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BACKGROUND BRIEF
IN SUPPORT OF
LETTER OF REQUEST FOR AUDIT OF
LONG TERM CARE FACILITIES IN ALBERTA
RESPECTFULLY SUBMITTED TO THE
AUDITOR GENERAL OF ALBERTA
MR. FRED J. DUNN, FCA
BY 12 CONCERNED CITIZNES
SEPTEMBER 5TH, 2003
Contact: Bev
McKay
Cochrane,
Alberta
(403)
932-5557
Email:
bevmckay@telus.net
Long Term Care Facilities Submission to the Auditor General of Alberta
BACKGROUND
In Alberta, facility-based long term care is provided primarily in nursing homes and auxiliary
hospitals. 1A number of beds in acute care hospitals, mental health hospitals and care centres are
also designated for long-term care. 2Nursing homes (public, voluntary and private) operate under
the authority of the Nursing Homes Act and the Operation Regulation and General Regulation
(1985). 2Auxiliary hospitals are governed by the Hospitals Act and the Hospitals Act
Hospitalization Benefits Regulation.
2Regional health authorities (RHAs) are responsible for the planning, delivery, managing and
monitoring of long-term care services. A key responsibility of 2RHAs is to administer contracts
with nursing home and auxiliary hospital operators in accordance with specific duties and powers
set out in the above-mentioned legislation.
2The Minister of Health and Wellness is held ultimately responsible for the overall quality of
health services in Alberta. 2The powers and duties of the Minister extend to the operation of
nursing homes and approved hospitals. 2The Minister also sets provincial legislation, regulations
and standards for these care settings; ensures that adequate resources are made available to health
authorities and health service providers to enable them to perform their responsibilities; and
assesses the overall performance of the health system.
Funding flows to nursing home and auxiliary hospital operators through two main sources: public
money allocated by regional health authorities in the form of a 1government per diem subsidy of
about $95 per resident for health services such as nursing care and rehabilitation therapy --- and
accommodation fees paid by the resident and 3set in regulation by the Minister of Health and
Wellness. 4 A Ministerial Order dated July 28, 2003 raised accommodation rates by 40 to 50
percent, effective August 1, 2003. Standard accommodation increased from $28.22 to $39.62; the
semi-private rate went from $29.93 to $42.00; and private from $32.60 to $48.30. These
substantial increases occurred without public consultation or input and without a government
business plan identifying how the money will be spent to improve services and residents' quality
of life. 5Documents presented to the Minister and Cabinet regarding the decision to raise these
fees are not available for public review.
Other funding sources include but are not limited to AISH, Veterans Affairs, private insurance
and extra unregulated charges (i.e. laundry service). At this point, Alberta taxpayers don't know
how much money is flowing into the province's long-term care industry from all sources and how
that money is spent. In other words, it appears the Alberta government is not required to provide
regular, accessible reports so Albertans can determine if public funds are being spent with due
regard for the best interests of the resident as well as economy and efficiency.
GOAL OF THIS INITIATIVE
A value-for-money audit of long-term care facilities in the province by the Auditor General of
Alberta to ensure that public funds are being used prudently, effectively and as intended.
1
Government of Alberta June 17, 2003 News Release
2
Alberta Health and Wellness - Achieving Accountability in Alberta's Health System , November 2001
3
Nursing Homes Operation Regulation, Section 3
4 Ministerial
Order
#87/2003
5 August
7th, 2003 communiqué to FAIRE from the Office of Health and Wellness
Citizens' Request for Audit September 5, 2003
1
Long Term Care Facilities Submission to the Auditor General of Alberta
MOTIVATION FOR PROPOSING A VALUE-FOR-MONEY AUDIT OF LONG-TERM
CARE FACILITIES ACTIVITY
Compared to 15 years ago, people living in long-term care facilities today are older, frailer, and
beset by more complex health problems and needs. 6In Alberta, almost 70% of the near 14,000
residents assess as having high care requirements. In recent years, families of residents in care,
health care unions and other stakeholders have identified a number of problem areas within the
long-term care system that pose a serious threat to residents' health, safety and welfare. These
include, but are not limited to:
1.
