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Special Report on Pandemic Readiness and Response in Long-Term Care

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Special Report on Pandemic Readiness and Response in Long-Term Care Office of the Auditor General of Ontario COVID-19 Preparedness and Management Special Report on Pandemic Readiness and Response in Long-Term Care April 2021 Office of the Auditor General of Ontario To the Honourable Speaker of the Legislative Assembly I am pleased to transmit my Special Report on COVID-19 Preparedness and Management, Chapter 5, under Section 12(1) of the Auditor General Act. Bonnie Lysyk, MBA, FCPA, FCA Auditor General April 2021 Toronto, Ontario ii Ce document est également disponible en français. Cover photograph credit: ISBN 978-1-4868-4851-5 (PDF) © iStockphoto.com/xavierarnau Table of Contents Reflections ..................................................................................................... 5 1.0 Summary ................................................................................................. 7 Overall Conclusion ..................................................................................... 11 2.0 Background .......................................................................................... 13 2.1 Overview of Ontario’s Long-Term-Care Sector ...................................... 13 2.2 Provincial Involvement with the Long-Term-Care Sector ......................20 2.3 Impact of COVID-19 on Ontario Long-Term-Care Homes .....................26 3.0 Objective and Scope .........................................................................33 3.1 Why We Are Issuing This Report .........................................................33 3.2 What We Did .......................................................................................33 4.0 Detailed Observations .....................................................................35 4.1 Long-Term-Care Homes Ill-Equipped to Prevent or Minimize COVID-19 Outbreaks Because of Long-Standing Facility, Staffing and Infection Prevention and Control Issues ...........................................................35 4.2 Long-Term-Care Sector Largely Disconnected from Rest of Health-Care System ................................................................50 4.3 COVID-19 Pandemic Response Actions Had Unintended Consequences on Long-Term-Care Residents and Staff ..................... 57 4.4 Delays, Unclear Communications and Lack of Enforcement by Long-Term Care Ministry Hampered Effectiveness of Measures to Contain COVID-19 ..........................................................................64 4.5 Ministry’s Oversight of Homes Before and During COVID-19 Pandemic Ineffective in Addressing Repeat Non-Compliance ............ 67 iv Chapter 5: Pandemic Readiness and Response in Long-Term Care 5 Reflections Bonnie Lysyk Auditor General of Ontario The COVID-19 pandemic has presented a challenge action all the more challenging for the stakeholders to health experts and government decision-makers involved. First, despite very specific observations around the world that in many ways is unpreced- and recommendations on preparing for future ented in its impact and complexity. Ontario health outbreaks made by the Expert Panel on SARS and experts, frontline workers and government decision- Infectious Disease Control led by Dr. David Walker, makers have worked together to respond to the the SARS Commission led by Mr. Justice Archie many challenges of the pandemic and its health, Campbell, our Office and others, actions taken economic and social impacts on Ontarians. over the years have been insufficient to ensure that By late March 2020, when COVID-19 had we would be better prepared as a province for the begun its ravage of long-term-care homes, it ‘next time’. became blatantly obvious that aggressive infec- Secondly, ongoing and repeated concerns raised tion prevention, detection and patient care actions for well over a decade about systemic weaknesses were needed—and needed quickly—to prevent in the delivery of long-term care to the elderly have staggering death rates from becoming the norm not, for the most part, been adequately addressed. across Ontario’s entire long-term-care community. Thirdly and finally, the long-term care sector’s Unfortunately, neither the Ministry of Long-Term lack of integration within the healthcare sector, Care, nor the long-term-care sector was sufficiently compounded by the timing of the reorganization of positioned, prepared or equipped to respond to the the healthcare sector, did not enable long-term-care issues created by the pandemic in an effective and homes to fully benefit from the needed lifesaving expedient way. This is the subject of this report— expertise in infection prevention and control that Chapter 5: Pandemic Readiness and Response in could have been provided to a much greater extent Long-Term Care—one in a series of reports our by public health units and hospitals. Office has published on Ontario’s response to This report contains 16 recommendations with COVID-19. 