case of these applicants LTC homes are deemed to have approved the admission of any long-stay resident who is or was a resident of the original nursing home immediately before the closure of his or her bed in the home

1168 Re-Determination of Eligibility

LTC home legislation requires that an applicantrsquos health and functional assessments be current within six months of admission The NHA states

s 201(13) The placement co-ordinator designated for a nursing home under subsection (3) may authorize the admission of a person to the nursing home only if (a) the placement co-ordinator or another placement co-ordinator has determined within the six months preceding authorization that the person is eligible for admission to a nursing homehellip

In the case of individuals who are on waiting lists for long periods of time the CCACrsquos assessment information must be current within six months of admission into a LTC home In the majority of cases the personrsquos eligibility will be reconfirmed Nevertheless there may be some situations where the personrsquos condition has improved or community resources are now available and adequate to address the personrsquos needs Alternatively the personrsquos condition may have changed to such a degree that the LTC home operator has grounds to withdraw its approval of admission or the CCAC determines that the personrsquos care requirements cannot be met in a LTC home (See LTC Home Withdrawal of Approval in subsection 1167 above in this manual)

September 2006 31

117 Accepting the Offer of Long-Stay Admission

Accommodation and Bed-Holding Fees

Long-term care (LTC) home legislation establishes timelines for the acceptance of a bed offer and admission that are designed to ensure existing beds in LTC homes are fully utilized When a Community Care Access Centre (CCAC) makes an offer of admission to a person the person is given a strict time limit in which to decide whether or not he or she will accept the offer and subsequently to move into the LTC home The LTC home is allowed to charge the applicant certain fees during the time that the bed is being held for the person

1171 Timeline for Acceptance of Offer of Admission

An applicant has one day to accept an offer of admission to a LTC home of his or her choice This timeframe is established by operation of the regulatory provisions related to authorization of admission The Nursing Homes Act (NHA) regulation states

Authorization of admission s 155(1) Subject to section 156 the placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act shall authorize the admission of a person to the home if and only if hellip (e) in the case of a person who is applying for authorization of his or her admission to the home as a long-stay resident the person agrees in writing with the licensee of the home that

(i) the person will move into the home before noon of the fifth day following the day on which he or she is informed of the availability of accommodation in the home

According to this provision an applicant is expected to move into the LTC home by the fifth day after the day on which the person is made the offer of admission That gives the person one day within receiving the offer to accept or reject the offer and sign the agreement with the home

1172 Accommodation and Bed-Holding Fees

Once a person has accepted the offer of admission the bed may be held for up to five days following the date of notification if the person pays the applicable bed holding and accommodation fees This means that a person who is offered admission will have five days to move in not counting the date of notification The date of notification does not count as one of the days for bed-holding purposes as it is the day the applicant has to decide whether to accept the offer of admission Section 155 of the NHA regulation sets out the applicable fees that the LTC home may charge during the five-day period and subsection 47(4) establishes the amount of the daily bed-

September 2006 32

holding fee which is payable in addition to the accommodation fee for that part of the period available for bed-holding Authorization of admission s 155 (1) Subject to section 156 the placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act shall authorize the admission of a person to the home if and only if hellip (e) in the case of a person who is applying for authorization of his or her admission to the home as a long-stay resident the person agrees in writing with the licensee of the home that

(i) the person will move into the home before noon of the fifth day following the day on which he or she is informed of the availability of accommodation in the home (ii) if the person moves into the home before noon of the fifth day following the day on which he or she is informed of the availability of accommodation in the home the person will pay

(A) for each day following the day on which the person is informed of the availability of accommodation in the home and preceding the day on which the person moves into the home the amount that the licensee would have charged him or her for accommodation for that day had he or she been a long-stay resident lodged in the available accommodation on that day and (B) if the person moves into the home on or after the third day following the day on which he or she is informed of the availability of accommodation in the home the daily bed-holding amount as determined under section 47 for each day from and including the second day following the day on which the person is informed of the availability of accommodation in the home and preceding the day on which the person moves into the home and

(iii) if the person does not move into the home before noon of the fifth day following the day on which he or she is informed of the availability of accommodation in the home the person will pay

(A) for each of the five days following the day on which the person is informed of the availability of accommodation in the home the amount that the licensee would have charged him or her for accommodation for that day had he or she been a long-stay resident lodged in the available accommodation on that day and (B) for each of the second third fourth and fifth days following the day on which the person is informed of the availability of accommodation in the home the daily bed-holding amount as determined under section 47

Absences s 47(4) The daily bed-holding amount for a day after March 31 1995 is $53 The following chart outlines the applicable accommodation and bed-holding fees for the five-day bed-holding period described in the above referenced provisions Note The date of notification (ie the day the offer is made) is identified as day 0 in the chart

September 2006 33

Day Resident Moves In Accommodation Fee Bed-holding Fee ($53)

Day 0 Date of Notification of Availability

Yes for day 0 No

Day 1 Following Notification

Yes for day 1 No

Yes for day 1 and 2 No

Yes for days 12 and 3 Yes for day 2

Yes for days 123 amp 4 Yes for days 2 and 3

Day 5 (Before Noon of Day 5) Following Notification

Yes for days 1234 and 5 Yes for days 23 and 4

Applicant does not move in

Saturdays and Sundays count for bed-holding purposes even if the LTC home does not admit applicants over the weekend This is owing to the fact that the ordinary meaning of the word ldquodayrdquo in the regulation means calendar day Therefore if a home does not admit on any particular day such as weekends or holidays the accommodation and bed-holding fees still apply if the particular day falls within the bed-holding period However there are no provisions in the regulation which address when the CCAC has to make a bed offer so a placement co-ordinator may wait to make a bed offer until after the weekend if he or she knows that the home does not admit applicants over the weekend Additionally the payment of accommodation and bed-holding fees is part of a contractual arrangement between the applicant and the LTC home operator

Accommodation and bed-holding fees apply to all applicants including those who are already residing in another LTC home and hospital-based applicants who are paying the chronic care co-payment

September 2006 34

1173 ldquoOne-Offerrdquo Policy

The NHA regulation sets out the requirements of the ldquoone-offerrdquo policy

s 141(1) A person shall be removed from the waiting list for each nursing home to which the person is awaiting admission as a long-stay resident and shall be placed on the refusal list if (a) the person

(i) is a long-stay resident of another nursing home an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act or (ii) is not described in subclause (i) and does not occupy a bed in

(A) a hospital under the Public Hospitals Act or a private hospital licensed under the Private Hospitals Act (B) a facility that is designated as a psychiatric facility under section 802 of the Mental Health Act and that is not exempt under that section from the requirement to provide in-patient services in paragraph 1 of subsection 4 (1) of Regulation 741 of the Revised Regulations of Ontario 1990 made under that Act or (C) a facility listed in Schedule 1 to Regulation 272 of the Revised Regulations of Ontario 1990 made under the Developmental Services Act and

(b) a placement co-ordinator offers to authorize the personrsquos admission to a nursing home an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act as a long-stay resident and the person

(i) refuses to consent to admission (ii) refuses to enter into the written agreement mentioned in clause 155 (1) (e) of this Regulation clause 86 (1) (e) of Regulation 69 of the Revised Regulations of Ontario 1990 made under the Charitable Institutions Act or clause 1221 (1) (e) of Regulation 637 of the Revised Regulations of Ontario 1990 made under the Homes for the Aged and Rest Homes Act as applicable or (iii) fails to move into the facility on or before the fifth day following the day on which he or she is informed of the availability of accommodation

(2) Subsection (1) does not apply if the reason the person acts in the manner described in subclause (1) (b) (i) (ii) or (iii) is that the person has a short-term illness or injury which (a) prevents the person from moving into the facility at that time or (a) would make moving into the facility at that time detrimental to the personrsquos health (3) If a person described in subclause (1) (a) (i) is removed from the waiting list for a nursing home under subsection (1) the person shall be placed on the waiting list for the home again to await admission as a long-stay resident if (a) the person provides to the placement co-ordinator designated for the home under subsection 201 (3) of the Act a new written request for authorization of his or her admission to the home as a long-stay resident and (b) placing the person on the waiting list for the home will not result in the total number of waiting lists for nursing homes approved charitable homes for the aged under the Charitable

September 2006 35

Institutions Act and homes under the Homes for the Aged and Rest Homes Act on which the person is placed exceeding three (4) If a person described in subclause (1) (a) (ii) is removed from the waiting list for a nursing home under subsection (1) the person shall be placed on the waiting list for the home again to await admission as a long-stay resident if (a) the person provides to the placement co-ordinator designated for the home under subsection 201 (3) of the Act a new written request for authorization of his or her admission to the home as a long-stay resident and

(i) the request is provided 24 weeks or more after the day the person was removed from the waiting list or (ii) the request is provided less than 24 weeks after the day the person was removed from the waiting list but there has been a deterioration in the personrsquos condition or circumstances and

(b) placing the person on the waiting list for the home will not result in the total number of waiting lists for nursing homes approved charitable homes for the aged under the Charitable Institutions Act and homes under the Homes for the Aged and Rest Homes Act on which the person is placed exceeding three (5) Clause (4) (b) does not apply to a person who will be placed in category 1A on the waiting list for the home

The ldquoone offerrdquo policy applies to applicants currently residing in the community setting and those who are currently in LTC homes waiting for transfer to another LTC home The policy does not apply to applicants in hospitals If a community or LTC home based applicant refuses a bed offer made by a CCAC relating to any of the LTC homes for which the person is waitlisted the CCAC must remove that person from all waiting lists and place the person on the refusal list The same applies if the person does not move into the LTC home within five days The only exception to this requirement is applicants who have a short-term illness or injury that affects their ability to move into the LTC home these applicants will not be removed from all of their LTC home waiting lists After removal from all waiting lists community based applicants will be required to wait six months before reapplying to the CCAC to be reassessed for admission to a LTC home unless their condition or circumstances deteriorate LTC home residents seeking to transfer to another home will also be required to re-apply however no waiting period will apply to these individuals In both cases however the person will lose his or her original priority for ranking on the waiting lists of his or her chosen LTC homes In light of the ldquoone-offerrdquo policy and the fact that a person will be removed from all waiting lists if he or she refuses an offer of admission applicants should be encouraged to choose only LTC homes for which they are truly willing to accept an offer of admission

September 2006 36

If a long-term care (LTC) home has a suitable vacancy available and the applicant has accepted the placement the next step is for the Community Care Access Centre (CCAC) to authorize the admission of the applicant to the LTC home Before doing so the CCAC must ensure that certain conditions are met

1181 Conditions for Authorizing Admission to a LTC Home

The Nursing Homes Act (NHA) regulation sets out the requirements for authorization of admission

Authorization of admission s 155(1) Subject to section 156 the placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act shall authorize the admission of a person to the home if and only if (a) the requirements set out in subsection 201 (13) of the Act are met

Note Subsection 201(13) requires that the person has been determined by the CCAC to be eligible for admission to a nursing home (within the six months preceding authorization) the nursing home to which the personrsquos admission is to be authorized approves the personrsquos admission to the home and the person or if the person is incapable his or her substitute decision-maker (SDM) consents to the person being admitted to the home

s 155(1)(b) the licensee of the home has not withdrawn the approval of the persons admission

under section 138 (c) the home has available the class of accommodation for which the person is recorded to be

waiting (d) there is no one on the waiting list for the home who is recorded to be waiting for the class of accommodation that is available who ranks ahead of the person and whose admission may be authorized under this section and (e) (See ldquoAuthorization of Admissionrdquo in subsection 1172 in this manual)

1182 Conditions Under Which Admission is Not Authorized

Sections 46(1) and (2) of the Health Care Consent Act 1996 (HCCA) set out conditions under which admission is not authorized Where the CCAC designated as the placement co-ordinator for the LTC home is informed that bull the person who was found to be incapable with respect to admission intends to apply or has

applied to the Consent and Capacity Board (the Board) for a review of the finding bull the incapable person intends to apply or has applied to the Board for appointment of a

representative to give or refuse consent to the admission on his or her behalf or

September 2006 37

bull another person intends to apply or has applied to the Board to be appointed as the representative of the incapable person to give or refuse consent to the admission on his or her behalf

Section 46(3) of the HCCA provides that in the above referenced circumstances authorization of admission to the LTC home cannot proceed and the person cannot be admitted bull until 48 hours have elapsed since the CCAC was first informed of an intended application

to the Board without an application being made or bull until the application to the Board has been withdrawn or bull until the Board has made a decision and none of the parties to the application before the

Board has informed the CCAC that he or she intends to appeal the Boardrsquos decision or bull if a party before the Board has informed the CCAC that he or she intends to appeal the

Boardrsquos decision bull until the period for commencing the appeal has elapsed without an appeal being

commenced or bull until the appeal of the Boardrsquos decision has been finally disposed of

Note If a person is determined by the decision of the Board or court to be capable and the person refuses to consent to the admission the personrsquos admission to the LTC home cannot proceed The same applies if the finding of incapacity is confirmed by the Board or court and the SDM on behalf of the incapable person refuses consent to the admission

Exception Under subsection 46(4) of the HCCA despite the above an incapable person may be authorized for admission where the CCAC is of the opinion that the incapable person requires immediate admission to a LTC home as a result of a crisis Pursuant to section 39 of the HCCA ldquocrisisrdquo means a crisis relating to the condition or circumstances of the person who is to be admitted to the LTC home

1183 Copies of the Authorization for Admission

Three copies of the authorization for admission must be made available One copy is for the eligible person one for the receiving LTC home and one for the CCAC The LTC home must retain the authorization in the personrsquos file as required by section 88 of the NHA regulation

s 88 Every administrator of a nursing home shall create and maintain a written record and file for each resident that shall be contained in the residentrsquos personal file and that shall include (a) particulars of admission transfer notification of admission to a hospital discharge accident or death

1184 Cancellation of Authorization of Admission

Subsection 155(3) of the NHA regulation sets out the conditions under which a placement co-ordinator must cancel an authorization of admission

September 2006 38

s 155(3) A placement co-ordinator who authorizes a personrsquos admission to a nursing home as a long-stay resident shall cancel the authorization if the person does not move into the home before noon of the fifth day following the day on which the person is informed of the availability of accommodation in the home

The CCAC must cancel the authorization of a personrsquos admission to a LTC home as a long-stay resident if the person does not move into the home after accepting an offer

September 2006 39

119 Short-Stay Programs Respite Care and Supportive Care

(Convalescent Care)

Respite care and supportive care are two short-stay programs that are offered in some long-term care (LTC) homes These programs are intended to support individuals who may benefit from or require a short-stay in a LTC home but who are expected to return to their homes in the community within a specific period of time In addition short-stay crisis admission of up to 14 days may be authorized if a person applying for admission for long-stay is on category 1A of the waiting list (This type of admission is explained in subsection 1194 in this manual)

1191 Respite Care Program

Respite care is intended to provide caregivers with temporary relief from their caregiving responsibilities Respite care may be provided to enable the caregiver to take a break The person entering the LTC home may also benefit from the programs and services offered by the home The anticipated length of stay is a maximum of 60 days