Legislation, Regulation, Standards
The Nursing Homes Act and Regulations have remained unchanged for more than 18 years. The
standards in these pieces of legislation are seriously deficient, particularly in the areas of staffing
and nursing care. For example:
a. Resident Care Hours - NH-OR: s14(4) (6)
Alberta has no minimum requirements for the number of nursing staff or staff-to-resident
ratios. The province's requirement of 1.9 hours of nursing care per resident per day ranks
well below 7the experts' recommended minimum of 4 hours of nursing care per day. It
also translates into dangerously low staff-to-resident ratios as demonstrated by the
following staffing levels in a Calgary
facility:
Days
1RN for 41 residents
1LPN/PCA for 12 residents
RN = Registered Nurse
Evenings (same as above)
1PCA/LPN for 15 residents LPN = Licensed Practical Nurse
Nights
1RN for 124 residents 1PCA for 28 residents
PCA = Personal Care
Not only are these staffing levels unsafe, 7they are also 2 to 4 times lower than the
experts' recommended minimum standard. 8 9 Research in the United States and Australia
shows that low numbers of staff are associated with poor quality care.
Alberta's seriously deficient staffing standards raise important questions. Are residents
more likely to be physically and chemically restrained or develop contractures, incontinence
and pressure sores due to insufficient staffing and nursing care? And does this not result in
10higher costs to the facility as well as to acute care hospitals that admit long-term care
residents for treatment of illnesses and complications associated with these outcomes?
b. Staff Qualifications: The Ministry of Health and Wellness has yet to set:
i. standard qualifications for health care aides who provide most of the day-to-day
personal and nursing care to residents
ii. standards stipulating the number of hours of training required for health care aides
prior to employment. The 1986 OBRA legislation in the United States requires aides
to have a minimum of 75 hours of training and to pass a competency test within 4
months of employment. 7In 2000, a panel of U.S. medical experts recommended
doubling the training requirement to 150 hr.
6
Alberta Health and Wellness, 2000/2001 Resident Classification Data
7
Experts Recommend Minimum Nurse Staffing Standards for Nursing Facilities in the United States, 2000
8
Harrington C. Residential nursing facilities in the United States. BMJ 2001;323:507-10
9
Braithwaite J. - The challenge of regulating care for older people in Australia. BMJ 2001;323:443-6
10 Rantz M. - Does Good Quality Care in Nursing Homes Cost More or Less Than Poor Quality Care?
Citizens' Request for Audit September 5, 2003
2
Long Term Care Facilities Submission to the Auditor General of Alberta
b. Staff Qualifications: (continued)
iii. standards requiring directors of nursing and registered nursing staff to update
their training and qualifications, specifically in the areas of gerontology
iv. standards requiring each nursing home to incorporate into its staff mix a nurse
practitioner with a specialty in the care of the elderly and disabled.
If staff are not properly qualified and adequately skilled to assess and care for the needs of
residents, does this not increase the likelihood that serious problems will be overlooked until
they become acute problems and require intensive, and more expensive treatment?
2.
Inspection and Enforcement
The negative effects of low standards are exacerbated by the government's ineffectual
system of inspection and enforcement. For example:
a.
Alberta does not require an annual inspection of each long-term care facility. 11In
2000-2001, only 56 or 32% of the province's 176 long-term care facilities received
an inspection.
b.
The Health Facilities Review Committee (Alberta's inspection body) 12does not have
the mandate to:
i.
inspect a facility in accordance with legislative standard
ii.
determine whether a facility is in compliance with or in contravention
of legislative requirements
iii.
enforce standards
iv.
sanction a facility for repeat violation of standards
v.
address general nursing practice issues as they pertain to the professional
conduct or competency of nurses
c.
There is no requirement for members of the Health Facilities Review Committee to
have the knowledge, expertise, skills or training required to conduct a proper
investigation.
d.
13 Routine inspection reports of Committee members are consistently void of any
resident care issues
Alberta's weak inspection and enforcement system raises serious questions. Does this
approach increase the likelihood that significant problems will be overlooked and that the
health and safety of residents will be jeopardized? Does it decrease the likelihood that
delinquent facilities will be held accountable?
11 FAIRE's analysis of inspection reports 2000 2001 accessed through Alberta Health Library Services
12 Health Facilities Review Committee 2002 correspondence to FAIRE
13 FAIRE's analysis of routine inspection reports (1994 though 1999 and 2000/2001)
Citizens' Request for Audit September 5, 2003
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Long Term Care Facilities Submission to the Auditor General of Alberta
3.
Monitoring Quality of Care
RHAs and/or the Ministry of Health & Wellness are failing to:
a.
Detect and address serious problems in nursing practice and in the level and quality
of care services provided by physicians, registered nurses and personal care aides;
b.
Address the weaknesses of the program (i.e. ensuring that staff mix and skills, and
the level and quality of services and nursing care are meeting the assessed needs
of each resident);
c.
Ensure effective and expert nursing management, leadership and supervision for
evaluating and ensuring best practice, and improving outcomes of care.
If the Health and Wellness Ministry and RHAs do not have a clear picture of risk-related
conditions in long-term care facilities, how can they act to address them? And why are there
no mechanisms to ensure that best practice methods are adhered to? Since the Alberta
government disburses public funds for use in long-term care facilities, why does it not insist
that the money be spent as intended, namely, on the services, programs and care required
to accommodate residents' individual needs and vulnerability?
