3829-41E (2012/08) Queen's Printer for Ontario, 2012 Disponible En Français Page 1 of 8

Ministry of Health Home for Special Care (HSC) and Long-Term Care Homes for Special Care Licence Inspection Report

Instructions:  If space is insufficient, attach additional sheet.  Each section of the report must be completed.  Where there is non-compliance, compliance requirement and date must be included on report.  Do not use white out.  Changes to report need to be made prior to signatures and changes should be initialed by HSC Field Staff and Homeowner.  Report must be provided to Ministry of Health and Long-Term Care by December 31.  Copy of inspection report to be provided to licensed homeowner.

Name of Home Home License Number

Address of Home Telephone (incl. Area Code) Licensed HSC Capacity

Name of Licensed Homeowner

Address of Licensed Homeowner Telephone (incl. Area Code)

Name of Manager/Operator (if different from owner)

Address of Manager/Operator Telephone (incl. Area Code)

HSC Staff Conducting Review HSC Office Date of Inspection (yyyy/mm/dd)

Who resides in the Home? Check appropriate boxes

/ / / / Owner Manager/Operator Home Staff Children’s Ages:

Other (Specify)

HSC Residents: Other: (non-HSC Residents) Male + Female = Total Male + Female = Total

Accommodation Provided

Number of Bedrooms with One Tenant per Bedroom: Number of Bedrooms with Two Tenants per Bedroom:

Number of Bedrooms with Three Tenants per Bedroom: Number of Bedrooms with Four Tenants per Bedroom :

Other – Please describe:

Original – Ministry of Health and Long-Term Care; Copy – Homes for Special Care Office

3829-41E (2012/08) © Queen's Printer for Ontario, 2012 Disponible en français Page 1 of 8 HSC Licence Inspection Report

The following are to be reviewed when inspecting an HSC for licence purposes.

YES = compliance and satisfactory NO = non-compliance and requires improvement/correction Residential Environment

Physical Environment and Health and Safety Issues

Fire and Safety N Y Compliance Requirements and Date Notes

1. Does the Home have a fire safety plan in place specifying Home Staff’s duties in the event of a fire?

2. Are monthly fire drills completed?

3. Are location of fire exits known to residents and Home Staff?

4. Are hallways and stairways clear of debris and well lit?

Bedrooms N Y Compliance Requirements and Date Notes

1. Are the tenants’ bedrooms located at or above the ground floor?

2. Are bedrooms adequate in size? (not less than 60 sq.ft./5.57m2 )

3. Are the bedrooms adequately ventilated and lit by natural light?

4. Is each bed placed so as not to overlap a window or radiator, and at least 30” from another bed?

5. Do windows have appropriate coverings?

6. Do the tenants have access to their bedrooms at all times?

7. Is the furniture sufficient for the number of tenants in the room?

8. Are bedroom furniture, floors and mattresses clean and in good repair?

9. Are bedrooms, including floors, vacuumed and cleaned on a regular basis?

10. Are tenants permitted to decorate their bedrooms and have they decorated them?

Rooms, Floors, Stairs, Landings N Y Compliance Requirements and Date Notes

1. Is there a common indoor sitting area provided with 24-hour access?

2. Is there a minimum of one television provided for tenant’s use in the common area?

3. Is there adequate lighting in the common area?

4. Do the common and dining areas adequately accommodate all of the tenants?

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Rooms, Floors, Stairs, Landings N Y Compliance Requirements and Date Notes

5. Are the common and dining areas and furniture clean and in good repair (wallpaper, paint and flooring)?

6. Is the general environment of rooms bright and cheerful?

7. Is the Home equipped with handrails on stairways, non-skid finishes and coverings on floors and stairways?

8. Is the Home free of faulty floors or missing treads on stairs or loose carpeting, which could cause tripping, or slipping?

Sanitary Facilities N Y Compliance Requirements and Date Notes

1. Are all sanitary facilities working and in good repair?

2. Do the tenants have 24-hour access to the bathrooms and are they easily accessible with privacy?

3. Is every tub and shower facility furnished with grab bars and slip resistant material that adheres to the bottom of tub/shower? 4. Are wash basins, toilets, urinals, bath tubs and shower stalls cleaned and sanitized once every day and are wastebaskets emptied regularly? 5. Are residents provided with adequate supplies of personal grooming/hygiene items? 6. Are hot water tanks set at 60 degrees Celsius (140 degrees Fahrenheit) and the water temperature controlled at fixture outlets/faucets controlled so water temperature does not exceed 49 degrees Celsius (120.2 degrees Fahrenheit)? 7. Is the ratio of tenant use to basins, tubs and toilets sufficient to meet the needs of the tenants (1 flush toilet/6 tenants; 1 bath tub or shower for every 12 tenants)?

