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Reproduced from Volume 1 Audits and recommendations; Seniors Care and Programs,
pages 185 -193, Report of the Auditor General 2005-2006,
http://www.oag.ab.ca/ The Reading Room



Seniors Care and Programs Summary
We made 11
In May 2005, we made 11 recommendations to the Departments of Health and
recommendations Wellness and Seniors and Community Supports (the Departments) to improve the
to 2 Departments
systems used to manage seniors care and programs in long-term care facilities and

supportive living settings.

Satisfactory
This year, we found that the Departments made satisfactory progress on three
progress on 3
recommendations on developing and maintaining care and accommodation
recommendations standards in long-term care facilities and supportive living settings.


Progress report
For the other eight recommendations, we obtained a summary of the significant
on other 8
actions the Departments have taken and their implementation plans. Significant work
remains, but the Departments are working closely with the Regional Health
Authorities (the Authorities) and other stakeholders.

We made
We also made a number of recommendations to each Authority to improve their
recommendations processes for delivering seniors care and programs in long-term care facilities. In
to each Authority
this case, we obtained a summary of the significant actions the Authorities have

taken and their implementation plans.
We will fully assess the Department's and Authorities progress on all our
recommendations and report the results in our 2007­2008 Annual Report.


Background to original audit
In 2005, we audited the Departments' systems used to deliver the Seniors Lodge
Program and services in long-term care facilities. Our objective was to determine if
the Departments had appropriate systems in place to manage seniors care and
programs.

Our audit was extensive and included examining the systems used by the
Departments, the Authorities, management bodies (also called lodge operators), and
long-term care facility operators to manage and deliver these services and
programs.

Systems for
We concluded that the systems required significant improvement. As a result, we
delivering care
made 11 recommendations to the two Departments and recommendations to each
and programs
Authority. Our key findings were that:
required
· standards for nursing and personal care housing services in long-term care
significant
facilities and standards for the Seniors Lodge Program were not current,
improvement

· standards were needed for services delivered in assisted living and other
supportive living settings,
· systems to monitor compliance with standards for both long-term care facilities and
lodges were inadequate,
· the Departments required further information to assess the effectiveness of the
services and programs, and
· only 68.7% of the basic care standards were met by the 25 long-term care facilities
we visited across Alberta. No facilities met all the basic care standards.



We made 2 other
We also made two recommendations to the Department of Seniors and Community
recommendations Supports to improve its systems for delivering the Alberta Seniors Benefit program.
on Seniors
We will follow up on these recommendations directly with the Department of Seniors
Benefit Program
and Community Supports and report the results in that Ministry's chapter in our

2006­2007 Annual Report.


Objective, scope, approach and criteria
This year, our objectives were to:
· assess the process the Departments used to develop new care and
accommodation standards
· obtain a report on the progress made by the Departments and Authorities in
implementing our 2005 recommendations on seniors care in long-term care
facilities and supportive living settings

To do this, we:
· reviewed the Departments' actions and plans to implement our recommendations
· examined the process the Departments used to develop the Continuing Care
Health Service Standards, the Long-Term Care Accommodation Standards, and
the Supportive Living Accommodation Standards
· reviewed Authorities' actions and plans to implement the recommendations in
our management letters
· reviewed Authorities' actions to deal with the significant findings from our visits
to the long-term care facilities in their region

We used the original audit criteria, focusing on the following unmet criteria. The
Departments should:
a) establish an accountability framework to ensure that responsibilities for services
and programs are fulfilled
b) have systems to determine, and strategies to meet, future needs for services and
programs
c) have systems to periodically measure, evaluate and report on the effectiveness of
services and programs
d) have systems to develop and maintain current standards for services and
programs
e) have systems to ensure compliance with standards for services and programs



Our audit findings and recommendations
1. Department of Health and Wellness and Department of Seniors and
Community Supports
1.1 Continuing care health service and accommodation standards--
satisfactory progress on three recommendations
Background
Living settings--the Alberta Government provides health, social, personal care,
and housing services to seniors in a variety of settings. The names of these settings
vary throughout the province. In this report, we use the following
3 categories for the settings:

3 categories of
· facility based--long-term care facilities, including both nursing homes and
care and housing auxiliary hospitals. Residents receive 24-hour registered nursing care,
personal care and housing services. There are 208 long-term care facilities
in the province with approximately 14,400 beds.
· supportive living--there are many types of supportive living settings
including assisted living, designated assisted living, lodges, enhanced lodges,
senior's complexes and group homes. Residents generally do not
require 24-hour nursing and personal care services but may receive a variety of
nursing care, personal care and housing services. The nature and extent of the care
and services varies between settings. There are 148 lodges with 8,800 beds and
approximately 12,000 beds in other supportive living settings.
· home living--these include single dwellings and apartments. Residents typically
receive home care health services.
Responsibilities--the Department of Health and Wellness is responsible for
publicly-funded health care services. The Department of Seniors and
Community Supports is responsible for overseeing the government's role in
providing accommodation services.