Respite Care Program ndash Eligibility Criteria Eligibility criteria for the Respite Care Program are set out in section 131 of the Nursing Homes Act (NHA) regulation

s 131(1) An applicant shall be determined to be eligible for admission to a nursing home as a short-stay resident in the respite care program if and only if (a) the applicants caregiver requires temporary relief from his or her caregiving duties (b) it is anticipated that the applicant will be returning to his or her residence within 60 days after admission to the nursing home and (c) the applicant meets the requirements of clauses 130 (1) (a) (b) (c) and (e) s 130(1) An applicant shall be determined to be eligible for admission to a nursing home if and only if (a) the applicant is at least 18 years old (b) the applicant is an insured person under the Health Insurance Act (b) the applicant meets at least one of the conditions set out in subsection (2) hellip (e) the applicants care requirements can be met in a nursing home s 130 (2) The following are the conditions referred to in clause (1) (c) 1 The applicant requires that nursing care be available on-site 24 hours a day 2 The applicant requires assistance each day with activities of daily living 3 The applicant requires at frequent intervals throughout the day on-site supervision or on-site monitoring to ensure his or her safety or well-being 4 The applicant is at risk of being financially emotionally or physically harmed if the applicant lives in his or her residence

September 2006 40

5 The applicant is at risk of suffering harm due to environmental conditions that cannot be resolved if the applicant lives in his or her residence 6 The applicant may harm someone if the applicant lives in his or her residence

Note There is no requirement to consider the availability of publicly-funded community-based services or other available arrangements when determining a personrsquos eligibility for short-stay respite care Respite Care Program ndash Application for Determination of Eligibility The application process for a determination of eligibility for the Respite Care Program is the same as that for an applicant seeking long-stay admission (see subsection 113 in this manual) Individuals (or if incapable their substitute decision-makers (SDMs)) must apply for a determination of eligibility and consent to be admitted to a LTC home for respite care

1192 Supportive Care ProgramConvalescent Care Program

The supportive care program referenced in the regulations provides the legal framework for the program now known as the Convalescent Care Program The primary focus of the program is to provide a supportive environment for people discharged from acute care settings who need to recover their strength endurance and functioning before returning home The Convalescent Care Program is a time-limited LTC home placement Although there may be monitoring by the case manager on an ongoing basis from a data perspective the person is a resident of the LTC home and not a Community Care Access Centre (CCAC) in-home client The Convalescent Care Program operates under the current legislation and regulations and is available to individuals coming from either the community or hospital It must be anticipated that the person will return to his or her residence within 90 days after admission Convalescent Care Program ndash Eligibility Criteria

The NHA regulation sets out the eligibility criteria for the convalescent care program

s 131(2) An applicant shall be determined to be eligible for admission to a nursing home as a short-stay resident in the supportive care program if and only if (a) the applicant requires a period of time in which to recover strength endurance or functioning and is likely to benefit from a short-stay in a nursing home (b) it is anticipated that the applicant will be returning to his or her residence within 90 days after admission to the nursing home and (c) the applicant meets the requirements of clauses 130 (1) (a) (b) (c) and (e) s 130(1) An applicant shall be determined to be eligible for admission to a nursing home if and only if (a) the applicant is at least 18 years old (b) the applicant is an insured person under the Health Insurance Act

September 2006 41

(c) the applicant meets at least one of the conditions set out in subsection (2) hellip (e) the applicants care requirements can be met in a nursing home s 130(2) The following are the conditions referred to in clause (1) (c) 1 The applicant requires that nursing care be available on-site 24 hours a day 2 The applicant requires assistance each day with activities of daily living 3 The applicant requires at frequent intervals throughout the day on-site supervision or on-site monitoring to ensure his or her safety or well-being 4 The applicant is at risk of being financially emotionally or physically harmed if the applicant lives in his or her residence 5 The applicant is at risk of suffering harm due to environmental conditions that cannot be resolved if the applicant lives in his or her residence 6 The applicant may harm someone if the applicant lives in his or her residence

Note There is no requirement to examine the availability of publicly-funded community-based services or other available arrangements when determining a personrsquos eligibility for short-stay convalescent care Convalescent care residents could include individuals recovering from surgery or an illness such as cancer or those with an impairment or disability Some residents could be preparing for active rehabilitation before returning home Others could have non-acute clinical conditions and need short-term 24-hour professional attention (eg intensive wound care) The level of medical need of a LTC homersquos convalescent care residents is determined by what the LTC home is able to provide What all these populations have in common is the need for short-term care before returning home specific populations will vary according to the community and LTC home

The care provided to convalescent care residents has a greater focus on reactivation in preparation for returning home The programrsquos philosophy is based on promoting self-care and self-sufficiency emphasizing adaptation to the current situation and drawing on the individualrsquos abilities and strengths Therefore the individuals best suited to the program are motivated to return home committed to participating in activities that will make this possible and capable of learning The individuals should have goals and timeframes that are clear realistic and able to be monitored The program is not for individuals who need permanent LTC home admission complex continuing care or palliative care

The Convalescent Care Program is not designed to serve individuals whose primary diagnosis is psychiatric and who have behavioural issues If however an applicant has some psychiatric issues along with a primary medical or surgical condition but does not have behavioural challenges the applicant might be eligible A LTC homersquos acceptance of a convalescent care applicant depends on its ability to provide the services the particular applicant would need

September 2006 42

Convalescent Care Program ndash Application for Determination of Eligibility and Admission Procedures

The application process for a determination of eligibility for the Convalescent Care Program is the same as that for an applicant seeking long-stay admission (See subsection 113 in this manual) Individuals (or if incapable their SDM) must apply for a determination of eligibility and also consent to be admitted to a LTC home for convalescent care Since this programrsquos primary focus is to assist in relieving pressures within the acute care setting there is an expectation that within 24-72 hours of having been identified in either the community or hospital an individual is assessed eligibility is determined goals are identified and a tentative date for discharge from convalescent care is set The RAI-HC is the assessment instrument used for the functional assessment of convalescent care applicants although a somewhat abbreviated version is used for applicants from hospital Once the application and assessment information are forwarded to the LTC homes selected by the applicant the LTC homes are expected to respond verbally within two hours about whether an applicant is approved for admission The individual is then to be admitted within 24 hours of being offered a bed The whole process should take no more than three to five days if a bed is available and if there is no waiting list The programrsquos terms and conditions specify that the LTC home be available to approve admission every day including weekends and holidays and for at least eight continuous hours during the daytime This program relies on and demonstrates the importance of collaboration among hospitals CCACs and LTC homes to schedule and co-ordinate referrals and admissions at mutually acceptable times Note A person who is a resident of a LTC home and who is on a leave of absence from the LTC home (eg on vacation or as a result of a home outbreak) may be eligible to receive home care services from the CCAC The same applies to a person who is on a leave of absence from the LTC home Convalescent Care Program or on a leave of absence from a hospital

1193 Determination of Ineligibility for Short-Stay Programs

Pursuant to subsection 205(1) of the NHA regulation if an applicant is determined ineligible for admission to a LTC home the CCAC must provide the applicant and the person if any who applied for the determination on behalf of the applicant with written notice outlining

bull the determination of ineligibility bull the reasons for the determination and bull the applicantrsquos right to apply to the Appeal Board for a review of the determination

If the applicant is a hospital inpatient the CCAC may advise the hospital of the CCACrsquos determination of ineligibility subject to the Personal Health Information Protection Act 2004 (PHIPA)

September 2006 43

1194 Admission Procedures for Short-Stay Programs

Choice and Consent for Admission

LTC home legislation and regulations specify that an applicant may select the LTC home to which he or she wishes to be admitted and this right also applies to respite and convalescent care (See subsection 114 in this manual) Individuals in one CCAC catchment area may apply for a respite or convalescent care bed in another CCAC catchment area As with long-stay applicants the CCACs will work together to place individuals in LTC homes across catchment areas Non-applicability of ldquoThree LTC Homerdquo Rule Unlike long-stay applicants individuals applying for short-stay may apply to as many LTC homes offering short-stay as they wish (there is no ldquothree LTC homerdquo rule) Subsection 1371(3) of the NHA regulation provides this exemption by stating

s 1371(1) A placement co-ordinator shall not provide the information and request referred to in subsection 137 (1) to a licensee of a nursing home selected by an applicant if at that point in time the total number of nursing homes approved charitable homes for the aged under the Charitable Institutions Act and homes under the Homes for the Aged and Rest Homes Act which have approved or are considering the applicantrsquos admission is three or more hellip (3) This section does not apply to a person who will be placed in category 1A or the short-stay category on the waiting list for the nursing home if the licensee approves his or her admission to the home

Prioritization for Short-Stay Beds Short-stay waiting lists are separate from long-stay lists Furthermore separate waiting lists are established for each of the short-stay programs This is set out in section 1484 of the NHA regulation s 1484(1) Sections 143 to 1483 do not apply to a person applying for authorization of admission to a nursing home as a short-stay resident in the respite care or supportive care program (2) A person referred to in subsection (1) shall be placed in the short-stay category on the waiting list for the nursing home

Pursuant to subsection 1484(1) of the NHA regulation applicants who are approved for admission to a short-stay program are prioritized in chronological order according to the time at which they applied for authorization of their admission to the nursing home (the waiting list categories for long-stay applicants do not apply to short-stay applicants) As well section 155(2) of the NHA regulation states

September 2006 44

s 155(2) For the purposes of clauses (1) (c) and (d) the following are the classes of accommodation for which a person may be recorded to be waiting 1 Accommodation for a woman in a respite care or supportive care program 2 Accommodation for a man in a respite care or supportive care program 3 Basic accommodation for a woman other than in a respite care or supportive care program 4 Basic accommodation for a man other than in a respite care or supportive care program 5 Semi-private accommodation for a woman other than in a respite care or supportive care program 6 Semi-private accommodation for a man other than in a respite care or supportive care program 7 Private accommodation for a woman other than in a respite care or supportive care program 8 Private accommodation for a man other than in a respite care or supportive care program Note Applicants for short-stay programs may also be on waiting lists for long-stay admission but cannot move directly from a short-stay to a long-stay admission without making a separate application and being waitlisted according to the prioritization requirements for long-stay applicants Authorization of Admission Sections 155 and 156 of the NHA regulation set out the requirements applicable to the authorization of admission of short-stay applicants

s 155(1) Subject to section 156 the placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act shall authorize the admission of a person to the home if and only if (a) the requirements set out in subsection 201 (13) of the Act are met

Clarification These requirements are

bull the person has been determined by the CCAC to be eligible for admission to a LTC home

(within the six months preceding authorization) bull the LTC home to which the personrsquos admission is to be authorized approves the personrsquos

admission to the home and bull the person or if the person is incapable his or her SDM consents to the person being

admitted to the home

s 155(1)(b) the licensee of the home has not withdrawn the approval of the persons admission under section 138 (c) the home has available the class of accommodation for which the person is recorded to be waiting (d) there is no one on the waiting list for the home who is recorded to be waiting for the class of accommodation that is available who ranks ahead of the person and whose admission may be authorized under this section and

September 2006 45

s 156 The placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act shall authorize a persons admission to the home as a short-stay resident if and only if the persons admission may be authorized under section 155 and (a) the person applied for authorization of his or her admission to the homes respite care or supportive care program or (b) the person did not apply for authorization of his or her admission to the homes respite care or supportive care program the person is in category 1A on the waiting list for the home at the time of authorization of his or her admission and the persons condition or circumstances are such that the placement co-ordinator believes that the person will be able to return to his or her residence within 14 days after admission to the home

Length of Stay The Convalescent Care Program is a time-limited LTC home placement Although there may be monitoring by the case manager on an ongoing basis from a data perspective the person is a resident of the LTC home and not a CCAC in-home client The conditions regarding length of stay for short-stay residents are set out in the NHA regulation which states

s 157(1) When a placement co-ordinator authorizes the admission of a person to a nursing home as a short-stay resident the placement co-ordinator shall indicate the length of the stay being authorized and the first day and last day of the stay (2) No placement co-ordinator shall authorize the admission of a person to a nursing home as a short-stay resident in the respite care program for a stay exceeding 60 days (3) No placement co-ordinator shall authorize the admission of a person to a nursing home as a short-stay resident in the supportive care program for a stay exceeding 90 days (4) No placement co-ordinator shall authorize the admission of a person to a nursing home as a short-stay resident in the respite care or supportive care program for a stay which when added to the personrsquos other stays during the year in the respite care or supportive care program of a nursing home a home under the Homes for the Aged and Rest Homes Act or an approved charitable home for the aged under the Charitable Institutions Act exceeds 90 days (5) No placement co-ordinator shall authorize the admission of a person to a nursing home as a short-stay resident under clause 156 (b) for a stay exceeding 14 days (6) No person whose admission has been authorized for a stay in the respite care or supportive care program of a nursing home shall apply for authorization of admission to extend the stay before the last day of the stay

Subsections 157(1)(2) and (3) of the NHA regulation provide that when a CCAC authorizes a personrsquos admission as a short-stay resident the CCAC is required to indicate the length of stay being authorized and the first and last day of the stay Admissions for short-stay respite care may only be authorized for up to 60 continuous days and admissions for short-stay convalescent care (supportive care) may only be authorized for up to 90 days Subsection 157(4) of the NHA regulation provides that an applicant may receive up to a maximum of 90 days in the short-stay programs per year The CCAC may not authorize a

September 2006 46

personrsquos stay in a respite care or supportive care program if the stay when added to his or her other short-stays in a respite program or supportive care program in one or more LTC homes exceeds 90 days in a calendar year Short-Stay Crisis Admissions Subsection 157(5) of the NHA regulation provides that a personrsquos admission as a short-stay resident may be authorized for up to 14 days where the person is prioritized as a category 1A (crisis) for the home as a long-stay resident and it is anticipated that the personrsquos condition and circumstances are such that he or she will be able to return home within 14 days of the admission Note There may be some situations where it is impossible to develop and implement plans for the person within 14 days In these cases the person if eligible could be transferred to the respite or Convalescent Care Program if available Eligibility determination and authorization for such an admission in accordance with the legislation would be undertaken by the CCAC for this transfer If a respite or convalescent care bed is not available or the person is not eligible for those programs regulations do not prevent the discharge and immediate re-admission of the person on a short-stay crisis basis up to a maximum of 14 days In other words the CCAC could authorize a further admission of up to 14 days if the person remains in category 1A (crisis) Under subsection 157(6) persons who have been admitted to a LTC home for a respite care or convalescent (supportive) care short-stay program cannot apply for authorization of admission to extend the stay before the last day of the stay Transfer to Long-Stay Beds in LTC Homes Persons in short-stay respite or convalescent care beds in LTC homes may not be transferred to long-stay beds in a LTC home without applying separately for long-stay admission This would entail having their eligibility for long-stay admission determined being authorized for admission by the CCAC and being placed on a waiting list according to long-stay prioritization criteria if a bed is not immediately available Resident Charges Resident accommodation fees apply for the Respite Care Program in accordance with the short-stay fees set out in table 3 of the NHA regulation The requirement for payment of these fees is set out in the NHA regulation

s 115(1) The maximum daily amount that may be demanded or accepted by or on behalf of a licensee for providing a short-stay resident with accommodation during a period in Column 1 of Table 3 is the amount in Column 2 of Table 3 set out opposite the period

