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Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Long-Term Care Homes Division
Long-Term Care Inspections Branch
Division des foyers de soins de
longue durée
Inspection de soins de longue durée
London Service Area Office
130 Dufferin Avenue 4th floor
LONDON ON N6A 5R2
Telephone: (519) 873-1200
Facsimile: (519) 873-1300
Bureau régional de services de
London
130 avenue Dufferin 4ème étage
LONDON ON N6A 5R2
Téléphone: (519) 873-1200
Télécopieur: (519) 873-1300
Public Copy/Copie du public
Report Date(s) /
Inspection No /
Date(s) du apport No de l’inspection
Aug 18, 2016
Log # /
Registre no
2016_229213_0022 017389-16
Type of Inspection /
Genre d’inspection
Complaint
Licensee/Titulaire de permis
CAPRICORN INVESTMENTS CORPORATION LIMITED
380 First Avenue North P.O. Box 7 CHESLEY ON N0G 1L0
Long-Term Care Home/Foyer de soins de longue durée
ELGIN ABBEY NURSING HOME
380 FIRST AVENUE NORTH P.O. BOX 7 CHESLEY ON N0G 1L0
Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs
RHONDA KUKOLY (213)
Inspection Summary/Résumé de l’inspection
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Homes Act, 2007
The purpose of this inspection was to conduct a Complaint inspection.
This inspection was conducted on the following date(s): June 27, 28, 29, 30, July 4,
5, 6, 7, 8, 2016
This complaint inspection was completed related to a concern related to resident
charges. The inspection was completed at the same time as the Resident Quality
Inspection (RQI log #016717-16).
Financial Inspectors #715, #716 & #719 participated in this inspection.
During the course of the inspection, the inspector(s) spoke with the Operators, the
Administrator, the Director of Care, two family members, one power of attorney and
one Public Guardian and Trustee.
The Inspectors also reviewed health records, financial records, administrative
records, resident bank statements, policies, and other relevant documentation.
The following Inspection Protocols were used during this inspection:
Reporting and Complaints
Resident Charges
Trust Accounts
During the course of this inspection, Non-Compliances were issued.
3 WN(s)
3 VPC(s)
0 CO(s)
0 DR(s)
0 WAO(s)
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Legend
Long-Term Care
the Long-Term Care
Homes Act, 2007
NON-COMPLIANCE / NON - RESPECT DES EXIGENCES
Legendé
WN – Written Notification
VPC – Voluntary Plan of Correction
DR – Director Referral
CO – Compliance Order
WAO – Work and Activity Order
WN – Avis écrit
VPC – Plan de redressement volontaire
DR – Aiguillage au directeur
CO – Ordre de conformité
WAO – Ordres : travaux et activités
Non-compliance with requirements under
the Long-Term Care Homes Act, 2007
(LTCHA) was found. (a requirement under
the LTCHA includes the requirements
contained in the items listed in the definition
of "requirement under this Act" in
subsection 2(1) of the LTCHA).
Le non-respect des exigences de la Loi de
2007 sur les foyers de soins de longue
durée (LFSLD) a été constaté. (une
exigence de la loi comprend les exigences
qui font partie des éléments énumérés dans
la définition de « exigence prévue par la
présente loi », au paragraphe 2(1) de la
LFSLD.
The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of
respect aux termes du paragraphe 1 de
section 152 of the LTCHA.
l’article 152 de la LFSLD.
WN #1: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s. 91.
Resident charges
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Specifically failed to comply with the following:
s. 91. (1) A licensee shall not charge a resident for anything, except in
accordance with the following:
1. For basic accommodation, a resident shall not be charged more than the
amount provided for in the regulations for the accommodation provided. 2007, c.
8, s. 91 (1).
2. For preferred accommodation, a resident shall not be charged more than can be
charged for basic accommodation in accordance with paragraph 1 unless the
preferred accommodation was provided under an agreement, in which case the
resident shall not be charged more than the amount provided for in the regulations
for the accommodation provided. 2007, c. 8, s. 91 (1).
3. For anything other than accommodation, a resident shall be charged only if it
was provided under an agreement and shall not be charged more than the amount
provided for in the regulations, or, if no amount is provided for, more than a
reasonable amount. 2007, c. 8, s. 91 (1).