Three
Recommendations
recommendations In our 2005 report, we made two recommendations to the Department of Health and
on standards
Wellness to work with the Regional Health Authorities and the Department of

Seniors and Community Supports to:
· update the Basic Service Standards for services in long-term care facilities
and implement a system to regularly review and update the Basic Service
Standards to ensure they remain current.
· establish standards for care and housing services provided in assisted living and
other supportive living settings.
We also made a third recommendation to the Department of Seniors and
Community Supports to update the Seniors Lodge Standards and implement a
process to maintain them.

Satisfactory
Our audit findings
progress
The Departments have made satisfactory progress implementing the three
developing
recommendations to develop and maintain standards. They still have to implement a
standards
system to regularly review and update the standards to ensure they remain current.


The Departments worked together to replace the Basic Service Standards and
Seniors Lodge Standards with the final Continuing Care Health Service
Standards (Care Standards), Long-Term Care Accommodation Standards and
Supportive Living Accommodation Standards.




The following table summarizes the final standards and key areas they cover:
A complete copy of the standards is available at
www.continuingcare.gov.ab.ca/Document_news.htm

Key areas
Standards
Department
Applies to
Key Areas covered
covered by new
responsible
standards
Continuing Care
Health and
publicly-funded
client concerns promoting

Health Service
Wellness
health care
wellness standardized
Standards
services provided
assessment care plans
in facility based,
medication management
supportive living
operational processes
and home living
health care providers
settings
service coordination
therapeutic services quality
improvement
Long-Term Care
Seniors and
accommodation
physical environment
Accommodation
Community
services provided
hospitality services safety
Standards
Supports
in all facility based
services personal services
settings
service coordination
residential services
human resources
management and
administration
Supportive Living
Seniors and
accommodation
physical environment
Accommodation
Community
services provided
hospitality services safety
Standards
Supports
in all supportive
services personal services
living settings
service coordination
residential services
human resources
management and
administration



Care standards
The Care Standards are outcome-focused. They provide specific guidance in the
are outcome-
areas of public concern and importance--integrated care plans and quality
focused
improvement. The Care Standards require the Authorities to establish policies and

processes for health service providers and medication management, and to ensure
that all facilities have a process to resolve concerns.

Broad
Process to develop standards--the Departments incorporated principles from
consultation to
the Canadian Council on Health Services Accreditation and the Health Quality
develop
Council of Alberta to develop standards that focus on quality care. The
standards
Departments prepared draft care and accommodation standards, which they gave to

the MLA Task Force for public consultation. The draft standards were also posted on
the Government of Alberta's "Continuing Care in Alberta" website for public comment.
In addition, the Department of Seniors and Community Supports shared the draft
standards with lodge operators. The Department of Seniors and Community Supports
performed lodge reviews, using the draft standards as a benchmark.



Stakeholders
Using results of the consultation process, and with legal help, the Departments
consulted
drafted revised standards. The Departments used stakeholder focus groups to refine

the revised standards and get consensus. The stakeholders included:
· Alberta Long Term Care Association
· Alberta Senior Citizens' Housing Association
· MLA task force representatives
· health care professionals (such as doctors and nurses)
· long-term care facility operators and home care agencies
· public and private supportive living facility operators
· regional health authorities
· dietitians
· senior lodge surveyors

Care and
The final standards were released on May 3, 2006. The Care Standards and the
accommodation
Long-term Care Accommodation Standards were released under directives of the
standards
Regional Health Authorities Act. The Supportive Living Standards were released by
released
the Department of Seniors and Community Supports. The Minister of Seniors and

Community Supports is now working with the Minister of Children's Services to sign a
memorandum of understanding that will allow the Minister of Seniors and Community
Supports to license supportive living facilities, set the Supportive Living
Accommodation Standards in regulation, and monitor compliance with the Supportive
Living Accommodation Standards under the Social Care Facilities Licensing Act.

Continuing Care
Ongoing monitoring and communication of standards--through the
Leaders Council
Department of Health and Wellness' accountability requirements, the
used to reduce
Authorities will report quarterly on key elements (such as access to services and
risk of
quality of care) of the final standards. Other initiatives, including the Continuing
inconsistency
Care Leaders Council (the Council) which is made up of representatives from

each Authority, and from the Departments, are designed to reduce the risk of
inconsistency in services provided, and non-compliance with standards across the
Authorities.

Standards
The Departments have worked together to communicate the final standards to the
communicated
Authorities, facility operators (long-term care and supportive living), home care

agencies, and other stakeholders--by visiting each region to hold information
sessions and answer questions.