September 2006 47

The resident charges for persons in respite care reflect that most people will continue to incur expenses related to a community dwelling while they are in the LTC home on a short-term basis There is no rate reduction available for the Respite Care Program As a matter of policy the Ministry of Health and Long-Term Care (MOHLTC) covers the accommodation fees for convalescent care residents through the subsidy paymentreconciliation process Consequently convalescent care residents are not charged the accommodation fees and LTC homes are not permitted to collect it from those residents Convalescent care residents may be charged for additional services such as telephone and television The requirements and fees associated with bed-holding for long-stay applicants do not apply to applicants for the short-stay programs (See subsection 155(1)(e) of the NHA in subsection 1172 in this manual which only applies to long-stay residents) Refusals of Offers of Short-Stay Admissions

Section 1411 of the NHA regulation permits but does not require the placement co-ordinator to remove an applicant from the waiting list if the applicant refuses an offer of admission

s 1411(1) A person may be removed from the waiting list for a nursing home to which the person is awaiting admission as a short-stay resident if the placement co-ordinator designated for the home under subsection 201 (3) of the Act offers to authorize the persons admission to the home and the person (a) refuses to consent to admission or (b) fails to move into the home on the day agreed to by the person

Removal from the list is at the discretion of the CCAC

s 1411(2) A person who is removed from the waiting list for a nursing home under subsection (1) shall be placed on the waiting list for the home again to await admission as a short-stay resident if the person provides to the placement co-ordinator designated for the home under subsection 201 (3) of the Act a new written request for authorization of his or her admission to the home as a short-stay resident

In order to get back on the waiting list for admission as a short-stay resident in a LTC home a person who has been removed from the waiting list must re-apply with a new written request for authorization of admission as a short-stay resident Note If the person who is removed from the waiting list waits longer than six months to request authorization for another short-stay admission to a LTC home the person must apply to have his or her eligibility re-determined Pursuant to section 155(4) of the NHA the CCAC may cancel the authorization of a short-stay admission if the person does not move into the LTC home on the day agreed to by the person

September 2006 48

s 155(4) A placement co-ordinator who authorizes a personrsquos admission to a nursing home as a short-stay resident may cancel the authorization if the person does not move into the home on the day agreed to by the person

The placement co-ordinator should cancel the authorization for admissions if the person does not move in on the agreed upon date unless there are exceptional circumstances where at the discretion of the placement co-ordinator the date of admission is changed

CCAC Client Services Policy Manual Chapter 12 Management of Long-Term Care Home Waiting Lists by CCACs

September 2006 1

Management of Long-Term Care Home Waiting Lists by CCACs

This subsection describes the requirements for prioritizing admissions to long-term care (LTC) homes and maintaining LTC home waiting lists All legislative references in this chapter unless stated otherwise are to the Nursing Homes Act (NHA) and Ontario Regulation 832 under the NHA and will be noted as such However similar provisions are contained in the Charitable Institutions Act (CIA) and Homes for the Aged and Rest Homes Act (HARHA) and their regulations

1211 Management of Waiting Lists

Section 139 of the NHA regulation sets out the requirements for the management of LTC home waiting lists by the Community Care Access Centre (CCAC) as follows

s 139(1) Each placement co-ordinator shall keep a waiting list for each of the nursing homes for which the placement co-ordinator is designated under subsection 201 (3) of the Act (2) The placement co-ordinator shall place on the waiting list rank for admission and remove from the list in accordance with sections 140 to 150 any person described in section 140 other than a person who is to be placed on the waiting list for interim beds under section 153 (3) Each placement co-ordinator shall also keep a refusal list for the purposes of section 141

Pursuant to section 139 the CCAC must bull keep an updated waiting list for each LTC home within its geographic area bull place a person on the waiting list rank the person for admission and remove the person

from the waiting list in accordance with the regulation and bull keep a refusal list

September 2006 2

1212 Placement on Waiting Lists for Admission to a LTC Home

Section 140 of the NHA regulation sets out the requirements related to the placement of persons on waiting lists for admission to LTC homes as follows

s 140(1) The placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act shall place a person on the waiting list for the nursing home if and only if (a) the person is determined by a placement co-ordinator to be eligible for admission to a nursing home (b) the person applies in accordance with this Regulation for authorization of his or her admission to the home (c) the licensee of the home approves the persons admission to the home and (d) placing the person on the waiting list for the home will not result in the total number of waiting lists for nursing homes approved charitable homes for the aged under the Charitable Institutions Act and homes under the Homes for the Aged and Rest Homes Act on which the person is placed exceeding three (2) Clause (1) (d) does not apply to a person who will be placed in category 1A or the short-stay category on the waiting list Note As a result of subsection 2 above the ldquothree LTC homerdquo waitlist limit does not apply to persons who will be placed in category 1A crisis or the short-stay category on the waiting list There are no restrictions on the maximum number of waiting lists on which these two groups may be placed

Pursuant to section 140 of the NHA the CCAC must

bull add the name of each eligible person to the waiting list of each LTC home to which the

person has applied after the LTC home operator has approved the personrsquos admission to the LTC home and

bull ensure that each eligible person is not placed on more than three LTC home waiting lists at any one time unless the applicant is in category 1A or applying for short-stay

1213 Application of Prioritization Criteria

The prioritization criteria set out in sections 143 to 1483 of the NHA regulation apply to persons who are seeking admission to a LTC home as long-stay residents Separate prioritization criteria apply to persons seeking admission to short-stay respite or supportive care programs (See subsection 119 in this manual) The various categories of prioritization for long-stay applicants are

bull category 1A bull category 1A1 bull category 1B bull category 2 bull category 3

September 2006 3

bull groups outside of numbered categories bull veterans bull exchange residents and bull LTC home residents who face relocation as a result of redevelopment to

bull related temporary home bull reopened home or bull replacement home

The ability of the CCAC to make an offer of admission to persons in the above referenced categories is dependant on the class of accommodation that becomes available in the LTC home Placement co-ordinators must take into account bull gender and bull type of accommodation (basic preferred semi-private preferred private)

1215 Overview of Prioritization Categories 1A-3

Note The CCAC must place a person on the highest possible category of the waiting list For example a person who meets the criteria for category 1B but is in crisis must be placed in category 1A of the waiting list

Prioritization Criteria Effective as of October 22 2004

Crisis Applicants I Person requires immediate admission as a result of a crisis arising from the personrsquos condition

or circumstances II Person occupies a bed in a hospital psychiatric facility or Schedule 1 facility and within six

weeks there will be no bed for the person as a result of a temporary or permanent closure of some or all of the beds due to an emergency or redevelopment

III Person occupies a bed in a long-term care home and within six weeks there will be no bed

for the person as a result of a temporary or permanent closure of all or some of the beds in the home1

Spousal Reunification

Reunification of spousespartners who are determined eligible as a result of their care needs and wish to reside together in the same long-term care home (This category applies in all of

1 This will only apply in situations where not all residents have been moved out of a long-term care home under category 2

At six weeks prior to closure of the long-term care home residents may be considered in crisis if they have not been placed in a long-term care home

September 2006 4

the following situations where both are still in the community one is already in a long-term care home or both are in a long-term care home but want to move together to another long-term care home)

Ethno-culturalreligious groups

Person is of the religion ethnic origin or linguistic origin primarily served by the long-term care home

I Person occupies a bed in a publicprivate hospital psychiatric hospital or Schedule 1

facility II Person is a resident of a long-term care home and will become homeless within 16

weeks as a result of a temporary or permanent closure of all or some of the beds in the long-term care home

III Person is a resident of a long-term care home and was or will be discharged from the

home - because of the inability of the home to provide a secure environment for the applicant

or - because of an absence for the purpose of receiving medical or psychiatric care or

undergoing medical or psychiatric assessment IV Person resides in the community and admission to a long-term care home is required

within the next three months because - should there be any change in the personrsquos condition or circumstances the person would

require immediate admission as a result of a crisis arising from the personrsquos condition or circumstances or

- attending to the personrsquos care needs is jeopardizing the health and well-being of the personrsquos caregiver

V Reunification of spousespartners who wish to reside together in the same long-term

care home (This only applies to a spousepartner determined eligible for the sole purpose of accompanying an eligible spousepartner into the same home for the purposes of reunification Ie Person does not have care needs of their own)

VI Person resides in a long-term care home and is waiting to move to their preferred long-

term care home

Persons who do not meet the requirements for placement in any other category

This includes but is not confined to

People residing in the community and waiting for a long-term care home but admission is

not required within the next three months because - the personrsquos condition is not expected to deteriorate or put the person at risk of physical

or emotional harm to self or others or

September 2006 5

- the personrsquos caregiver is able to continue to provide the same level of care without risk or harm to the person requiring care or to self

People already residing in a long-term care home who are not waiting for their preferred

long-term care facility but decide they want to move to another long-term care home

1216 Change of Category

A personrsquos condition can change very quickly The CCAC must place a person in a different category on the waiting list when the CCAC is aware that there has been a change in the personrsquos condition or circumstances or a change in the LTC home for which the person is on the waiting list This requirement is set out in subsection 154(1) of the NHA regulation as follows

s 154(1) If a placement co-ordinator knows of a change in the condition or circumstances of a person who is on a waiting list kept by the placement co-ordinator or knows of a change in a nursing home for which the person is on the waiting list and if the person should be placed in a different category on the waiting list under sections 142 to 1484 as a result of the change in his or her condition or circumstances or as a result of the change in the home the placement co-ordinator shall place the person in the different category

For example a person residing in his or her home in the community who is ranked in category 3 may undergo a significant change in his or her condition such that he or she can not continue to live in the community This person would then require immediate admission to a LTC home if he or she could not be served in the community In such a case the CCAC must consider whether to rank this person in category 1A (crisis)

1217 Notification

The CCAC must inform the person of his or her position on the waiting list and provide an estimate of waiting time to the best of his or her knowledge

1218 Mandatory Reporting of LTC Home Vacancies

Subsection 155(5) of the NHA regulation requires LTC home operators to report LTC home vacancies

s 155(5) A licensee of a nursing home shall inform the placement co-ordinator designated for the home under subsection 201 (3) of the Act of available accommodation in the home within 24 hours after the accommodation becomes available

Within 24 hours after a discharge occurs (which includes ldquodeathrdquo as the regulation now requires a discharge upon death) the LTC home operator is required to inform the CCAC designated for the LTC home that there is accommodation available in the home

September 2006 6

This provision is intended to ensure that a CCAC has current information to facilitate more efficient and timely handling of all placements and improved waitlist management It does not necessarily mean that a CCAC must immediately admit a new person The reporting provision relates to the reporting of bed vacancies not to the timeframe within which a bed must be filled There may be legitimate reasons why a vacant bed could be considered ldquounavailablerdquo for a couple of days following a vacancy (eg internal transfers need to clean and paint time to allow family to remove the residentrsquos belongings) but the LTC home must still inform the CCAC of the bed vacancy The CCAC and the LTC home operator must work together to determine when a vacant bed is ready for admission and the CCAC must keep track of the date on which a LTC home advises them of a bed vacancy Note The CCAC is not responsible for enforcing this regulatory requirement placed on LTC home operators This is the role of the Ministry of Health and Long-Term Care (MOHLTC) If a CCAC becomes aware of any LTC home operator that is not complying with this notification requirement the CCAC must advise the MOHLTCrsquos compliance advisor responsible for the LTC home in question

September 2006 7

Section 143 of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 1A of the waiting list for a long-term care (LTC) home s 14 (1) A person shall be placed in category 1A on the waiting list for a nursing home if the person requires immediate admission as a result of a crisis arising from the personrsquos condition or circumstances (2) A person shall be placed in category 1A on the waiting list for a nursing home if (a) the person occupies a bed in

(i) a hospital under the Public Hospitals Act or a private hospital licensed under the Private Hospitals Act (ii) a facility that is designated as a psychiatric facility under section 802 of the Mental Health Act and is not exempt under that section from the requirement to provide in patient services in paragraph 1 of subsection 4 (1) of Regulation 741 of the Revised Regulations of Ontario 1990 made under that Act or (iii) a facility listed in Schedule 1 to Regulation 272 of the Revised Regulations of Ontario 1990 made under the Developmental Services Act and

(b) there will be no bed for the person in the hospital or facility within six weeks as a result of (i) a permanent closure of all or some of the beds in the hospital or facility or (ii) a temporary closure of all or some of the beds in the hospital or facility due to an emergency or redevelopment

(3) A person shall be placed in category 1A on the waiting list for a nursing home if (a) the person is a long-stay resident of another nursing home an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act and (b) there will be no bed for the person in the facility within six weeks as a result of a permanent or temporary closure of all or some of the beds in the facility Note The Schedule 1 facilities under the Developmental Services Act (DSA) include Huronia Regional Centre (Orillia) Rideau Regional Centre (Smith Falls) and Southwestern Regional Centre (Blenheim)

1221 Types of Crisis Situations

The above referenced provision sets out three types of crisis situations bull community-based bull hospital andor LTC home based and bull clients requiring relocation due to hospital or LTC home closure within six weeks As no one situation is more critical than any other these three types of crisis situations are not ranked in the order in which they are listed above Ranking among crisis applicants is according to the urgency of each applicantrsquos need for admission

September 2006 8

1222 Community-Based Crisis

In the case of community-based clients a category 1A (crisis) admission to a LTC home occurs when a person as a result of some accident or event requires services that cannot be provided in the community and necessitates the personrsquos immediate admission to a LTC home Persons requiring crisis admission take precedence over other individuals on the waiting list for LTC home admission and must meet the eligibility criteria for admission to a LTC home To be considered in a crisis situation the Community Care Access Centre (CCAC) must consider the personrsquos condition or circumstances to be of such severity that it requires the CCAC to make every effort to arrange for his or her admission to a LTC home within the next seven days or as soon as possible depending on the availability of an appropriate vacancy Regardless of the type of crisis situation only the CCAC is entitled to determine eligibility for and authorize admission to a LTC home

When a personrsquos situation is designated as a crisis the CCAC must move the person to the top of the waiting list for immediate admission to his or her selected LTC home(s) If the personrsquos selected homes cannot accommodate an immediate admission the CCAC must advise the person and discuss with the person whether he or she will consent to being admitted into the homes that have vacancies (A similar issue may arise where a person selects a particular type of accommodation in a LTC home which is not available The CCAC must advise the person and discuss with the person whether he or she will agree to change the type of accommodation requested in order to facilitate his or her admission into a selected LTC home) When a person is in the crisis category the person is expected to accept the first available bed in a home of their choice2 However the person cannot be required to do so If a person refuses the first available vacancy in a LTC home of his or her choice the CCAC should as a matter of policy consider whether the person still meets the criteria for the crisis category The CCAC must not place a person in the crisis category to accommodate the personrsquos desire to ensure speedy access to a LTC home of choice In addition the CCAC must not categorize a personrsquos situation as a crisis as a strategy to move persons who for whatever reasons are resisting movement out of the hospital