4. Despite paragraph 3, a resident shall not be charged for anything that the
regulations provide is not to be charged for. 2007, c. 8, s. 91 (1).
s. 91. (4) A licensee shall not accept payment from or on behalf of a resident for
anything that the licensee is prohibited from charging for under subsection (1) and
shall not cause or permit anyone to make such a charge or accept such a payment
on the licensee’s behalf. 2007, c. 8, s. 91. (4).
Findings/Faits saillants :
1. The licensee has failed to ensure that residents in preferred accommodation are not
charged more than what can be charged for basic accommodation unless the preferred
accommodation was provided under an agreement.
The “Long Term Care Home Accommodation Agreement” for resident #002 indicated
that the resident was charged preferred accommodation rate as of the date of admission
however, the Long Term Care Home Accommodation Agreement, indicating preferred
accommodation, was not signed.
On July 7, 2016, the Administrator agreed that the Long Term Care Home
Accommodation Agreement for resident #002 was not dated or signed by the resident or
a person acting on behalf of the resident.
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the Long-Term Care
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There was no signed accommodation agreement for preferred accommodation for
resident #002. [s. 91. (1) 2.]
2. The licensee has failed to ensure that payment was not accepted on behalf of a
resident for anything that the licensee was prohibited to charge for.
Resident #002 and #003 were admitted to the home in the same month.
Bank statements for the home, provided by the home for specified months indicated
payments by direct deposit for resident #002 and #003.
Bank statements for resident #002 provided by the resident’s family for the same
specified months indicated withdrawals from resident #002's bank account related
resident #002's charges as well as resident #003's charges.
In an interview, the family of resident #002 said that the financial institution alerted the
family to unusual amounts withdrawn from the account by the home.
In an interview on June 30, 2016, the Operator #121 said that the trust account records
for resident #002’s account number had inadvertently been entered into the direct
deposit information for resident #003. This resulted in fees for resident #003 being
withdrawn from the bank account of resident #002 as well as fees for resident #002.
The licensee accepted payment on behalf of resident #002 when prohibited to charge for
such payment. [s. 91. (4)]
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Long-Term Care
the Long-Term Care
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Additional Required Actions:
VPC - pursuant to the Long-Term Care Homes Act, 2007, S.O. 2007, c.8, s.152(2)
the licensee is hereby requested to prepare a written plan of correction for
achieving compliance to ensure that payment is not accepted on behalf of a
resident for anything that the licensee is prohibited to charge for, to be
implemented voluntarily.
WN #2: The Licensee has failed to comply with O.Reg 79/10, s. 101. Dealing with
complaints
s. 101. (2) The licensee shall ensure that a documented record is kept in the home
that includes,
(a) the nature of each verbal or written complaint; O. Reg. 79/10, s. 101 (2).
(b) the date the complaint was received; O. Reg. 79/10, s. 101 (2).
(c) the type of action taken to resolve the complaint, including the date of the
action, time frames for actions to be taken and any follow-up action required; O.
Reg. 79/10, s. 101 (2).
(d) the final resolution, if any; O. Reg. 79/10, s. 101 (2).
(e) every date on which any response was provided to the complainant and a
description of the response; and O. Reg. 79/10, s. 101 (2).
(f) any response made in turn by the complainant. O. Reg. 79/10, s. 101 (2).
s. 101. (3) The licensee shall ensure that,
(a) the documented record is reviewed and analyzed for trends at least quarterly;
O. Reg. 79/10, s. 101 (3).
(b) the results of the review and analysis are taken into account in determining
what improvements are required in the home; and O. Reg. 79/10, s. 101 (3).
(c) a written record is kept of each review and of the improvements made in
response. O. Reg. 79/10, s. 101 (3).
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1. The licensee has failed to ensure that a documented record was kept in the home that
included, (a) the nature of each verbal or written complaint; (b) the date the complaint
was received; (c) the type of action taken to resolve the complaint, including the date of
the action, time frames for actions to be taken and any follow-up action required; (d) the
final resolution, if any; (e) every date on which any response was provided to the
complainant and a description of the response; and (f) any response made in turn by the
complainant.
No documentation related to a complaint received by the home from the family of
resident #002 was found in the home’s complaint log.
On June 30, 2016, the Administrator #101 said that she was aware of the complaint from
the family of resident #002 and had not documented anything related to the complaint as
the Operator had completed the follow up related to this complaint.
On June 30, 2016, in a phone interview, the Operator #121 said that he was aware of the
complaint from the family of resident #002 and had not documented anything related to
the complaint or follow up.