What remains to
To finish implementing our recommendations on developing and maintaining
be done
standards, the Departments need to put in place a process for maintaining the

standards that:
· ensures the standards are current and relevant
· considers information gathered from monitoring compliance with the standards
· considers the results of complaints, incidents and investigations
· obtains information from key stakeholders




1.2 Eight other recommendations--progress report
Background
Progress report
In our 2005 report, we made eight other recommendations to improve the systems
on 8
used to provide services in long-term care facilities. The recommendations covered
recommendations monitoring compliance with care and accommodation standards, measuring the

effectiveness of long-term care services and determining future needs for long-term
care services. We now report progress on these eight recommendations, although it
is too early to assess implementation.


Progress report
Departments' actions to implement recommendations--since the release of
our report, working together, the Departments have:

Accountability
· updated the Guide to Health Authority Accountability Documents, which includes a
documents
section on 3-year Health Plans; the Guide requires Authorities to establish goals and
updated
targets, including key elements of the Care Standards and report against them--one

target is the average paid hours of care (nursing and personal) per resident-day,
which increased to 3.4 hours from 1.9 hours.
Targeted funding
· provided targeted funding for long-term care facilities to implement an information

system to assist with care assessment and planning.

· required Authorities--through the 3-year planning process--to report their progress
implementing the information system.
Training plan
· developed (Department of Health and Wellness) a training plan for the final Care
developed
Standards to ensure that all facility staff (long-term care and supportive living), and

staff responsible for continuing care at the Departments, know all the final standards
by the end of 2006. This training will be supplemented with specific training in high-
risk areas (such as infection control, abuse, medication) over the next 12 to 18
months.
Lodge reviews
· performed (Department of Seniors and Community Supports) reviews of
completed
lodges using draft accommodation standards as a benchmark.


What remains to
Departments' plans to implement recommendations--the Departments plan to:
be done
· update the Accountability Documents to include additional reporting on elements of

the final standards
· continue to monitor Authorities' progress on their Ten-Year Continuing Care
Strategic Services Plans through the accountability requirements of the 3-year Health
Plans
· decide how they will monitor compliance with the final standards · train facility
operators (long-term care and supportive living) on the final standards
· implement (Department of Seniors and Community Supports) supportive living
facility licensing, develop a complaints reporting and resolution mechanism, and
decide how supportive living facility operators will be accredited




2. Regional Health Authorities--progress report
Background In 2005, through management letters, we made recommendations to
each Authority to improve their processes for delivering services in long-term care
facilities.
Long-term care
As part of the original audit, we also visited a sample of 25 of 179 long-term care
facilities not
facilities across Alberta. Overall, our most significant concerns were about facilities
complying with
failing to meet basic care standards for:
all care and
· providing medication to residents,
housing
· maintaining medical records, particularly the application and recording of
standards

physical and chemical restraints, and
· developing, implementing and monitoring resident care plans

Authorities'
Progress report
actions on
Authorities' actions to implement recommendations--the Authorities have:
recommendations · updated their 3-year Health Plans to include current goals and targets, including key

elements of the final standards, as required by the Department of Health and
Wellness accountability documents
· updated contracts with facility operators to ensure they state that they are
complying with all applicable legislation
· increased the average paid hours of care (nursing and personal) per resident-day to
3.4 hours from 1.9, as required by the Department of Health and Wellness
· assessed long-term care facility services--either by conducting site visits or by
facility self-reviews followed up with site visits

Authorities'
Authorities' actions on key findings from visits to long-term care facilities--
actions on key
the Authorities have also followed up on the actions facilities took to deal with the
findings at
significant findings we identified last year in the areas of medication management,
facilities
maintenance of medical records, and resident care plans. Through our review of the

Authorities actions, we were satisfied that the areas of significant concern in our
report as described above have been dealt with at the facilities we visited during our
2005 audit. However, we have not verified this by visiting the facilities.

Authorities need
Implementing the final standards at Authorities--since the release of the final
to develop
care and accommodation standards in May 2006, Authorities have started planning to
policies and
implement them. It is too early to comment on their plans.
processes
Significant tasks facing the Authorities include developing medication management

and health service provider policies and processes and ensuring that all facilities
have a process to resolve concerns.

Management at the Authorities has also indicated the following key hurdles to
implementing the final standards:
· ability to recruit and retain qualified professional staff
Hurdles affecting
· resources to develop polices and processes required under the final standards and
implementation
resources to demonstrate compliance with standards
of standards
Training

· time to train all staff and the ability to fill in for staff away at training
Capacity (particularly rural and northern regions)
· availability of sufficient beds

Authorities
The Continuing Care Leaders Council (the Council), is assisting Authorities and the
working together
Departments in overcoming these hurdles. The Council:
and with
· identifies obstacles to implementation as they arise
Departments
· develops strategies to deal with obstacles identified

· promotes consistency in policies and practices
· shares best practices across the province
· keeps the lines of communication between Authorities and the Departments open

Document Outline