Note The classification of a person in prioritization category 1A does not suspend the consent requirement in LTC home legislation Even in this situation the CCAC shall not authorize a person for admission to a selected LTC home unless the person (or if the person is incapable the personrsquos substitute decision-maker) has applied for admission to the specific home and consented to the admission to the specific home The only exception occurs where the person is in such a crisis situation that the person requires an immediate admission to a selected home and it is not reasonably possible to obtain the immediate consent of the personrsquos substitute decision-maker (SDM) In this case the CCAC may authorize the admission without consent but must take reasonable steps to locate the personrsquos SDM in order to seek his or her consent or refusal of consent to the admission (See chapter 4 in this manual for information on consent to admission to a LTC home)

2 Once in a LTC home the person can remain on the waiting list in category 2 for his or her preferred choice of LTC home

September 2006 9

Crisis admissions of community-based applicants usually arise from the following circumstances

bull an unexpected change in the personrsquos condition or circumstances that makes existing care

arrangements no longer appropriate or bull a person being at risk of physical emotional or financial abuse or harm if he or she remains

in the same environment or bull others in the environment being at risk of physical emotional or financial abuse or harm or bull caregiver breakdown

The CCAC determines the presence of a crisis situation based on assessments that indicate the personrsquos andor caregiverrsquos ability to function safely in his or her current environment has been compromised The CCAC also needs to consider whether the personrsquos health and safety needs can be met immediately by the provision of community-based services including the capacity of the CCAC to exceed the service maximums for personal support and homemaking services for up to 30 days in exceptional circumstances under subsection 3(3) of Regulation 38699 of the Long-Term Care Act 1994 (LTCA) It must be noted that community services cannot be provided without the consent of the person or SDM if the person is incapable of making the decision

1223 Hospital or Facility-Based Crisis

The majority of applicants deemed to be in a crisis situation by the CCAC will probably reside in the community However there may be instances where people could be deemed to be in a crisis situation while residing in a LTC home or hospital These could be as a result of bull condition or circumstances unique to the individual or bull systemic pressures HospitalLTC Home-Based Crisis Individual Condition or Circumstances

Individual condition or circumstances that could result in a person being declared in a crisis situation while staying in a hospital or LTC home setting include but are not limited to the following bull The person has been physically assaulted or injured by another patient or resident Despite

corrective measures taken to ensure that this does not occur again the person does not feel reassured and remains in a constant state of agitation

bull The person has been physically abused by a hospitalhome employee Despite corrective action the person no longer feels safe in the current environment

bull The person is at risk of jeopardizing the care of other patients because the hospital environment is not able to provide the necessary security to ensure the safety of the person or of others Of course the personrsquos care requirements must be able to be met in a LTC home and there may be some persons in this circumstance who require admission to a psychiatric facility

September 2006 10

The CCAC must review the individual circumstances of the case to determine if the person is in crisis arising from the personrsquos condition or circumstances

Presentation at an Emergency Ward The fact that a person on the waiting list for a LTC home appears at a hospital emergency ward does not automatically result in the person being prioritized in category 1A If the personrsquos condition has changed the CCAC must of course reassess the person On the basis of the reassessment the CCAC may decide to bull facilitate community-based services for the person bull initiate or increase CCAC in-home services or bull change the personrsquos priority category on the LTC waiting list The CCAC must not reprioritize the person if the conditions or circumstances necessitating admission to an LTC home have not changed

Social Admissions for Emergency Clients

A hospital may be the only place that can provide the necessary emergency careshelter (social admission) to a person experiencing a crisis situation who cannot be safely cared for with community services and where no LTC home vacancy is immediately available In this situation the person could be admitted to hospital and continue to be ranked under priority category 1A-crisis for admission to a LTC home In this situation the CCAC must conduct a comprehensive assessment of the personrsquos condition and circumstances After the personrsquos condition has been stabilized the person may not require admission to an LTC home particularly if the personrsquos condition is of short-term duration Note The CCAC must use this provision judiciously so that applicants do not inappropriately present themselves at emergency wards in order to be placed in the crisis category of the waiting list

Hospital-Based Crisis Systemic Pressures

Hospitals often have patients who respond well to treatment and no longer require acute hospital care However the patient is not able to return home These patients may require care in a complex continuing care hospital rehabilitation hospital or LTC home These patients are designated as alternative level of care (ALC) Hospitals have different capabilities to accommodate patients designated as ALCs When capacity to admit persons to a hospital is severely compromised one strategy for resolution is to classify that hospitalrsquos patients who require care in a LTC home as being in a crisis situation and requiring immediate admission into a LTC home

September 2006 11

There may be circumstances when there is a systemic crisis and it is appropriate to expedite the admission of ALC patients to LTC homes The CCAC has the authority to change the waiting list category of ALC patients to category 1A Indicators that there is a systemic crisis that may be resolved by expediting the admission of ALC patients to LTC homes include bull normally scheduled elective acute care admissions are cancelled or deferred due to bed

occupancy pressures bull non-elective acute care patients cannot be admitted to the hospital and are being transferred

to other acute care hospitals due to bed occupancy pressures bull patients appropriate for admission to one care unit andor critical care unit cannot be

admitted due to bed occupancy pressures in the units and bull number of overnight emergency department patients (ie admit to ldquono bedsrdquo) impedes

operations in the emergency department Since this is a community systems issue it must be addressed by all service partners in the community Situations that are not to be considered a systemic crisis include but are not limited to the following bull temporary periods of congestion that only last a few days bull hospitals closing down beds temporarily in the summer time and bull hospitals that retain ALC clients in hospital as long as possible to keep a bed filled until

these beds are required and then request the CCAC to place applicants in LTC homes in a compressed time period

Processes involved in designating a systemic crisis include

1 Discussions between the Ministry of Health and Long-Term Care (MOHLTC) Regional

Director CCAC and hospital regarding the situation and the hospitalrsquos ALC patientsrsquo discharge plans and where appropriate discussions between other MOHLTC regional offices

2 Investigation by MOHLTC staff of the situation to ensure that the hospitalrsquos ability to meet

the acute care needs of the community is severely compromised as a result of

bull severe bed blocking in acute care beds and bull external forces specific to that community exacerbating the situation

3 MOHLTC staff ensuring that the hospitalrsquos discharge and assessment practices are

reviewed and these practices deemed acceptable

September 2006 12

4 Assessment of ALC patients by the CCAC to determine if they are eligible for LTC home placement or if their needs could or should be met through other resources including rehabilitation or chronic care facilities or community-based services

bull CCACs must ensure that the personrsquos needs cannot be met by community-based

resources as part of the eligibility determination process for admission to LTC homes bull A hospital may recommend that a person be placed in a LTC home however the

CCAC determines whether the person is eligible for admission 5 CCACs in collaboration with the MOHLTC developing a strategy that will not

compromise the safety of community-based residents who are also in crisis and waiting for LTC home admission Persons placed in the crisis category must be ranked in terms of urgency of their need for admission consequently an approach that would place all hospital-based clients ahead of community-based applicants would disregard the risk to community-based persons

6 Determining a specific time period during which this provision will be in effect This can

not be an open-ended arrangement

Notes bull A specific timeframe will be established based on the CCACrsquos estimate of the length of

time required to reduce congestion in a specific hospital (eg two weeks) Discussions will have to occur between the CCAC hospital and MOHLTC in this regard

bull The time period that this provision will be in effect must be clearly defined (eg days or weeks) and a date when the situation will be reviewed should be specified Timeframes must not be specified in an open-ended manner (eg during the flu season)

7 The decision to use the systemic crisis provision must be made on a hospital-by-hospital

basis as the regulations require that the crisis is due to the personrsquos circumstances (or condition) The determination of a crisis and the subsequent strategy involving admissions to LTC homes apply to a specific community and at a specific time

The determination of a crisis situation at a particular hospital and the strategies to deal with the crisis are not automatically transferable to other hospitals in that community Nor are they transferable to other communities

Notes bull The classification of hospital inpatients in prioritization category 1A due to a systemic

crisis situation does not suspend the consent provisions of LTC home legislation Even in this situation the CCAC cannot authorize a person for admission to a selected LTC home unless the person (or if the person is incapable of making the decision the personrsquos SDM)

September 2006 13

has applied to the specific home and consented to the admission to the specific home The only exception occurs where the person is in such a crisis situation that the person requires an immediate admission to a selected home and it is not reasonably possible to obtain the immediate consent of the personrsquos SDM In this case the CCAC may authorize the admission without consent but is required to take reasonable steps to locate the personrsquos SDM in order to seek his or her consent or refusal of consent to the admission (See chapter 4 in this manual for additional information on consent to admission to a LTC home)

bull Furthermore the regulations require that a CCAC offer an applicant the class of accommodation that the applicant requested If the applicant has requested a certain class of accommodation but the first bed available is in a different class the CCAC may discuss with the applicant the possibility of amending the personrsquos choices and taking the available bed If the person accepts and the bed is in a LTC home that is not the personrsquos first choice the person is then be able to wait for a transfer to his or her preferred LTC home in prioritization category 2 If the person accepts a different class of accommodation in the personrsquos first choice home in that case the person could ask to be placed on the homersquos transfer list under section 158 of the NHA regulation Nevertheless the CCAC cannot compel the hospital applicant to amend his or her choices to take the alternate bed If the hospital applicant is unwilling to take the alternate bed the CCAC has no authority to authorize admission See the comments above concerning consent to admission

LTC Home-Based Crisis Emergency Situations in LTC Homes Emergency situations requiring crisis admission of residents from one LTC home into another LTC home include bull an operator suddenly going out of business or bull natural or environmental disasters such as a fire or a gas leak In disaster situations an

emergency response involving the relevant service partners in the community will be necessary to ensure the safe and speedy relocation of all residents

1224 Clients Requiring Relocation Due to Home Closure within Six Weeks

A LTC home may need to close temporarily or permanently and partially or totally Closures may be the result of planned renovations or closures or emergency situations With planned closures either temporary or permanent it is anticipated that residents will be relocated in a timely manner and that the usual movement of residents and a moratorium on admissions would assist the process Nevertheless there may be situations where residents have not been relocated within six weeks of the planned closing If these persons are not relocated they will become homeless To ensure that such persons are appropriately relocated they are considered to be in a category 1A (crisis) situation and the CCAC must prioritize them as such

September 2006 14

Note 1A also applies to hospitals psychiatric facilities and Schedule 1 DSA facilities that are permanently closing beds or are temporarily closing beds due to emergency or redevelopment (See section 143(2)(b) of the NHA regulation)

September 2006 15

Section 1431 of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 1A1 of the waiting list for a long-term care (LTC) home

s 1431 A person shall be placed in category 1A1 on the waiting list for a nursing home if (a) the person does not meet the requirements for placement in category 1A (b) the personrsquos spouse or partner is a long-stay resident of the nursing home or neither the person nor his or her spouse or partner is a long-stay resident of the nursing home but both wish to reside in the nursing home and (c) the person meets the eligibility criteria set out in subsection 130 (1) According to the above provision spousespartners who both wish to reside in the same LTC home and are both eligible as a result of their care needs are to be placed in category 1A1 of an LTC homersquos waiting list A spousepartner who does not require care but who is determined eligible only for the purpose of accompanying (or joining) his or her eligible spouse will continue to be placed in category 2

Note There is no change to the requirement to place persons requiring immediate admission as a result of a crisis arising from their condition or circumstances into category 1A of the waiting list As a result of the wording of clause ldquo(b)rdquo above the 1A1 category of prioritization applies in all of the following situations when both spousespartners have care requirements bull when a person is seeking reunification with a spousepartner who is already in the home to

which the person is applying bull when the person and the personrsquos spousepartner are still in the community but both wish

to reside in the same LTC home bull when both are in different LTC homes but wish to live together in the same home be it

one of the two where they currently reside or a completely different LTC home and bull when both are in the same LTC home but wish to move together to a different LTC home Note In the situation where a spousepartner who has no care needs of his or her own wishes to accompany a spousepartner who is eligible for placement based on care needs the two individuals will be in different categories of prioritization The person with the care needs will be prioritized in category 1A1 while the spousepartner who has no care needs will be prioritized in category 2 (See subsection 125 in this manual for additional information on prioritization category 2) A further important and somewhat different feature of the 1A1 category relates to the ranking of applicants within this category Eligible spousespartners placed in category 1A1 are ranked in this category according to the time at which their spousespartners applied for authorization of their admission to the home

September 2006 16

The fact that this date of authorization may predate the determination of eligibility of the spousepartner who is seeking to be reunified is not relevant as its sole purpose is for ranking within this category If the applicantrsquos category were to change to another category (eg if the applicant became a crisis applicant) the spousersquospartnerrsquos date of authorization would no longer apply In the case where the spousespartners are prioritized differently because one has care needs and the other does not (ie category 1A1 for the spouse with care needs and category 2 for the spouse who has no care needs) their ranking will also differ The ranking of spousespartners who are prioritized in category 2 is according to the date of their own application (See subsection 1282 in this manual for additional information on rules for ranking within categories)

Community Care Access Centres (CCACs) with clients who are spousespartners seeking admission to the same LTC home must caution applicants that prioritization in category 1A1 will not result in all eligible spousespartners being reunited immediately or necessarily being able to share the same room once both are admitted to the same LTC home Some spousespartners may not even be in the same part of the home This can result from the lack of availability of accommodation or differing care requirements For example one spouse with a severe cognitive impairment could potentially be in a different part of the home than a spouse who does not have a cognitive impairment In other cases reunification may not be as fast if the spousespartners are waiting for specific types of accommodation to become available such as basic semi-private or private rooms These are circumstances that go beyond prioritization It is also important to note that the regulation applies to ldquospouses or partnersrdquo and the term partners is defined in subsection 1(2) of the NHA regulation as

s 1(2) Two persons are partners for the purpose of this Regulation if they have lived together for at least one year and have a close personal relationship that is of primary importance in both persons lives

September 2006 17

Section 144 of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 1B of the waiting list for a long-term care (LTC) home

s 144 A person shall be placed in category 1B on the waiting list for a nursing home if (a) the person does not meet the requirements for placement in category 1A or 1A1 (b) the home is primarily engaged in serving the interests of persons of a particular religion ethnic origin or linguistic origin and (c) the person is of the religion ethnic origin or linguistic origin primarily served by the home