The licensee failed to ensure that a documented record was kept related to the complaint
for resident #002. [s. 101. (2)]
2. The licensee has failed to ensure that the documented record was reviewed and
analyzed for trends at least quarterly; the results of the review and analysis taken into
account in determining what improvements are required in the home; and a written
record kept of each review and of the improvements made in response.
On June 30, 2016, the Administrator #101 said that the home had not reviewed and
analyzed the complaints log at least quarterly for trends and there was no documented
record of any reviews or analysis of complaints completed in the home. The
Administrator was not aware of the requirement to complete an analysis of complaints
received in the home for trends and improvements required in the home. [s. 101. (3)]
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Long-Term Care
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achieving compliance to ensure that a documented record is kept in the home that
includes, (a) the nature of each verbal or written complaint; (b) the date the
complaint is received; (c) the type of action taken to resolve the complaint,
including the date of the action, time frames for actions to be taken and any
follow-up action required; (d) the final resolution, if any; (e) every date on which
any response is provided to the complainant and a description of the response;
and (f) any response made in turn by the complainant, to be implemented
voluntarily.
WN #3: The Licensee has failed to comply with O.Reg 79/10, s. 241. Trust
accounts
s. 241. (1) Every licensee of a long-term care home shall establish and maintain at
least one non-interest bearing trust account at a financial institution in which the
licensee shall deposit all money entrusted to the licensee’s care on behalf of a
resident. O. Reg. 79/10, s. 241 (1).
s. 241. (5) Every licensee shall establish a written policy and procedures for the
management of resident trust accounts and the petty cash trust money, which
must include,
(a) a system to record the written authorizations required under subsection (8);
and O. Reg. 79/10, s. 241 (5).
(b) the hours when the resident, or the person acting on behalf of the resident, can
make deposits to or withdrawals from the resident’s funds in a trust account and
make withdrawals from the petty cash trust money. O. Reg. 79/10, s. 241 (5).
s. 241. (7) The licensee shall,
(a) provide a resident, or a person acting on behalf of a resident, with a written
receipt for all money received by the licensee from the resident, or any other
person, for deposit in a trust account on behalf of the resident; O. Reg. 79/10, s.
241 (7).
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Long-Term Care
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Homes Act, 2007
(b) where the licensee has deposited in a trust account money received from any
person on behalf of a resident, make part or all of the money available to the
resident or a person acting on behalf of the resident,
(i) in accordance with the instructions of the resident or a person acting on behalf
of the resident in respect of the property the resident or the person is legally
authorized to manage, and
(ii) upon the resident, or the person acting on behalf of the resident, signing an
acknowledgement that the resident, or the person acting on behalf of the resident,
received the funds; O. Reg. 79/10, s. 241 (7).
(f) provide to the resident, or to a person acting on behalf of a resident, a quarterly
itemized written statement respecting the money held by the licensee in trust for
the resident, including deposits and withdrawals and the balance of the resident’s
funds as of the date of the statement; and O. Reg. 79/10, s. 241 (7).
1. The licensee has failed to establish and maintain one non-interest bearing trust
account at a financial institution for depositing money entrusted to the licensee's care on
behalf of a resident.
On June 30, 2016 the Administrator #101 said that there were no trust accounts
established for any residents in the home to her knowledge. She said that there were
residents with petty cash in the home, managed by the home, using a manual petty cash
record. The Administrator said that resident #014 had a petty cash fund in the home that
was managed by the Administrator.
The home’s “Resident Petty Cash Record/Bill Payment/Cash/Cheque Received” for
resident #002 indicated documented record of deposits and withdrawals with balances.
On June 30, 2016 the Operator #121 said that there were no trust accounts established
for any residents in the home. He said that there were residents with petty cash in the
home, managed by the home, using a manual petty cash record.
Trust accounts were not established at a financial institution for depositing money
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Homes Act, 2007
entrusted to the licensee’s care on behalf of resident #014. [s. 241. (1)]
2. The Licensee has failed to establish policies and procedures for the management of
resident trust accounts and the petty cash trust money that included: a system to record
written authorizations, and the hours when the resident or persons acting on behalf of the
resident can make deposits or withdrawals from the funds in a trust account and from
petty cash trust money.
On June 30, 2016, the Administrator #101 said that she was not aware of policies and
procedures that related to the management of the resident trust accounts and the petty
cash trust money.
On June 30, 2016, the Operator #121 said that if a policy existed for the home that it
would be located in the policy binders provided to the inspectors by the Administrators.