4.
Health, Safety and Protection of Residents
a.
More than 4,000 allegations of abuse and neglect have been reported under the
Protection for Persons In Care Act (PPICA) since 1998. Although well-intentioned,
this Act has proven inadequate to the task of identifying and preventing abuse and
crimes committed against residents. Victims are not compensated and perpetrators
are rarely prosecuted. The stated purpose of this Act is 14 "educative and preventive
rather than being quasi-judicial and punitive," but there is little evidence it has
improved the situation. The PPICA is currently undergoing a five-year review. The
Alberta government restricted the composition of the review panel to 3 MLAs, 2
Ministry staff and 4 prominent facility owners/operators. The lack of consumer and
stakeholder representation on the panel remains an issue of considerable concern.
15 16Anecdotal and/or photographic accounts of mistreatment, premature deaths and
possible criminal offences have also been filed by advocacy groups working to raise
awareness and eradicate the abuse and neglect of residents in Alberta's long-term
care facilities.
b.
Other relevant issues of concern:
i.
possible inadequate recording and reporting of outbreaks of contagious
infections, the number of people affected and the number of associated
deaths; possible lack of effort to correlate the number of outbreaks per
facility with sanitation practices, environmental cleanliness or resident
hygiene;
ii.
under-reporting and ineffective redress of complaints
iii.
possible inadequacy of fire safety inspections and standards
iv.
the lack of laws stipulating an owner or company must have a reputation
above repute in order to receive a license to operate or manage a facility in
this province
14 Alberta Community Development May 2003 letter to FAIRE
15 The Shame of Canada's Nursing Homes, FAIRE 2001
16 Creating Protections for Better Lives of Vulnerable Seniors in Care Today and in the Future, FAIRE 2003
Citizens' Request for Audit September 5, 2003
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Long Term Care Facilities Submission to the Auditor General of Alberta
4.
Health, Safety and Protection of Residents (continued)
If there are no effective mechanisms to protect residents, does this not increase the
likelihood of a continuum of serious injuries to residents and premature deaths? Will this
not result in hospitalizations and higher liability insurance for the industry - added costs
subsidized either directly or indirectly by taxpayers?
5. Sanctions
Various sanctions can be applied to long-term care facilities that contravene legislative
requirements or cause harm to residents or pose a serious threat to their health and safety.
These sanctions include suspension of admissions, revocation or suspension of a facility
license, taking over the operation of a nursing home and prosecutions.
Despite the growing reports of possible violation of standards and the serious and
potentially life-threatening problems in the delivery of care in this province, there is no
indication that sanctions have been applied against delinquent facilities. Do residents,
families of residents, as well as Alberta taxpayers have a right to know why this is?
6.
Public Funding and Accountability
The apparent lack of government control over the significant amount of public funds
flowing into Alberta's long-term care system is a cause for concern. 17 While government
subsidizes approximately 70% of the cost of a long-term care bed, there appear to be no
rules specifying the amount of money to be spent on important areas such as services and
programs, staffing and education, and direct bedside care. In addition, there seem to be no
limits placed on: the financial returns that can be allocated to shareholders; salaries for
chief executive officers; or spending on administrative and capital costs. Furthermore,
Alberta has no mechanism for monitoring or addressing fraud an issue that is only too
common in the nursing home industry in the United States.
If the Alberta government is reluctant to intervene in areas that affect profit margins or to
retain control over expenditures of owners/operators in the areas of staffing, skill mix and
types of services to be provided, does this not increase the potential for the indiscriminate
and inappropriate spending of public funds? And does this not leave vulnerable frail
elderly people at risk of abuse, neglect and poor care?
SUMMARY
From the information provided in this single submission, it is easy to conclude that Albertans in
long-term facilities are highly vulnerable to mistreatment, exploitation and poor care. We believe
a value-for-money audit of Alberta's long-term care system would serve the interests of residents,
their families, facility staff, Alberta taxpayers and those who might one day need residential long-
term care. Furthermore, we believe the objectives of this initiative are consistent with the mission
statement of the Office of the Auditor General of Alberta, namely "to identify opportunities and
propose solutions for the improved use of public resources, and to improve and add credibility to
performance reporting, including financial reporting, to Albertans." It is our hope that the
Auditor General of Alberta will look upon this submission as an opportunity to improve the
province's long-term care program and, ultimately, the quality of life and quality of care of
elderly and disabled citizens living in these care settings.
17 Government of Alberta News Release, November 2001
Citizens' Request for Audit September 5, 2003
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