A Community Care Access Centre (CCAC) may only place persons of a particular religion ethnic origin or linguistic origin in category 1B of a LTC homersquos waiting list if the LTC home is ldquoprimarilyrdquo engaged in serving the interests of the particular group

ldquoPrimarilyrdquo engaged means that the main intent of the LTC home is to serve persons of a particular religion ethnic or linguistic origin This means that if a LTC home dedicates only a portion of its beds to serve the needs of a particular religion ethnic or linguistic community it does not pass the regulatory test that it is ldquoprimarilyrdquo engaged in serving the needs of a particular community As such the CCAC may not place persons from the religion ethnic or linguistic community in category 1B on the waiting list for this LTC home There are no provincial guidelines or standardized processes for acknowledging determining and designating LTC homes that provide services on a religious ethnic or linguistic basis The CCAC must determine whether a particular LTC home meets the regulatory test so it can place persons on the waiting list into categories It is expected that the CCAC would have developed its own processes to determine whether a particular LTC home meets the test Under LTC home legislation the CCAC must consider an applicantrsquos preferences relating to admission based on spiritual ethnic linguistic familial and cultural factors

September 2006 18

Section 145 of the Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 2 of the waiting list for a long-term care (LTC) home

s 145(1) A person shall be placed in category 2 on the waiting list for a nursing home if (a) the person does not meet the requirements for placement in category 1A 1A1 or 1B and (b) the person occupies a bed in

(i) a hospital under the Public Hospitals Act or a private hospital licensed under the Private Hospitals Act (ii) a facility that is designated as a psychiatric facility under section 802 of the Mental Health Act and is not exempt under that section from the requirement to provide in-patient services in paragraph 1 of subsection 4 (1) of Regulation 741 of the Revised Regulations of Ontario 1990 made under that Act or (iii) a facility listed in Schedule 1 to Regulation 272 of the Revised Regulations of Ontario 1990 made under the Developmental Services Act

(2) A person shall be placed in category 2 on the waiting list for a nursing home if (a) the person does not meet the requirements for placement in category 1A 1A1 or 1B (b) the person is a long-stay resident of another nursing home an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act and (c) there will be no bed for the person in the facility within 16 weeks as a result of a permanent or temporary closure of all or some of the beds in the facility (3) A person shall be placed in category 2 on the waiting list for a nursing home if (a) the person does not meet the requirements for placement in category 1A 1A1 or 1B (b) the person was or is a long-stay resident of another nursing home an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act and (c) the person was or will be discharged from the facility

(i) because the facility cannot provide a sufficiently secure environment to ensure the safety of that person or the safety of persons who come into contact with that person or (ii) because of an absence for the purpose of receiving medical or psychiatric care or undergoing medical or psychiatric assessment

(4) A person shall be placed in category 2 on the waiting list for a nursing home if (a) the person does not meet the requirements for placement in category 1A 1A1 or 1B and (b) the person requires admission within three months because

(i) should there be any change in the personrsquos condition or circumstances the person would require immediate admission as a result of a crisis arising from the personrsquos condition or circumstances or (ii) attending to the personrsquos care needs is jeopardizing the health and well-being of the personrsquos caregiver

September 2006 19

(5) A person shall be placed in category 2 on the waiting list for a nursing home if (a) the person does not meet the requirements for placement in category 1A 1A1 or 1B (b) the personrsquos spouse or partner is a long-stay resident of the nursing home or neither the person nor his or her spouse or partner is a long-stay resident of the nursing home but both wish to reside in the nursing home and (c) the person meets the eligibility criteria set out in section 132

(6) If a person applies for authorization of his or her admission to a nursing home a home under the Homes for the Aged and Rest Homes Act or an approved charitable home for the aged under the Charitable Institutions Act as a long-stay resident and a placement co-ordinator with the consent of the person authorizes the personrsquos admission to a facility that is not the personrsquos first choice the person shall if he or she wishes be kept on the waiting lists for the personrsquos preferred nursing homes and shall be placed in category 2

The following is a simplified description of the six types of applicants listed in the above provision who fall within this category 1 A person who is in a hospital psychiatric facility or a facility listed in Schedule 1 of the

regulations under the Developmental Services Act (DSA) and cannot be discharged home because the community-based services are inadequate or inappropriate to meet his or her needs or because he or she does not have an informal caregiver to provide them with the assistance they require at home

Note The Schedule 1 facilities under the DSA include Huronia Regional Centre (Orillia) Rideau Regional Centre (Smith Falls) and Southwestern Regional Centre (Blenheim)

2 A resident of a LTC home who will become homeless within 16 weeks as a result of a

temporary or permanent closure of all or some of the beds in the LTC home

Note Where residents have not been relocated within six weeks of the planned closing the Community Care Access Centre (CCAC) must categorize them in category 1A (crisis)

3 A resident (or a previous resident) of a LTC home who will be (was) discharged from the

LTC home and requires readmission to a LTC home Two specific types of situations which can result in discharge are identified

a) Resident who requires transfer to another LTC home because the home cannot provide

a sufficiently secure environment

Sometimes a residentrsquos condition changes after he or she is admitted to a LTC home For example some people with cognitive impairment may reach a stage where they require a secure ward to prevent them from wandering If the LTC home operator is advised by the health care professionals providing care to the resident that the home cannot provide a sufficiently secure environment to ensure the safety of the resident or the safety of persons who come into contact with the

September 2006 20

resident the LTC home operator may discharge the resident provided that other arrangements are made to provide the accommodation care and secure environment required by the person

These residents may apply to other LTC homes and the CCAC must place them in category 2

b) Resident who exceeds the permitted length of time to be absent from a LTC home as a

result of a medical or psychiatric leave or assessment

LTC homes are required to discharge a resident who exceeds the time limits set out in the regulations for medicalpsychiatric leaves of absences (See section 471 of Regulation 832 of the NHA for provisions related to absences for medical and psychiatric leaves) LTC homes are not required to advise the CCAC when a resident is transferred to a psychiatric facility or hospital However the CCAC will be advised of situations involving discharge when the discharged resident or his or her substitute decision-maker contacts the CCAC seeking LTC home admission back to the original LTC home or another LTC home These individuals may apply to the CCAC for readmission to the home from which they were discharged and the CCAC must place them in category 2

In the majority of cases persons prefer to go back to the LTC home where they originally resided Re-admission of these persons is possible if the previous LTC home can provide the type of care the person requires and a vacancy is available If a vacancy is not immediately available the person can consent to be admitted to another LTC home until a bed becomes available in his or her preferred LTC home The CCAC must provide updated and relevant assessment information about the applicant to the LTC home to which the person wishes to return or to another chosen LTC home if the preferred LTC home is not available Each LTC home must approve the admission to ensure that the required care can be provided

4 A community-based applicant whose condition is expected to deteriorate within three months or attending to the personrsquos care needs is jeopardizing the health and well-being of the caregiver

The Ministry of Health and Long-Term Care (MOHLTC) has developed guidelines that provide a framework for CCACs to differentiate between persons who require admission within three months (category 2) and those who do not Category 2 applicants are

bull persons who are totally dependent on others for three or more activities of daily

living (eg eating toileting personal hygiene and locomotion) bull persons who are verbally or physically abusive resistant to care or wander and

require 24-hour supervision

September 2006 21

bull persons who have moderate to severe cognitive impairments and require 24-hour supervision and

bull persons who have a combination of other issues that may necessitate admission within the next three months include but are not limited to the following bull environmental safety issues bull medical conditions requiring treatment bull recent history of falls or visits to the emergency department or bull a change in the capacity of formalinformal caregiving systems to provide the

support the person requires

5 A spousepartner who has no care needs of his or her own who wishes to accompany or reunite with a spousepartner who is eligible for placement or is already living in a LTC home

This category of prioritization only applies in the case of a spousepartner who is determined eligible for admission to a LTC home solely for the purpose of joining or accompanying the other spousepartner and not as a result of a personal need for LTC home care (This contrasts with the prioritization of spousespartners who are both determined eligible for admission to a LTC home on the basis of their own care needs as these individuals must be prioritized by the CCAC in category 1A1) The ranking of spousespartners who are prioritized in category 2 is according to the date of their own application This also differs from the ranking of spousespartners prioritized in category 1A1 as these individuals are ranked according to the date of application of their spousepartner

CCACs must be cautious about counselling a well spousepartner with regard to the timing of his or her application if the possibility exists that the well spousepartner could be admitted sooner than the spousepartner who has care needs For example if the well spouse is a male and beds for male applicants have been becoming available more frequently than beds for females a situation could arise where the well spousepartner will have to be made a bed offer before the spousepartner who needs care In such a situation acceptance of the offer could leave the spousepartner who requires care without a caregiver while a refusal of the offer will result in the personrsquos name being removed from all lists and not being able to re-apply for 24 weeks (unless there has been a deterioration in the personrsquos condition or circumstances in which case the person may apply sooner)

Notes bull The term spouse is defined in subsection 1(1) of the NHA regulation as

s 1(2) a person (a) to whom the person is married or

September 2006 22

(b) with whom the person is living or was living immediately before one of them was admitted to a nursing home in a conjugal relationship outside marriage if the two persons

6 A person who is admitted to a LTC home that is not the personrsquos first choice and he or she

wishes to remain on the waiting list for his or her preferred LTC home

Persons who enter a LTC home that is not their preferred choice and choose to wait for a bed to become available in their LTC home preferred choices remain in category 2 on the waiting list of their preferred home Such persons shall be ranked in category 2 according to the original date used to rank the person for admission to the preferred LTC home If a person agrees to be admitted to a LTC home that is not his or her first choice the CCAC must determine if the person wants to remain on other LTC home waiting lists at the time of admission to the LTC home If an applicant does not express the wish to remain on the waiting list of his or her preferred choice of LTC home upon admission to the second or third choice home and decides at a later date that he or she wishes to be on a waiting list for a different LTC home (eg because a new LTC home is opened) the resident will be placed in category 3 on the waiting list The original authorization date will not apply and this will be treated as a new application for transfer from one LTC home to another

September 2006 23

The Nursing Homes Act (NHA) regulation sets out the requirements for placement in category 3 of the waiting list for a long-term care (LTC) home

s 1483 A person shall be placed in category 3 on the waiting list for a nursing home if the person does not meet the requirements for placement in any other category

Persons ranked in category 3 include but are not limited to bull persons residing in the community who are waiting for a LTC home but admission is not

required within the next three months and bull persons resident in a LTC home who would like to move to another LTC home but are not

currently on a waiting list for any other home 1261 People Residing in the Community

The first group includes people residing in the community who do not require admission to a LTC home within the next three months They have conditions that are not expected to deteriorate or put themselves or others at risk and their caregivers are able to continue in the caregiver role without putting the person at risk or jeopardizing their own health and well-being ldquoPeople in the communityrdquo should be interpreted broadly They may be living in their own homes or settings where support may be available through private means or government-funded programs They may be receiving community-based services but the services are inadequate to meet their needs If community-based services are available and adequate the Community Care Access Centre (CCAC) must not declare them eligible for LTC home admission

Sometimes people requiring care may be in a community where no community-based services are available and may be at risk At other times informal caregivers are not able to supplement formal services or their ability to provide care is time-limited Without admission to a LTC home some of these people would be admitted to an acute care hospital unnecessarily

1262 People Residing in a LTC Home

The second group includes residents of a LTC home who would like to move to another LTC home and are not currently on a waiting list for another LTC home These people are different from those in a LTC home whose needs can no longer be met by the LTC home and therefore require a transfer to another LTC home (category 2) or people in a LTC home waiting to move to a LTC home of their preferred choice (category 2) People in a LTC home who wish to move to another LTC home must apply to the CCAC to request a transfer There could be any number of reasons why a person might want to move to

September 2006 24

another LTC home but two common examples include wanting to move to a newly opened LTC home in an area closer to family or preferring another LTC home

Although the CCAC must automatically determine these residents eligible for admission to another LTC home in accordance with section 133 of the NHA regulation the resident must still apply for authorization of admission to the selected LTC home The resident must also make an informed decision about choice of LTC home The CCAC must provide the operator of the LTC home chosen by the person with the application package so that the operator can determine whether to approve the admission If the LTC home operator approves the personrsquos admission the CCAC shall place the person on the waiting list for the LTC home in category 3 if no other prioritization categories apply Note LTC home operators may not transfer residents between LTC homes without going through the CCAC Only the CCAC can authorize admission to a LTC home

September 2006 25

The groups that are outside the numbered categories include bull veterans applying for veteransrsquo priority access (VPA) accommodation (see subsection 1271

in this manual) bull clients involved in specific hospital ndash LTC home trades (exchange category) (see subsection

1272 in this manual) and bull Long-term care (LTC) home residents who face relocation as a result of the LTC

redevelopment initiatives (see subsection 1273 in this manual) 1271 Veteransrsquo Priority Access Beds Category

The Nursing Homes Act (NHA) regulation sets out the criteria for placement in the veteransrsquo category

s 146 Despite sections 143 to 145 a person shall be placed in the veteran category on the waiting list for a nursing home if (a) the home contains veterans priority access beds (b) the person has applied for authorization of his or her admission to a veterans priority access bed and (c) the person is a veteran

The Ministry of Health and Long-Term Care (MOHLTC) and Veteranrsquos Affairs Canada have a negotiated agreement whereby a veteran who is eligible for LTC home admission and has applied for admission to a VPA bed in a LTC home will have priority for admission to the VPA bed over all other applicants The Community Care Access Centre (CCAC) must ask applicants whether they might qualify as a veteran and if so whether they want to apply for a VPA bed The CCAC must ensure that the application for admission is forwarded to Veteranrsquos Affairs Canada so that the CCAC can determine whether the applicant is an eligible veteran The CCAC must maintain a separate waiting list for eligible veterans who have applied for VPA accommodation An eligible veteran may choose any LTC home If the home does not have VPA accommodation the CCAC must place the veteran on the home waiting list and prioritize the veteran for admission in accordance with the regulatory provisions for non-veterans Note A veteran can apply for both VPA accommodation and a non-VPA accommodation within the same LTC home For the purpose of the three home waiting list rule this is considered as being on one LTC home waiting list

September 2006 26

1272 Exchange Category

The NHA regulation sets out the criteria for placement in the exchange category

s 147 Despite sections 143 to 145 a person shall be placed in the exchange category on the waiting list for a nursing home if (a) the person

(i) occupies a bed in a hospital under the Public Hospitals Act or a private hospital licensed under the Private Hospitals Act (ii) occupies a bed in a facility that is designated as a psychiatric facility under section 802 of the Mental Health Act and is not exempt under that section from the requirement to provide in-patient services in paragraph 1 of subsection 4 (1) of Regulation 741 of the Revised Regulations of Ontario 1990 made under that Act (iii) occupies a bed in a facility listed in Schedule 1 to Regulation 272 of the Revised Regulations of Ontario 1990 made under the Developmental Services Act or Note The Schedule 1 facilities under the Developmental Services Act (DSA) include Huronia Regional Centre (Orillia) Rideau Regional Centre (Smith Falls) and Southwestern Regional Centre (Blenheim) (iv) is a long-stay resident of another nursing home an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act

