New voluntary standards released for long-term care homes devastated by the pandemic
The voluntary standards are meant to shore up a sector that saw a massive number of pandemic deaths
Promised new national standards for long-term care homes in Canada have now been published — part of Ottawa's attempt to avoid a repeat of the alarming death tolls in long-term care homes that marked the early phase of the pandemic.
The Health Standards Organization (HSO) published 60 pages of comprehensive standards Tuesday, to complement the release of 115 pages of standards from the Canadian Standards Association Group (CSA) in December. The federal government launched the standards project in the spring of 2021.
Both organizations were tasked with coming up with standards to improve the quality of care in long-term care (LTC) homes across the country. The HSO focused on the care itself and the CSA on the physical infrastructure.
While the new standards are voluntary, health experts say they won't do the job unless LTC homes adopt all of them without exceptions.
"This is very much a kind of all-or-nothing thing. This is basically what the standard of care needs to be," said Dr. Samir Sinha, director of geriatrics at Sinai Health and the University Health Network in Toronto and chair of the HSO technical committee that drafted the standards.
"My greatest fear is that if we don't take these standards to heart and make sure that they are the basis of inspections, enforcements, quality improvements and accountability ... I'm worried that these standards will just sit on the shelf."
The pandemic exposed fatal weaknesses in the LTC sector. In the first few months of the pandemic, more than 80 percent of Canada's known COVID-19 deaths happened in long-term care and retirement homes — the highest such rate among nations in the Organisation for Economic Co-operation and Development (OECD).
More than 17,000 residents of long-term care homes in Canada had died because of COVID-19 as of July 2022, according to the National Institute on Ageing.
Thousands of staff members in LTC facilities have been infected as well; more than 30 have died as a result. In some provinces, the Canadian Armed Forces had to be called in to help out at LTC homes.
Dr. Sinha said the standards rolled out today would have saved many lives had they been in force when COVID-19 hit.
"If these standards were in place before, I believe we would not be leading the world in having the worst performance in long-term care. I think, frankly, we would have been one of the best," he said.
The two sets of standards are meant to complement each other. They go beyond pandemic preparedness and address everything from preventing falls and maintaining flexible meal schedules (some LTC residents went without meals during staff shortages over the course of the pandemic) to end-of-life-care and emergency plans for catastrophic events.
The new standards also directly address how COVID-19 affected the quality of long-term care. So they include recommendations for flexible visitor policies, for rules that balance LTC residents' rights with the health and safety of others, and for maintaining social interaction with family even during public health emergencies — along with page after page of standards for infection prevention and control.
"These standards are first and foremost going to increase the quality of care for their residents, but it is also going to improve the business of care as well if these homes are showing that they're making these improvements," said Alex Mihailidis, a professor at the University of Toronto's institute of biomedical engineering and chair of the CSA Group technical subcommittee that developed the infrastructure standards.
New standards for LTC buildings
The standards set a new bar for LTC home construction and renovation. They state that single rooms in LTC homes should have dedicated 3-piece bathrooms for residents, while shared rooms should have access to special privacy rooms for "intimate acts."
The CSA standards call for dedicated hand hygiene sinks and access to outdoor space for every level of a long-term care home. They offer guidance on waste management, video monitoring, signage and the design of staff rooms.
"Changing infrastructure and building infrastructure is costly," said Mihailidis. "But … time is of the essence as there are plans across the country … to build new long-term homes. Our hope is that they will be looking at our standard."
Much of the pressure on LTC homes due to the pandemic was blamed on short-staffing and recruitment struggles. The standards stop short of requiring specific ratio staff-to-resident ratios and do not prescribe a certain amount of hours of care. But they do point out that evidence strongly supports requiring an average of 4.1 hours of daily care.
"The biggest challenge for many long-term care homes right now is retaining and recruiting staff, especially when hospitals are also facing significant staffing shortages and pay much higher wage rates," said Dr. Sinha.
For many of those still grieving the loss of a loved one in long-term care during the pandemic, the standards are a welcome step forward — but only a first step.
Eddie Calisto-Tavares' father Manuel Calisto was one of 56 people who died at the Maples Long Term Care Home in Winnipeg in the fall of 2020 during the second wave of COVID-19. It was the worst-hit home in that province.
"How do families like mine get these standards (to be implemented)? They're beautiful in writing, but how do we get them to be enforced? And then how do we get these homes to be accountable?" Calisto-Tavares asked.
Calisto-Tavares fought to get access to her father when he fell ill with COVID-19 at the end of October 2020. She arranged to self-isolate at a hotel so that she could continue visiting and caring for him. She said that what she saw at his LTC home still haunts her.
"I would hear people cry out. They were hungry … they were so cold. They were crying out that they were thirsty," she said. "I could do nothing but say, 'Help is coming, help is coming,' knowing that there was very little help coming."
While the standards were commissioned by the federal government, health care delivery falls under provincial jurisdiction. Some critics and family members of LTC residents have called on Ottawa to legislate the standards, to make them mandatory.
A $13.7 billion problem
Minister for Seniors Kamal Khera said the government is still in the very preliminary stages of developing the Safe Long Term Care Act the Liberals promised during the last election campaign. She argued the introduction of the standards is itself an important milestone.
"These standards will make a difference and it's a step in the right direction and making sure we improve the lives of Canadians and seniors from across Canada," she said.
In Budget 2021, Ottawa set aside $3 billion to help provinces implement the standards. Experts say the work will cost far more.
The Parliamentary Budget Officer estimated the cost of fixing long-term care at $13.7 billion per year beyond what is being spent now. Many advocates for long-term care clients are hoping that a much-anticipated new health-care deal between the federal government and provinces could cover at least some of that cost.
"What sort of carrots and sticks will be involved? Will it be the Canada Health Transfer and money linked to that? Will it be each province signing onto these standards and providing the funding necessary to implement these standards?" asked Terry Lake, CEO of the B.C. Care Providers Association, an industry association that represents providers of long-term care and assisted living in B.C.
Lake, a former provincial health minister, said he fears the issue of long-term care has "fallen off the political radar."
"Of course, through the pandemic it was the number one issue … and now we see it kind of falling down the list of priorities. And we can't let that happen," he said.
Much of the debate over long-term care in Canada has been about whether for-profit facilities should be allowed to operate. Lake said the outcomes from for-profit and not-for-profit homes in B.C. were roughly equal.
The process of developing the standards saw a very high level of input from the public — which suggests that politicians need to catch up to the public's desire for change, said a union official.
"If there's any resistance from the premiers across the country on any of these standards, or any kind of federal interference into this file, I think they're significantly misreading the will of the people that they represent," said Candace Rennick, national secretary treasurer of CUPE, one of the main unions representing tens of thousands of long-term care workers across Canada. She has worked in long-term care homes in a variety of positions.
"People want standards that are enforceable. They want penalties and consequences for people who are not following the rules. They want to know that when they send their loved ones to these facilities, that they're going to spend their last days with dignity and respect. And that's not happening."
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