55 action items to address our audit findings. From a big-picture perspective, there were three There should be no surprises in the content and underlying issues that made practical and timely recommendations in this report. Many of the issues 6 and recommendations have either been highlighted and other significant and urgent care issues, on or recommended previously by this Office, or were long-term-care home residents. the subject of public discussions or publications The province has committed to making amongst the various stakeholders we met with improvements by increasing the provincial average during our audit, as well as other interested groups direct care time provided per resident per day, and individuals. Given the longstanding nature of and has committed to increasing beds available these issues and the risks of severe outcomes, there for long-term care. Steps are also being initiated to is a need to keep decision-makers’ attention focused address personal support worker training require- on what needs to change, even though vaccines ments and update infection prevention and control have helped to significantly reduce COVID-19 requirements at long-term-care homes. Continued outbreaks and deaths in long-term care homes. attention to the implementation of these commit- Proactively implementing the recommendations ments and additional recommendations would in this report, in concert with similar recommen- go a long way toward ensuring seniors living in dations likely contained in the upcoming report of Ontario’s long-term-care homes are accorded the the Long-Term Care COVID-19 Commission, would well-deserved dignity, safety and comfort that is better prepare the Ministry and the long-term-care clearly envisioned in Section 1 of the Long-Term sector for the impact of future disease outbreaks, Care Homes Act, 2007. Sincerely, Bonnie Lysyk, MBA, FCPA, FCA Auditor General of Ontario Special Chapter 5: Report Pandemic Readiness and Response in Long-Term Care onset of the pandemic in January 2020 (when 1.0 Summary the first case was identified in Ontario) up to December 31, 2020. Our work addresses some of the much-publicized issues surrounding the impact This chapter is one in a series of audits under- of COVID-19 in long-term-care homes and provides taken by our Office on the province’s response specific and pragmatic recommendations to address to the Coronavirus Disease 2019 (COVID-19) these issues. pandemic (see Figure 1). Chapter 5, Pandemic This chapter covers a significant sector (one that Readiness and Response in Long-Term Care, looks has typically operated separately from hospitals at the preparedness and response of Ontario’s and public health in the health-care system) that long-term-care sector to COVID-19 between the Figure 1: Six Key Areas of the COVID-19 Audit by the Office of the Auditor General of Ontario Prepared by the Office of the Auditor General of Ontario Emergency Management in Ontario—Pandemic Response, Chapter 1 Personal Protective Outbreak Planning and Equipment, Decision-Making, Chapter 6 Chapter 2 COVID-19 Preparedness and Management Overview Pandemic Readiness Laboratory Testing, and Response in Case Management Long-Term Care, and Contact Tracing, Chapter 5 Chapter 3 Management of Health-Related COVID-19 Expenditures, Focus of this report Chapter 4 7 8 experienced severe human health impacts when levels, quality of care, access to family support and COVID-19 directly affected the lives and well-being other community services, and oversight of homes of many residents and staff in long-term-care facili- by the Ministry of Long-Term Care (Ministry). ties. The first cases of COVID-19 were identified Long-standing systemic problems in the sector in four long-term-care homes on March 17, 2020. were quickly and starkly amplified at the onset and From March 2020 to December 31, 2020, 475 during the first and second waves of the pandemic, or 76% of long-term-care homes in Ontario had and were contributing factors to the outbreaks reported cases of COVID-19 among their residents and spread of COVID-19 in the long-term-care and staff. homes. Many other studies and reports, including Under Section 1 of the Long-Term Care Homes some prior audit reports issued by our Office, have Act, 2007, “A long-term care home is primarily the identified these long-standing systemic issues that home of its residents and is to be operated so that have remained largely unresolved over the years it is a place where they may live with dignity and in by the province even with the increasing health- security, safety and comfort and have their physical, related needs of residents over the last decade. For psychological,
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