(b) the person is the subject of an agreement between the nursing home to which the person seeks admission at least one hospital or facility mentioned in subclause (a) (i) (ii) or (iii) and possibly one or more other hospitals facilities or homes to exchange identified residents or patients in order to meet the specialized requirements of any of the exchanged residents or patients and (c) the result of the exchange will be that the person will become a resident of the nursing home to which the person seeks admission and a resident of the nursing home will be discharged

People who are the subject of an agreement between LTC homes and hospitals psychiatric facilities or Schedule 1 facilities under the DSA for the purpose of exchanging residents or patients to meet their specialized requirements do not fall within the numbered priority categories This separate exchange category exists to facilitate these mutually beneficial exchanges The CCAC will be informed when an exchange is being considered In such situations the CCAC must

bull ensure that the person who is to be admitted to a LTC home has been determined as eligible

for LTC home admission and has been approved by the LTC home operator bull ensure that the necessary forms and required assessments are conducted and up- to-date in

accordance with the legislative requirements and

September 2006 27

bull authorize the admission to the LTC home according to the regulations and applicable LTC home Act (for example the requirement for the personrsquos consent to admission applies)

1273 Categories for Residents Facing Relocation Due to LTC Home

Redevelopment

Separate provisions have been placed in the regulation to streamline the admission process for persons who are directly affected by the LTC home redevelopment process The purposes of these provisions are to

bull minimize the impact on the CCAC workload bull limit unnecessary discharges and re-applications by LTC home residents who must be

relocated and bull facilitate as much as possible a smooth transfer between LTC homes for residents and

their families

Note Subsections 86(1) and (2) of the NHA regulation provide that an operator of a LTC home who intends to close all or some of the beds on a temporary or permanent basis is required to provide 16 weeks written notice of the closure to the director (LTC Homes Branch MOHLTC) home administrator affected residents (and their substitute decision-makers (SDMs)) and the CCAC designated for the home After receiving notice of the closure the CCAC must contact each affected resident or his or her SDM to begin the process of finding another LTC home A number of transfer scenarios will occur as a result of LTC home redevelopment activities These are bull relocation of residents to a ldquorelated temporaryrdquo LTC home managed by the same operator

followed by a transfer to the ldquore-openedrdquo LTC home managed by the same operator bull relocation of residents to a ldquonon-related temporaryrdquo LTC home managed by a different

operator followed by a transfer to the ldquore-openedrdquo LTC home and bull direct transfer of residents to a redeveloped ldquoreplacementrdquo LTC home managed by the same

operator Note The regulatory provisions related to the ldquorelated temporaryrdquo ldquore-openedrdquo and ldquoreplacementrdquo categories of prioritization apply only to persons who are or were long-stay residents of the original LTC home Once all the residents from the ldquooldrdquo LTC home have been relocated the remaining beds in the new LTC home will be governed by the other waiting list categories

Scenario 1 Relocation of Residents to a ldquoRelated Temporaryrdquo Home Followed by a Transfer to the ldquoRe-Openedrdquo Home Sections 148 and 1481 of the NHA regulation state

September 2006 28

s 148 Despite sections 143 to 145 and section 147 but subject to section 146 a person shall be placed in the related temporary nursing home category on the waiting list for a nursing home if (a) the nursing home is or will be a related temporary nursing home and (b) the person is a long-stay resident of the original nursing home or was a long-stay resident of the original nursing home immediately before the closure of his or her bed in the home s1481 Despite sections 143 to 145 and section 147 but subject to section 146 a person shall be placed in the re-opened nursing home category on the waiting list for a nursing home if (a) the nursing home is or will be a re-opened nursing home and (b) the person is a long-stay resident of the original nursing home or was a long-stay resident of the original nursing home immediately before the temporary closure of his or her bed in the home This situation occurs when all or some of the beds in a LTC home close temporarily and another LTC home managed by the same operator provides accommodation to the residents on a temporary basis until the beds in the original LTC home re-open and are available for these residents Residents who accept to transfer to the related temporary LTC home and later move back to the re-opened LTC home will go through a streamlined admission process Pursuant to sections 134(2) and (3) 136(11) and 1381(1) and (2) of the NHA regulation the following streamlined admission process applies to both the initial move and the move back to the re-opened home at a later date

Streamlined Admission Process

1 The long-stay applicants of the original LTC home are exempt from

bull establishing that they are at least 18 years old bull providing their request for a determination of eligibility on the form provided by the

Minister of Health and Long-Term Care bull providing proof that the person is an insured person under the Health Insurance Act

(HIA) bull providing an up-to-date health assessment of the person bull providing an up-to-date functional assessment and bull providing their request for authorization of admission in writing

2 The CCAC is not required to provide the LTC home with the information relevant to a

determination of whether to give or withhold approval for the personrsquos admission to the LTC home or request that the LTC home determine whether to give or withhold approval of the personrsquos admission to the home

3 The LTC home is deemed to approve the applicantrsquos admission to the related temporary and later the re-opened LTC home

September 2006 29

Subject to the availability of vacancies residents would be guaranteed the same type of accommodation (basic preferred) in the re-opened LTC home as they had in the old LTC home In a situation where the related temporary or re-opened LTC home has fewer beds than the original home and cannot accommodate all of the original residents residents will be ranked according to the date of their admission to the original LTC home (See subsection 1282 in this manual for additional information on rules for ranking within categories) Any residents of the original LTC home who do not transfer to the related temporary or the re-opened LTC home3 will have to go through the regular admissions process and be prioritized in either category 1A (crisis) or category 2 depending on the number of weeks left until the residentrsquos bed closes

Scenario 2 Relocation of Residents to a ldquoNon-Related Temporaryrdquo Home Followed by a Transfer to the ldquoRe-Openedrdquo Home This situation occurs when some or all of the beds in a LTC home are temporarily closing and another LTC home managed by a different operator provides accommodation to the residents on a temporary basis until the beds in the re-opened LTC home are available

In keeping with existing legislative requirements all residents temporarily relocated to accommodation managed by another LTC home operator during the redevelopment will go through the regular admission process while the transfer back to the re-opened LTC home is subject to the streamlined admission process described above When residents accept to transfer to the non-related temporary LTC home only those exemptions that apply in all cases of LTC home to LTC home transfer apply This means that to transfer to a non-related temporary home long-stay applicants of the original LTC home are only exempt pursuant to subsection 134(2) of the NHA regulation from

bull establishing that they are at least 18 years old bull providing proof that the person is an insured person under the HIA bull providing an up-to-date health assessment of the person and bull providing an up-to-date functional assessment

The transfers back to the re-opened LTC home are subject to the same streamlined admissions process as described in the previous scenario under items 1 to 3 above

Scenario 3 Direct Transfer of Residents to a Redeveloped ldquoReplacementrdquo LTC Home

The NHA regulation states

3 Circumstances where a resident may not be transferring to the related temporary or re-opened LTC home could include situations where the resident chooses not to transfer to the LTC home or where a LTC home has downsized and can no longer accommodate all of the former residents

September 2006 30

s 1482 Despite sections 143 to 145 and section 147 but subject to section 146 a person shall be placed in the replacement nursing home category on the waiting list for a nursing home if (a) the nursing home is or will be a replacement nursing home and (b) the person is a long-stay resident of the original nursing home or was a long-stay resident of the original nursing home immediately before the permanent closure of his or her bed in the home In this situation some or all of the LTC homersquos beds are closing on a permanent basis and the new LTC home managed by the same operator is the replacement for the LTC home being closed The development of the new replacement LTC home proceeds without interfering with the operation of the existing LTC home When the new LTC home is completed residents in the existing LTC home have the option of transferring to the new replacement LTC home Residents who accept the option to transfer to the new replacement LTC home go through the streamlined admission process described in scenario 1 above Subject to the availability of vacancy residents are guaranteed the same type of accommodation (basic preferred) in the new replacement LTC home as they had in the old LTC home If the new replacement LTC home has fewer beds than the old LTC home a program of attrition during the construction period is mandated as part of the LTC homersquos service agreement with the MOHLTC If despite the program of attrition not all of the original residents can be accommodated in the new home residents will be ranked according to the date of their admission to the original LTC home (See subsection 1282 in this manual for additional information on rules for ranking within categories) Residents from the original LTC home who do not transfer to the replacement LTC home must go through the regular admission process They will be prioritized as category 1A (crisis) or category 2 depending on the number of weeks left until the residentrsquos bed closes Note While the admission process has been streamlined for residents facing relocation due to LTC home redevelopment the CCAC must still ensure that the person consents to the admission The CCAC must prioritize the person manage the waiting list and authorize the personrsquos admission to the new or redeveloped LTC home

September 2006 31

128 Ranking of Priority Categories 1281 Ranking of Categories

The Nursing Homes Act (NHA) regulation sets out the method of ranking the priority categories

s 149 For each class of beds set out in a column of Table 4 the categories on the waiting list shall be ranked in the order set out in the rows below that class of beds such that a category mentioned in a higher row ranks ahead of a category mentioned in a lower row

TABLE 4

Ranking of Waiting List Categories

Column 1 Column 2 Column 3 Column 4 Column 5 Column 6

Class of Beds

Beds in a related temporary nursing home other than veteransrsquo priority access beds

Beds in a re-opened nursing home other than veteransrsquo priority access beds

Beds in a replacement nursing home other than veteransrsquo priority access beds

Veteransrsquo priority access beds in a nursing home other than a related temporary re-opened or replacement nursing home

Veteransrsquo priority access beds in a related temporary re-opened or replacement nursing home

All other beds in a nursing home

Related temporary

Re-opened Replacement Veteran Veteran Exchange

Exchange Exchange Exchange Exchange Related temporary re-opened or replacement as applicable

1A 1A 1A 1A Exchange 1A1

1A1 1A1 1A1 1A1 1A 1B

1B 1B 1B 1B 1A1 2

2 2 2 2 1B 3

3 3 3 3 2

Waiting List Categories

September 2006 32

Category 1A is the highest ranking priority category while category 3 is the lowest category where it will take longer for an applicant to be placed An applicant may be on two waiting lists in different categories For example a person applying as an ethno-cultural applicant to a long-term care (LTC) home primarily engaged in services and programs to meet the specific ethno-cultural needs would be in category 1B However the same person may also wait for another LTC home that is not primarily engaged in the ethno-cultural services and programs In this case the person would be placed in another waiting list category for the other LTC home This situation does not affect the applicability of the three choice rule This rule still applies with the exception of applicants in prioritization category 1A

1282 Rules for Ranking within Categories

The NHA regulation sets out the method of ranking within the priority categories

s 150(1) Within a waiting list category set out in Column 1 of Table 5 persons shall be ranked for admission in accordance with the rules set out opposite the category in Column 2 of Table 5

TABLE 5

Rules for Ranking within Categories

Item Category Rules

1 Related temporary re-opened and replacement nursing home

Persons shall be ranked according to the date of their admission to the original nursing home

2 Veteran (a) Veterans who require immediate admission as a result of a crisis arising from their condition or circumstances shall rank ahead of all other veterans

(b) As among themselves veterans who require immediate admission as a result of a crisis arising from their condition or circumstances shall be ranked according to the urgency of their need for admission

(c) Veterans who do not require immediate admission as a result of a crisis arising from their condition or circumstances but are continuum of care applicants on the waiting list for the continuum of care nursing home shall rank ahead of all other veterans who do not require immediate admission as a result of a crisis arising from their condition or circumstances

September 2006 33

Item Category Rules

(d) As among themselves veterans who do not require immediate admission as a result of a crisis arising from their condition or circumstances but are continuum of care applicants shall be ranked according to the time at which they applied for authorization of their admission to the nursing home

(e) As among themselves veterans who do not require immediate admission as a result of a crisis arising from their condition or circumstances and are not continuum of care applicants shall be ranked according to the time at which they applied for authorization of their admission to the nursing home

3 1A Persons shall be ranked according to the urgency of their need for admission

31 1A1 Persons shall be ranked according to the time at which their spousespartners applied for authorization of their admission to the nursing home

4 All categories other than those in items 1 2 3 31 and 5

(a) Persons who are continuum of care applicants on the waiting list for the continuum of care nursing home shall rank ahead of all other persons in the same category

(b) As among themselves persons in the same category who are continuum of care applicants shall be ranked according to the time at which they applied for authorization of their admission to the nursing home

(c) As among themselves persons in the same category who are not continuum of care applicants shall be ranked according to the time at which they applied for authorization of their admission to the nursing home

5 Short-stay Persons shall be ranked according to the time at which they applied for authorization of their admission to the nursing home

Some persons are ranked for admission in a category according to the date and time at which the person applied for authorization of admission This means the date and time at which the CCAC received all the information required for the application (eg the written request for authorization medical history functional and health assessments) The LTC home operator

September 2006 34

must approve the application and then the person is placed on a waiting list based on the authorization date

1283 Applicability of Rules for Ranking Regarding Additional Applications and

Appeal Situations

Subsection 150(2) of the NHA regulation sets out the ranking for homes to which an applicant makes application within six weeks of an initial application

s 150(2) If within six weeks after making his or her first application for authorization of admission to one or more nursing homes homes under the Homes for the Aged and Rest Homes Act or approved charitable homes for the aged under the Charitable Institutions Act as a long-stay resident and before being admitted to one of such facilities a person makes one or more additional applications for authorization of his or her admission to one or more nursing homes as a long-stay resident the additional applications made within the six-week period shall for the purpose of Table 5 be deemed to have been made at the time that the first application was made

Long-stay applicants who prior to their admission make additional applications within six weeks of their original application(s) are ranked with respect to the additional applications in accordance with the date of their original application Subsection 150(3) of the NHA regulation sets out the ranking for individuals who are determined eligible following an appeal to the Health Services Appeal and Review Board or Divisional Court relating to eligibility

s 150(3) If a person who was determined by a placement co-ordinator to be ineligible for admission to a nursing home as a long-stay resident is determined to be eligible for admission as a long-stay resident as a result of an application to the Appeal Board under subsection 205 (2) of the Act or an appeal to the Divisional Court under subsection 208 (1) of the Act and if the person then makes an application for authorization of his or her admission to one or more nursing homes homes under the Homes for the Aged and Rest Homes Act or approved charitable homes for the aged under the Charitable Institutions Act as a long-stay resident (a) that application for authorization shall for the purposes of Table 5 be deemed to have been made at the time that the placement co-ordinator determined that the person was ineligible for admission and (b) all additional applications for authorization of admission to one or more nursing homes as a long- stay resident made by the person within six weeks after making the first application and before being admitted to one of such facilities shall for the purpose of Table 5 be deemed to have been made at the time that the first application is deemed under clause (a) to have been made The authorization date for purposes of ranking a person who has been determined eligible following an appeal to the Health Services Appeal and Review Board or the Divisional Court is deemed to be the date that the CCAC determined that the person was ineligible In addition the

September 2006 35

authorization date of any applications made within six weeks of the original application is deemed to be the date that the CCAC determined that the person was ineligible