There were no policies or procedures for the management of resident trust accounts and
the petty cash trust money included within these binders.
On July 5, 2016, the Operator #121 emailed the home’s “Resident Petty Cash Policy”
dated February 7, 2014. The policy did not include the management of resident trust
accounts or the petty cash trust money that included a system to record written
authorizations.
There were no policies or procedures for the management of resident trust accounts or
the petty cash trust money in the home. [s. 241. (5)]
3. The licensee has failed to provide the resident or the person acting on behalf of a
resident with a written receipt for all money received by the licensee from the resident, or
any other person, for deposit in a trust account on behalf of the resident.
The petty cash record titled “Resident Petty Cash Record/Bill Payment/Cash/Cheque
Received” for resident #014, on whose behalf petty cash was maintained by the home
was a documented record of deposits and withdrawals with balances.
There were no copies of receipts for money received by the home on file.
On June 30, 2016 the Administrator #101 said that no receipts were provided to this
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Long-Term Care
the Long-Term Care
Homes Act, 2007
resident or any other residents that had funds entrusted to the home.
On June 30, 2016, the Operator #121 said that no receipts were provided to residents
that had funds held in trust by the home.
No receipts were provided to resident #014 or a person acting on behalf of the resident
for money held in trust by the home. [s. 241. (7) (a)]
4. The Licensee has failed to ensure that where money was entrusted to the home on
behalf of a resident, part or all of the money was made available to the resident or a
person acting on behalf of the resident in accordance with:
- Instructions of the resident or a person acting on behalf of the resident, in respect of
property that the resident or person is legally authorized to manage
- A signed acknowledgement that the resident or the person acting on behalf of the
resident received the funds.
The petty cash record titled “Resident Petty Cash Record/Bill Payment/Cash/Cheque
Received” for resident #014, on whose behalf petty cash was maintained by the home
was a documented record of deposits and withdrawals with balances.
There were no instructions obtained from the resident or person acting on behalf of the
resident regarding how money was to be made available to the resident or the person
acting on behalf of the resident.
There was no signed acknowledgement that the resident or the person acting on behalf
of the resident, received the petty cash funds.
On June 30, 2016, the Administrator #101 said that there were no signed
acknowledgements of receipt of funds for the petty cash funds that were managed by the
home. The Administrator was not able to provide details or instructions from the resident
or person acting on behalf of the resident on how the petty cash money was to be used.
There were no instructions for how to use funds and no signed acknowledgements that
resident #014 received the funds. [s. 241. (7) (b)]
5. The Licensee has failed to provide the resident or a person acting on behalf of a
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Long-Term Care
the Long-Term Care
Homes Act, 2007
resident with quarterly itemized written statements respecting money held by the licensee
in trust for the resident, including deposits, withdrawals, and the balance of the resident’s
funds as of the date of the statement.
There were no itemized statements respecting money held in trust by the home for
resident #014.
On June 30, 2016, the Administrator said that there were no quarterly itemized
statements provided to any residents for money held on their behalf.
On June 30, 2016, the Operator said that there were no quarterly itemized statements
provided to any residents for money held on their behalf. [s. 241. (7) (f)]
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Long-Term Care
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achieving compliance :
- To establish and maintain one non-interest bearing trust account at a financial
institution for depositing money entrusted to the licensee's care on behalf of a
resident.
- To establish policies and procedures for the management of resident trust
accounts and the petty cash trust money that includes a system to record written
authorizations.
- To provide the resident or the person acting on behalf of a resident with a written
receipt for all money received by the licensee from the resident, or any other
person, for deposit in a trust account on behalf of the resident.
- To ensure that where money was entrusted to the home on behalf of a resident,
part or all of the money was made available to the resident or a person acting on
behalf of the resident in accordance with:
- Instructions of the resident or a person acting on behalf of the resident, in
respect of property that the resident or person is legally authorized to manage
- A signed acknowledgement that the resident or the person acting on behalf
of the resident received the funds.
- To provide the resident or a person acting on behalf of a resident with quarterly
itemized written statements respecting money held by the licensee in trust for the
resident, including deposits, withdrawals, and the balance of the resident’s funds
as of the date of the statement.
All of the above, to be implemented voluntarily.
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Issued on this
22nd
Long-Term Care
the Long-Term Care
Homes Act, 2007
day of August, 2016
Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs
Original report signed by the inspector.
Page 14 of/de 14

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