Towels, Linens, Laundry N Y Compliance Requirements and Date Notes

1. Are there sufficient clean towels, washcloths and bed linens available to all tenants and are these changed at lease once per week? 2. Are laundry receptacles for soiled laundry provided?

3. Are laundry services provided to the tenants? 4. Is there access to the washer, dryer, iron and ironing board and laundry supplies for those tenants who choose and are able to do their own laundry? 5. Is the laundry equipment clean and in good working order?

Windows, Ventilation, Lighting, Heating N Y Compliance Requirements and Date Notes

1. Is there adequate ventilation in all rooms to minimize excess heat and odours? 2. Is the home in compliance with the Smoke- Free Ontario Act? (i.e. Home to be smoke free unless there is a controlled smoking area in the home which has been approved by the Ministry of Health and Long-Term Care.) 3. Do all windows that open have an attached screen in proper working order and coverings (i.e. shades, blinds and curtains)? 4. Is adequate lighting provided throughout the Home’s hallways, stairways, landings, and ramps and at all entrances and exits?

5. Is the temperature of the Home kept comfortable (i.e. minimum 21 C [69.8F] in winter and at least one air conditioned room in periods of extreme heat in summer)?

Kitchen Facilities/Food Preparation N Y Compliance Requirements and Date Notes

1. Are kitchen countertops and other food preparation surfaces kept clean? 2. Are the eating and cooking utensils clean and in good condition (i.e. no cracked or chipped dishes)? 3. Are Home Staff knowledgeable in food preparation?

4. Is a satisfactory standard of dishwashing used? 5. Are separate cutting boards used? (1 for raw meats, seafood, 2nd for poultry and turkey and 3rd for raw fruits and vegetables)? 6. Are there adequate kitchen equipment, supplies and food storage area? 7. Are cleaning, toxic and hazardous materials stored separately from supplies and clearly labelled? 8. Are there convenient hand washing facilities provided in or near the kitchen and are clean hand towels and napkins provided? 9. Are perishable foods refrigerated as required?

Garbage Receptacles, Screening N Y Compliance Requirements and Date Notes

1. Is all garbage contained in receptacles that are covered with tight-fitting lids? 2. Are the premises adequately protected And screened against rodents, flies and other pests?

Outdoor Area N Y Compliance Requirements and Date Notes 1. Is the outdoor area of the Home well maintained, free of debris and in good repair? 2. Is an outdoor seating area for seasonal use provided which is comfortable and adequate for the number of tenants in the Home?

General Health

Nutrition N Y Compliance Requirements and Date Notes 1. Does the meal plan meet the “recommended daily intake” for energy essential nutrients as stated in Canada’s Food Guide, including the availability of fresh fruits and vegetables? 2. Are adequate portions and variety of foods provided (according to individual needs)?

3. Are tenants consulted during meal planning?

4. Are special diets provided (i.e. cultural, physician ordered and preferences)?

5. Are meals provided on a flexible time schedule?

6. Are nutritional snacks provided for tenants?

7. Are packed lunches or late meals provided or saved for tenants when advanced notice is given?

8. Are menus posted?

Personal Care N Y Compliance Requirements and Date Notes 1. Are tenants who require assistance, assisted with personal care (i.e. hygiene and grooming)? 2. Is information and teaching about personal care available for residents?

3. Are tenants provided with the opportunity to individually purchase clothing?

Medical/Dental Care N Y Compliance Requirements and Date Notes

1. Do tenants have personal physicians?

2. Do tenants receive yearly physical examinations?

3. Do Home Staff handle emergency situations in a timely and appropriate manner (i.e. contact relevant people)?

4. Do tenants get regular dental care?

Medication N Y Compliance Requirements and Date Notes

1. Is medication stored in a locked cabinet?

2. Does the Home have an appropriate system of medication management (i.e. blister packs and MAR sheets)? 3. Does the Home maintain a list of contents for drug cabinets and update them on a regular basis (weekly)? 4. Does the Home Owner/Home Staff monitor and report noted unusual behaviour possibly linked to side effects of medication?