1284 Explanation of Continuum of Care

Continuum of care provisions relate to applicants who have resided in certain retirement or supportive housing residences as of a date prior to July 1 1994 and who are applying for admission to an affiliated LTC home4 (eg retirement homes affiliated with nursing homes or supportive housing programs attached to homes for the aged) The continuum of care residences and affiliated long-term care homes are listed in the Continuum of Care Facility Table published by the Ministry of Health and Long-Term Care (MOHLTC) and dated October 24 1996 Continuum of care applicants are given first choice of the available affiliated long-term care home beds through their ranking within categories Table 5 item 4 of the NHA regulation provides that ldquoPersons who are continuum of care applicants on the waiting list for the continuum of care nursing home shall rank ahead of all other persons in the same categoryrdquo This means that continuum of care applicants are not prioritized ahead of any categories but within the specific categories they are given the first choice of admission to the affiliated long-term care home It is important to note that this provision continues to apply only to those individuals who resided in an affiliated continuum of care residence prior to July 1 1994 There has been no expansion of this client group since that date

4 The placement co-ordination regulations which were first introduced in 1994 reflected the governments intent to make access to government funded LTC more equitable and primarily dependent upon a persons care needs However at that time the government also recognized the need to address the situation of individuals who had been made promises of access to long-term care homes on the basis of making their residence in an affiliated retirement residence The manner in which this issue was addressed in the 1994 regulations was to identify individuals who had entered into a continuum of care arrangement prior to the introduction of the new regulations as continuum of care applicants and to provide a separate category of prioritization for these individuals This separate category of prioritization for these individuals was intended as a transitional category that was expected to be phased out once all of the individuals who had been made this type of promise had been placed or otherwise removed from the waiting lists of these homes Amendments to the regulations that took effect May 1 2002 continued to honour the earlier commitment of recognizing individuals who were made promises of access to an affiliated long-term care facility albeit with some differences Continuum of care applicants were removed as a separate priority category but are given first choice of the available affiliated long-term care home beds through their ranking within categories This means that continuum of care applicants are not prioritized ahead of any categories but within the specific categories they are given the first choice of admission to the affiliated long-term care facility Please note that the revised provisions continue to apply only to those individuals who resided in an affiliated continuum of care residence prior to July 1 1994 There was no expansion of this client group as a result of the 2002 amendments

September 2006 36

The Community Care Access Centre (CCAC) must maintain a separate waiting list for admission to interim beds in long-term care (LTC) homes that have entered into a service agreement for interim beds Access to interim beds is restricted to hospital patients only Only a person who is a patient in a public hospital may be admitted to an interim bed Community-based applicants are not eligible and cannot be admitted to an interim bed Subsections 1(2) and 153 of the Nursing Homes Act (NHA) regulation state s1(2) Interim bed means a bed that exists in a nursing home for a temporary period of time under the terms of a service agreement for interim beds s 153(1) The placement co-ordinator designated under subsection 201 (3) of the Act for a nursing home that has entered into a service agreement for interim beds shall keep a waiting list for admission to the interim beds (3) The waiting list for interim beds shall be kept in addition to and separately from the waiting list required to be kept under section 139 (4) A person shall be placed on the waiting list for interim beds for a nursing home if (a) the person meets the requirements of section 140 Section 140 of the NHA requires bull the person is determined eligible for admission to a LTC home bull the person applies for authorization of his or her admission to the home bull the licensee of the home approves the personrsquos admission and bull the total number of waiting lists on which the person is placed does not exceed three

The three waiting list rule applies to persons seeking admission to interim beds located in LTC homes A person may apply for admission to both interim beds and long-stay beds however the combined number of waiting lists upon which the person can be placed cannot exceed three unless the person is prioritized in category crisis 1A

s153(4)(b) the person is a patient in a hospital that is a public hospital as defined in section 1 of the Public Hospitals Act (c) a physician has determined that the person does not require the acute care services provided by the hospital and (d) the person has applied for authorization of his or her admission to an interim bed in the nursing home The policy underlying the above regulatory provisions is to restrict who can be admitted to interim beds in order to restrict the beds to hospital patients thereby alleviating hospital pressures The purpose of interim beds is to provide for the preferential placement of persons who are in hospital These beds are not available to anyone else and individuals placed into these beds should remain on the waiting list for a regular long-stay bed even if their preferred choice home is the same as where the interim bed is located This is to ensure continued ldquoflow-throughrdquo of hospital-based applicants

September 2006 37

1291 Ranking for Interim Beds

All ranking for interim beds is according to the date and time at which the person applied for the authorization of admission Subsection 153(5) of the NHA regulation states s 153(5) Persons on a waiting list for interim beds for a nursing home shall be ranked for admission according to the time at which they applied for authorization of their admission to an interim bed in the nursing home There are two exceptions to the ranking of applicants according to their date of application for authorization (See Applicability of Rules for Ranking Regarding Additional Applications and Appeal Situations in subsection 1283 in this manual)

September 2006 38

1210 Refusals of Offers of Long-Stay Admission to LTC Homes 12101 Refusal List

The Community Care Access Centre (CCAC) must maintain a refusal list for persons whose names are removed from the waiting list for admission as long-stay residents under section 141 of the Nursing Homes Act (NHA) regulation subject to the exception noted in 12103 in this manual The NHA regulation states s 141(1) A person shall be removed from the waiting list for each nursing home to which the person is awaiting admission as a long-stay resident and shall be placed on the refusal list if (a) the person

Note The Schedule 1 facilities under the Developmental Services Act (DSA) include Huronia Regional Centre (Orillia) Rideau Regional Centre (Smith Falls) and Southwestern Regional Centre (Blenheim)

(b) a placement co-ordinator offers to authorize the persons admission to a nursing home an approved charitable home for the aged under the Charitable Institutions Act or a home under the Homes for the Aged and Rest Homes Act as a long-stay resident and the person

September 2006 39

12102 ldquoOne-Offerrdquo Requirement

Under the ldquoone-offerrdquo requirement community-based applicants and those already resident in a long-term care (LTC) home waiting to transfer to another LTC home must be removed from all LTC home waiting lists if the CCAC advises them that a bed is available in one of their selected LTC homes and they refuse to consent to be admitted to the LTC home refuse to enter into the agreement referred to in the regulation or fail to move into the home as referred to in the regulation After removal from all waiting lists the CCAC must place these applicants on a separate list (the ldquoRefusal Listrdquo) The person is still considered eligible for admission however he or she will not be contacted when a vacancy becomes available The ldquoone-offerrdquo requirement does not apply to hospital-based applicants (as well as psychiatric facility patients and residents of Schedule 1 DSA facilities) who refuse to consent to be admitted to a selected LTC home While LTC home legislation does not permit the CCAC to authorize individuals for admission without their consent hospital-based applicants should be encouraged to take the first vacancy that becomes available from among their LTC home choices even if that home is not their first choice These applicants should be advised that if they accept placement into a LTC home that is not their first choice they can wait for their other preferred LTC home choices in priority category 2 and be transferred when a bed becomes available However these hospital or facility-based applicants cannot be compelled to accept placement in a home that is not their first choice The ldquoone-offerrdquo requirement is intended to reduce the number of refusals to offers of LTC home admissions The policy is expected to speed up the process of admissions to LTC homes

12103 Exemption to the ldquoOne-Offerrdquo Requirement Short-Term Illness

Subsection 141(2) of the NHA regulation states s 141(2) Subsection (1) does not apply if the reason the person acts in the manner described in subclause (1) (b) (i) (ii) or (iii) is that the person has a short-term illness or injury which (a) prevents the person from moving into the facility at that time or (b) would make moving into the facility at that time detrimental to the persons health Persons who refuse an offer of admission as a result of a short-term illness or injury that prevents them from moving into the LTC home will not be removed from the waiting list(s) of their LTC home choice(s) They will remain on the waiting list for other offers of admission This ensures that persons who must refuse an offer of admission as a result of a short-term illness (eg the flu or a LTC home that is in outbreak and cannot accept an offer of admission or injury) are not disadvantaged by the ldquoone-offerrdquo requirement

September 2006 40

12104 Reinstatement and Ranking on Waiting List after Refusal

Subsection 141(3) of the NHA regulation states s 141(3) If a person described in subclause (1) (a) (i) is removed from the waiting list for a nursing home under subsection (1) the person shall be placed on the waiting list for the home again to await admission as a long-stay resident if (a) the person provides to the placement co-ordinator designated for the home under subsection 201 (3) of the Act a new written request for authorization of his or her admission to the home as a long-stay resident and (b) placing the person on the waiting list for the home will not result in the total number of waiting lists for nursing homes approved charitable homes for the aged under the Charitable Institutions Act and homes under the Homes for the Aged and Rest Homes Act on which the person is placed exceeding three Persons residing in LTC homes who refuse an offer of admission to another LTC home will lose their priority and are required to re-apply There is no waiting period to re-apply for LTC home-based applicants They may re-apply to transfer to another LTC home at any time The resident must provide the CCAC with a new written request for authorization of admission Subsection 141(4) of the NHA regulation states s 141(4) If a person described in subclause (1) (a) (ii) is removed from the waiting list for a nursing home under subsection (1) the person shall be placed on the waiting list for the home again to await admission as a long-stay resident if (a) the person provides to the placement co-ordinator designated for the home under subsection 201 (3) of the Act a new written request for authorization of his or her admission to the home as a long-stay resident and

(i) the request is provided 24 weeks or more after the day the person was removed from the waiting list or (ii) the request is provided less than 24 weeks after the day the person was removed from the waiting list but there has been a deterioration in the persons condition or circumstances and

(b) placing the person on the waiting list for the home will not result in the total number of waiting lists for nursing homes approved charitable homes for the aged under the Charitable Institutions Act and homes under the Homes for the Aged and Rest Homes Act on which the person is placed exceeding three (5) Clause (4) (b) does not apply to a person who will be placed in category 1A on the waiting list for the home Community-based applicants must wait six months before re-applying to get back on any LTC home waiting list unless their situation or condition deteriorates

September 2006 41

12105 Ranking upon Re-application

Subsection 150(4) of the NHA regulation states s 150(4) Despite subsection (2) if a person provides to the placement co-ordinator designated for a nursing home under subsection 201 (3) of the Act a new request for authorization of admission to the home under subsection 141 (3) or (4) or 1411 (2) the person shall for the purpose of Table 5 be deemed to have applied for authorization of admission to the home at the time of the provision of the new request A person whose name has been removed from the waiting list as a result of a refusal under sections 141(1) or 1411(2) and who re-applies for admission to a LTC home must be ranked by the CCAC on the waiting list according to the date of the new request for admission to a LTC home This provision applies to persons who apply for LTC home admission as short-stay or long-stay residents

September 2006 42

1211 Waiting Lists for Short-Stay Programs 12111 Waiting lists for Short-Stay Programs

The Community Care Access Centre (CCAC) must maintain a separate waiting list for admissions to short-stay beds in long-term care (LTC) homes Subsection 1484(1) of the Nursing Homes Act (NHA) regulation states s 1484(1) Sections 143 to 1483 do not apply to a person applying for authorization of admission to a nursing home as a short-stay resident in the respite care or supportive care program (2) A person referred to in subsection (1) shall be placed in the short-stay category on the waiting list for the nursing home

12112 Ranking for Short-Stay Programs

Subsection 150(1) of the NHA sets out the methodology of ranking for short-stay programs as follows s 150 (1) Within a waiting list category set out in Column 1 of Table 5 persons shall be ranked for admission in accordance with the rules set out opposite the category in Column 2 of Table 5 Table 5 states that for short-stay applicants persons shall be ranked according to the time at which they applied for authorization of their admission to the LTC home (See Table 5 in subsection 1282 in this manual)

September 2006 43

1212 Refusals of Offers of Short-Stay Admissions to LTC

Homes 12121 Refusals of Offers of Short-Stay Admissions to LTC Homes

(See subsection 1194 in this manual) 12122 Ranking upon Re-application

(See subsection 12105 in this manual)

CCAC Client Services Policy Manual Appendix A Glossary of Terms

September 2006 1

Appendix A

Glossary of Terms

Acts and Regulations CA ndash means the Corporations Act CCACA ndash means the Community Care Access Corporations Act 2001 SO 2001 chapter 33 CIA ndash means the Charitable Institutions Act RSO 1990 chapter C9 DSA ndash means the Developmental Services Act EA ndash means the Education Act RSO 1990 chapter E2 FLSA ndash means the French Language Services Act RSO 1990 chapter F32 HARHA ndash means the Homes for the Aged and Rest Homes Act RSO 1990 chapter H13 HARPA ndash means the Healing Arts Radiation Protection Act RSO 1990 chapter H2 HCCA ndash means the Health Care Consent Act 1996 SO 1996 chapter 2 HIA ndash means the Health Insurance Act RSO 1990 chapter H6 HSCA ndash means the Homes for Special Care Act RSO 1990 chapter H12 LTCA ndash means the Long-Term Care Act 1994 SO 1994 chapter 26 LTCSLAA ndash means the Long-Term Care Statute Law Amendment Act 1993 MHA ndash means the Mental Health Act RSO 1990 chapter M7 MHARBA ndash means the Ministry of Health Appeal and Review Boards Act 1998 SO 1998 chapter 18 Schedule H NA ndash means the Nursing Act 1991 SO 199 chapter 32 NHA ndash means the Nursing Homes Act RSO 1990 chapter N7 ODBA ndash means the Ontario Drug Benefit Act RSO 1990 chapter O10

September 2006 2

PHIPA ndash means the Personal Health Information Protection Act 2004 SO 2004 chapter 3 Schedule A RHPA ndash means the Regulated Health Professions Act 1991 SO 1991 chapter 18 SDA - means the Substitute Decisions Act 1992 SO 1992 chapter 30 SWSSWA ndash means the Social Work and Social Services Work Act 1998 SO 1998 chapter 31

Definitions Appeal Board ndash means the Health Services Appeal and Review Board under the Ministry of Health Appeal and Review Boards Act 1998 as defined in the long-term care home legislation ldquothe Boardrdquo ndash means the Consent and Capacity Board an independent adjudicative body created to conduct hearings under the Mental Health Act and the Health Care Consent Act 1996 case manager ndash means all individuals who perform the case management function Some Community Care Access Centres use different names or titles such as care co-ordinator or care manager for the role of the case manager ldquodirectorrdquo ndash means an officer of the Ministry of Health and Long-Term Care appointed by the Minister of Health and Long-Term Care for the purposes of the Nursing Homes Act as defined in subsection 3(2) of the Nursing Homes Act legislation ndash means the laws of Ontario as enacted by the legislature LTC home ndash means a long-term care home for which the Community Care Access Centre is responsible to manage admission (Note legislation refers to long-term care ldquofacilitiesrdquo) placement co-ordinator ndash depending on the specific citation in the long-term care home legislation may mean the Community Care Access Centre or the Community Care Access Centre case manager responsible for assessing a personrsquos eligibility for admission to a long-term care home policy ndash means the Ministry of Health and Long-Term Care directives guidelines policies and procedures set out in this manual regulation ndash means a regulation made or approved under an act of the legislature

September 2006 3

Acronyms and Abbreviations ABI ndash acquired brain injury (services)

ADP ndash Assistive Devices Program

ADS ndash adult day services

ALC ndash alternative level of care

ALSSH ndash assisted living services in supportive housing

ARR ndash annual reconciliation report

the Board ndash Consent and Capacity Board

CCAC ndash Community Care Access Centre

CTCs ndash childrenrsquos treatment centres

EDU ndash Ministry of Education and Training

EOL ndash End-of-Life (Care Strategy)

Enhanced Respite

ndash Enhanced Respite for Children who are Medically Fragile andor Technology Dependent

FIM ndash Finance and Information Management

FM ndash frequency modulation

FormularyCDI

ndash Ontario Drug Benefit FormularyComparative Drug Index

HNLU ndash Health Number Look-Up (service)

HOP ndash Home Oxygen Program

HRP ndash Hospital Replacement Program

HSARB ndash Health Services Appeal and Review Board

IFH ndash Interim Federal Health (program)

IPRC ndash Identification Placement and Review Committee

ISNC ndash Integrated Services for Northern Children

IVR ndash Interactive Voice Response (system)

LHIN ndash Local Health Integration Network

LTC ndash long-term care (home)

MCSS ndash Ministry of Community and Social Services

MCYS ndash Ministry of Children and Youth Services

MDS-HC ndash Minimum Data Set for Home Care

September 2006 4

MIS ndash management information system

MOHLTC ndash Ministry of Health and Long-Term Care

OACCAC ndash Ontario Association of Community Care Access Centres

ODB ndash Ontario Drug Benefit

OHIP ndash Ontario Health Insurance Plan

PCS ndash placement co-ordination service

PPM81 ndash PolicyProgram Memorandum No 81

RAI-HC ndash Resident Assessment Instrument-Home Care

RCMP ndash Royal Canadian Mounted Police

SDM ndash substitute decision-maker

SEAC ndash Special Education Advisory Committee

SHSS ndash school health support service

VPA ndash veteransrsquo priority access

CCAC Client Services Policy Manual Appendix B Website Addresses

September 2006 1

Appendix B

Website Addresses

Acts and Regulations Charitable Institutions Act

[httpwwwe-lawsgovoncaDBLawsStatutesEnglish90c09_ehtm] Community Care Access Corporations Act 2001

[httpwwwe-lawsgovoncaDBLawsStatutesEnglish01c33_ehtm] French Language Services Act

[httpwwwe-lawsgovoncaDBLawsStatutesEnglish90f32_ehtm] Healing Arts Radiation Protection Act [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90h02_ehtm] Health Care Consent Act 1996 [httpwwwe-lawsgovoncaDBLawsStatutesEnglish96h02_ehtm] Health Insurance Act [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90h06_ehtm] Homes for the Aged and Rest Homes Act

[httpwwwe-lawsgovoncaDBLawsStatutesEnglish90h13_ehtm] Homes for Special Care Act [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90h12_ehtm] Long-Term Care Act 1994 [httpwwwe-lawsgovoncaDBLawsStatutesEnglish94l26_ehtm] Ministry of Health Appeal and Review Boards Act 1998 [httpwwwe-lawsgovoncaDBLawsStatutesEnglish98m18_ehtm] Nursing Homes Act [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90n07_ehtm] Ontario Drug Benefit Act [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90o10_ehtm]

September 2006 2

Personal Health Information Protection Act 2004 [httpwwwe-lawsgovoncaDBLawsStatutesEnglish04p03_ehtm] Regulated Health Professions Act 1991 [httpwwwe-lawsgovoncaDBLawsStatutesEnglish91r18_ehtm] Social Work and Social Services Work Act 1998 [httpwwwe-lawsgovoncaDBLawsStatutesEnglish98s31_ehtm] Substitute Decisions Act 1992 [httpwwwe-lawsgovoncaDBLawsStatutesEnglish92s30_ehtm] Forms Application for Northern Health Travel Grant form (014-0327-88)

[httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailopenformampENV=WWEampNO=014-0327-88]

Consent for Placement Coordination Services to Collect Keep on File and Release Information form (014-2724-69)

[httpwwwformsssbgovoncambsssbformsssbformsnsfFormDetailOpenFormampACT=RDRampTAB=PROFILEampENV=WWEampNO=014-2747-69]

Health Number Release form (014-1265-84)

Health Report form (014-2734-69)

Hospital Replacement Program Questionnaire [httpwwwhealthgovoncaenglishprovidersprogramadphrpquestionnairepdf] Booklets and Memoranda A Guide to Choosing Appropriate Patient Transportation [httpwwwambulance-transitioncom] Interim Federal Health Program Information Handbook for Health Care Providers

[httpwwwfasadmincomimagespdfifh_information_handbookpdf]

September 2006 3

Interministerial Guidelines for the Provision of Speech and Language Services (as applicable to the Education Act) 1988 [httpwwwedugovoncaextraengppm81html] Ontario Drug Benefit FormularyComparative Drug Index (FormularyCDI) [httpwwwhealthgovoncaenglishprovidersprogramdrugsodbf_eformularyhtml] PolicyProgram Memorandum 81 (PPM81)

[httpwwwedugovoncaextraengppm81html] PolicyProgram Memorandum 131 (PPM131)

[httpwwwedugovoncaextraengppm131html]

Information Consent and Capacity Board including application forms and contact information [httpwwwccboardonca] FAS benefit administration [wwwfasadmincom] Identification Placement and Review Committee for childrenyouth in publicly-funded schools

[httpwwwedugovoncaenggeneralelemsecspecedidentifihtml]

Integrated Services for Northern Children [httpwwwchildrengovoncaCSenprogramsSpecialNeedsintegratedServicesforNorthernChildrenhtm]

Local Health Integration Networks [httpwwwlhinsoncaenglishmainhomeasp] Medical Air Transport Centre [httpwwwgovoncaMOHenglishprogramambulairambhtml] Ministry of Education

[httpwwwedugovoncaengfunding] Ministry of Health and Long-Term Care [httpwwwhealthgovoncaenglishpublicpublic_mnhtml] Northern Health Travel Grant application [httpwwwhealthgovoncaenglishpublicpubohipnorthernhtml] Table 5 Rules for Ranking within Categories in the Nursing Home Act [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90n07_ehtm]

September 2006 4

Table 6 in the Charitable Institutions Act [httpwwwe-lawsgovoncaDBLawsStatutesEnglish90c09_ehtm]

Full Doc Index

00 Notice

01 Introduction to the Manual

02 Legislation

03 Eligibility Criteria for CCAC Services

04 Consent to Treatment Admission to LTCH and Community Services

05 Information and Referral Services

06 CCAC Case Management

07 CCAC Home Care Services

08 Supplementary Services

09 CCAC School Services

10 Complaints and Appeals

11 Admission to Long-Term Care Homes

12 Management of Long-Term Care Home Waiting Lists by CCACs

Appendix A Glossary of Terms

Appendix B Website Address

12 Overview of Ontarios Long-Term Care System

Access to Home and Community Care Services (flowchart)

Chapter 2 Legislation 15 pages | 56 Kb | PDF

21 Introduction

22 Long-Term Care Act 1994

23 Ontario Regulation 552 under the Health Insurance Act

Chapter 3 Eligibility Criteria for CCAC Services 21 pages | 71 Kb | PDF

34 Persons without OHIP Coverage are Ineligible for CCAC Services

35 Out-of-Province Applicants to Ontarios Long-Term Care Homes

37 OHIP CoverageCCAC Services for Refugees

38 OHIP CoverageCCAC Services for a Person on Leave of Absence from a LTC Home

39 Eligibility for Adult Day Services

310 Eligibility for Enhanced Respite Funding

Chapter 4 Consent to Treatment Admission to Long-Term Care Home and Community Services 52 pages | 148 Kb | PDF

42 Definitions of Terms of Health Care Consent Act 1996

93 Service Maximums

111 Introduction

APPENDICES

Notice

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

132 Legislation

September 2006 7

September 2006 8

September 2006 9

care services

September 2006 10

September 2006 11

September 2006 12

Date Description

September 2006 13

Date Description

September 2006 14

schooling

September 2006 15

September 2006 16

SERVICES SERVICES

HOMEMAKING)CCACCCAC

CASEMANAGEMENT

WITH CLIENT

REFERRAL

September 2006 1

Legislation

21 Introduction

211 Background

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

Applications

The HIA states

September 2006 7

September 2006 8

September 2006 9

Services

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 22

467 Keeping Records

September 2006 23

Treatment

September 2006 24

Parties

September 2006 25

September 2006 26

September 2006 27

September 2006 28

September 2006 29

September 2006 30

September 2006 31

September 2006 32

486 Evaluator

September 2006 33

September 2006 34

September 2006 35

September 2006 36

September 2006 37

September 2006 38

September 2006 39

September 2006 40

September 2006 41

September 2006 42

September 2006 43

September 2006 44

September 2006 45

September 2006 46

September 2006 47

September 2006 48

September 2006 49

September 2006 50

September 2006 51

September 2006 52

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

assessment 621

reassessment 625

621 Assessment

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

625 Reassessment

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

communication

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 1

812 Eligibility

September 2006 2

814 Funding

September 2006 3

September 2006 4

September 2006 5

822 Eligibility

September 2006 6

824 Exclusions

September 2006 7

Clarifications

Situations

93 Service Maximums

Community Groups

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

intervene

September 2006 9

September 2006 10

September 2006 11

Care Home

September 2006 12

September 2006 13

September 2006 14

intervene

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

Determination

September 2006 12

September 2006 13

September 2006 14

Health Assessment

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 22

September 2006 23

September 2006 24

September 2006 25

September 2006 26

September 2006 27

September 2006 28

September 2006 29

September 2006 30

September 2006 31

September 2006 32

September 2006 33

Yes for day 0 No

Yes for day 1 No

September 2006 34

September 2006 35

September 2006 36

September 2006 37

September 2006 38

September 2006 39

(Convalescent Care)

September 2006 40

September 2006 41

September 2006 42

September 2006 43

September 2006 44

September 2006 45

September 2006 46

September 2006 47

September 2006 48

September 2006 1

September 2006 2

September 2006 3

September 2006 4

term care home

September 2006 5

1217 Notification

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 22

September 2006 23

September 2006 24

September 2006 25

September 2006 26

September 2006 27

Redevelopment

their families

September 2006 28

September 2006 29

September 2006 30

September 2006 31

TABLE 4

Class of Beds

Related temporary

1A1 1A1 1A1 1A1 1A 1B

1B 1B 1B 1B 1A1 2

2 2 2 2 1B 3

3 3 3 3 2

September 2006 32

TABLE 5

Item Category Rules

September 2006 33

Item Category Rules

September 2006 34

Appeal Situations

September 2006 35

September 2006 36

September 2006 37

September 2006 38

September 2006 39

September 2006 40

September 2006 41

September 2006 42

September 2006 43

September 2006 1

Appendix A

Glossary of Terms

September 2006 2

September 2006 3

Enhanced Respite

FormularyCDI

September 2006 4

September 2006 1

Appendix B

Website Addresses

September 2006 2

September 2006 3

September 2006 4

Full Doc Index

00 Notice

02 Legislation

93 Service Maximums

111 Introduction

APPENDICES

Notice

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

132 Legislation

September 2006 7

September 2006 8

September 2006 9

care services

September 2006 10

September 2006 11

September 2006 12

Date Description

September 2006 13

Date Description

September 2006 14

schooling

September 2006 15

September 2006 16

SERVICES SERVICES

HOMEMAKING)CCACCCAC

CASEMANAGEMENT

WITH CLIENT

REFERRAL

September 2006 1

Legislation

21 Introduction

211 Background

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

Applications

The HIA states

September 2006 7

September 2006 8

September 2006 9

Services

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 22

467 Keeping Records

September 2006 23

Treatment

September 2006 24

Parties

September 2006 25

September 2006 26

September 2006 27

September 2006 28

September 2006 29

September 2006 30

September 2006 31

September 2006 32

486 Evaluator

September 2006 33

September 2006 34

September 2006 35

September 2006 36

September 2006 37

September 2006 38

September 2006 39

September 2006 40

September 2006 41

September 2006 42

September 2006 43

September 2006 44

September 2006 45

September 2006 46

September 2006 47

September 2006 48

September 2006 49

September 2006 50

September 2006 51

September 2006 52

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

assessment 621

reassessment 625

621 Assessment

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

625 Reassessment

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

communication

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 1

812 Eligibility

September 2006 2

814 Funding

September 2006 3

September 2006 4

September 2006 5

822 Eligibility

September 2006 6

824 Exclusions

September 2006 7

Clarifications

Situations

93 Service Maximums

Community Groups

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

intervene

September 2006 9

September 2006 10

September 2006 11

Care Home

September 2006 12

September 2006 13

September 2006 14

intervene

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 1

September 2006 2

September 2006 3

September 2006 4

September 2006 5

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

Determination

September 2006 12

September 2006 13

September 2006 14

Health Assessment

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 22

September 2006 23

September 2006 24

September 2006 25

September 2006 26

September 2006 27

September 2006 28

September 2006 29

September 2006 30

September 2006 31

September 2006 32

September 2006 33

Yes for day 0 No

Yes for day 1 No

September 2006 34

September 2006 35

September 2006 36

September 2006 37

September 2006 38

September 2006 39

(Convalescent Care)

September 2006 40

September 2006 41

September 2006 42

September 2006 43

September 2006 44

September 2006 45

September 2006 46

September 2006 47

September 2006 48

September 2006 1

September 2006 2

September 2006 3

September 2006 4

term care home

September 2006 5

1217 Notification

September 2006 6

September 2006 7

September 2006 8

September 2006 9

September 2006 10

September 2006 11

September 2006 12

September 2006 13

September 2006 14

September 2006 15

September 2006 16

September 2006 17

September 2006 18

September 2006 19

September 2006 20

September 2006 21

September 2006 22

September 2006 23

September 2006 24

September 2006 25

September 2006 26

September 2006 27

Redevelopment

their families

September 2006 28

September 2006 29

September 2006 30

September 2006 31

TABLE 4

Class of Beds

Related temporary

1A1 1A1 1A1 1A1 1A 1B

1B 1B 1B 1B 1A1 2

2 2 2 2 1B 3

3 3 3 3 2

September 2006 32

TABLE 5

Item Category Rules

September 2006 33

Item Category Rules

September 2006 34

Appeal Situations

September 2006 35

September 2006 36

September 2006 37

September 2006 38

September 2006 39

September 2006 40

September 2006 41

September 2006 42

September 2006 43

September 2006 1

Appendix A

Glossary of Terms

September 2006 2

September 2006 3

Enhanced Respite

FormularyCDI

September 2006 4

September 2006 1

Appendix B

Website Addresses

September 2006 2

September 2006 3

September 2006 4

Full Doc Index

00 Notice

02 Legislation