Communicable Diseases N Y Compliance Requirements and Date Notes

1. Does the Home use routine practices (infection control precautions) to promote infection control?

Emergency Care N Y Compliance Requirements and Date Notes 1. Does the Home have appropriate procedures in place to respond to emergency care situations? 2. Are Home Staff trained in first aid measures and CPR available at all times in the home?

3. Are tenants familiar with emergency procedures?

4. Are first aid kits available and updated on a regular basis?

Tenant Lifestyles Race and Culture, Religious Expression, Sexuality N Y Compliance Requirements and Date Notes 1. Are tenants’ rights regarding race, culture, religion and sexuality respected by the Homeowner/Home Staff?

Privacy N Y Compliance Requirements and Date Notes

1. Are tenants’ rights respected and promoted (i.e. privacy in bedrooms, to visit with visitors, unopened mail, and private telephone calls)?

2. Is the home accessible to tenants on a 24 hour basis?

3. Are tenants free to enter and leave the Home at their choosing?

4. Is there an organized forum available for tenants to raise concerns (i.e. house meeting)? Daily Living Life Skills, Social and Recreational Programs

In-Home Living Activities N Y Compliance Requirements and Date Notes

1. Does the Home provide adequate/appropriate in-home activities? 2. Do tenants have an opportunity to participate in the development of life skills within the home?

Activity Programs in the Community N Y Compliance Requirements and Date Notes 1. Does the Homeowner/Home staff assist the tenant in participating in community activities (i.e. fitness, community programs)?

Tenants’ Spending Money N Y Compliance Requirements and Date Notes

1. Are tenants aware of their financial status and matters of estate? 2. Does the Home maintain appropriate books and records for those tenants who are assisted with their spending money?

Administration

Staffing

List the names of Home Staff:

Staffing N Y Compliance Requirements and Date Notes

1. Is there Home Staff on duty 24 hours a day?

2. Is tenant supervision satisfactory to meet tenant needs with current staffing level?

3. Is the local HSC office informed prior to staff changes and criminal reference checks (CPICs) acquired for all new staff? 4. Is there appropriate and satisfactory communication between the Home Staff and residents and HSC Field Staff?

5. Are Home Staff adequately supervised?

6. Is job orientation and relevant training provided for all home staff?

Licensing N Y Compliance Requirements and Date Notes

1. Are fire inspections completed and provided to HSC Field Office by Nov. 15 of each year? 2. Does the homeowner report to have adequate insurance as set out in the Operating Guidelines for HSC? 3. Does the homeowner report to have CPICs (including vulnerable sector screening) for him/herself, spouse, and any person the homeowner has in the home who has unsupervised access to tenants? Are CPICs updated on a 3 year cycle? Records, Confidentiality, Conflicts, Conflict Resolution N Y Compliance Requirements and Date Notes 1. Does the Home Owner keep appropriate records as per the Operating Guidelines for HSC? 2. Are documents and records pertaining to tenants stored in a locked and secure cabinet? 3. Does homeowner/home staff understand confidentiality requirements and consents?

4. Are there written/verbal complaint procedures in place in the home? 5. Is homeowner/home staff free of conflicts of interest as set out in the Operating Guidelines for HSC?

Reporting Requirements N Y Compliance Requirements and Date Notes 1. Does the home have procedures for serious incidents/occurrences (including notifying police)?

2. Does the homeowner report all serious incidents in time (within 24 hours)? Emergencies

Abuse and Neglect N Y Compliance Requirements and Date Notes 1. Does the homeowner provide a home environment free from emotional, physical, financial, verbal or sexual abuse? 2. Does the homeowner ensure that each tenant is not subject to neglect and is provided with necessary food, clothing, services, care and assistance required for health and safety and well-being? General 1. Does the homeowner/home staff show an understanding of the Operating Guidelines for HCS and requirements of the HSC program?

2. Does the homeowner have a copy of, or access to, the Operating Guidelines for HSC, including appendices?

Instructions Once inspection report is completed, it must be signed by the homeowner and HSC field staff. Licence recommendations can only be made once areas of non-compliance have been rectified. This report have been reviewed by: Signature of Homeowner Print Name of Homeowner x Date (yyyy/mm/dd)

Comments of Homeowner

Signature of HSC Field Staff Print Name of HSC Field Staff x Signature of HSC Field Staff Print Name of HSC Field Staff x Comments of HSC Field Staff

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