Standards Comparison

REVISED SEPTEMBER 2014
(applicable to reviews starting January 1, 2015)
/ ORIGINAL AUGUST 2009
(applicable to reviews until December 31, 2014)
Note: Text in red indicates new criteria or changes (additions or deletions) to performance measures.
Standard 1: Bill of Rights
Reference: Personal Care Homes Standards Regulation Sections 2, 3, & 4
Bill of Rights
The operator of a personal care home shall ensure that a residents’ bill of rights is developed for the home in consultation with the residents and their designates. The bill of rights must be reviewed and approved annually by the residents and their designates (at minimum, the members of the Resident Council).
What the bill of rights must contain
The bill of rights must be consistent with the act and this regulation and must, at minimum, clearly reflect the following principles:
  1. Residents are to be treated with courtesy and respect, and in a way that promotes their dignity and individuality.
  2. Residents are to be sheltered, fed, dressed, groomed and cared for in a manner consistent with their needs.
  3. Residents or their legal representatives have the right to give or refuse consent to treatment, including medication, in accordance with the law.
  4. Subject to safety requirements and the privacy rights of other residents, residents are encouraged to exercise their freedom of choice whenever possible, including the freedom to do the following:
  1. Exercise their choice of religion, culture and Language;
  2. Communicate with, and have contact with and visits to and from friends, family and others in private if desired;
  3. Choose recreational activities;
  4. Choose the personal items to be kept in their rooms, when space permits; and
  5. Select the clothing to be worn each day.
  1. Residents are to be afforded reasonable privacy while being treated and cared for.
  2. Residents are to be provided with a safe and clean environment.
  3. Residents may communicate and meet with their legal representative as often as necessary and in private if desired.
Bill of rights to be respected and promoted
The operator shall ensure that the bill of rights is respected and promoted in the personal care home (PCH).
The bill of rights must be posted in standard CNIB print (Arial 14 font or larger) in locations that are prominent and easily accessible to residents, family, designates and staff.
Expected Outcome: The resident’s right to privacy, dignity and confidentiality is recognized, respected and promoted.
Performance Measures
1.01 / The personal care home has a
resident bill of rights. / 1.1 / The personal care home has a current resident bill of rights.
1.02 / The bill of rights is reviewed and/or their designates annually / 1.2 / The bill of rights is consistent with the requirements of the Personal Care Homes Standards Regulation. The bill of rights reflects:
a) Residents are treated with courtesy and in a way that promotes their dignity and individuality.
The bill of rights is posted:
1.03 / In minimum standard CNIB print (Arial font 14 or larger), and; / 1.3 / b) Residents are sheltered, fed, dressed, groomed and cared for in a manner consistent with their needs.
1.04 / In locations that are prominent and easily accessible by residents, families and staff. / 1.4 / c) Residents or their legal representative has the right to give or refuse consent to treatment, including medication, in accordance with the law.
The bill of rights is consistent with the requirements of the PCH Standards Regulation and reflects that:
1.05 / Residents are treated with courtesy and in a way that promotes their dignity and individuality;prev 1.2 a / 1.5 / Subject to safety requirements and privacy rights of other residents, residents are free to:
a) Exercise their freedom of choice of religion, culture and language;
1.06 / Residents are sheltered, fed, dressed, groomed and cared for in a manner consistent with their needs, and;prev 1.3 b / 1.6 / b) Residents are free to communicate with, have contact with and visits to and from friends, family and others in private if desired;
1.07 / Residents or their legal representative have the right to give or refuse consent to treatment, including medication, in accordance with the law.prev 1.4 c / 1.7 / c) Residents are free to choose their recreational activities;
Subject to safety requirements and the privacy rights of other residents, the facility’s Bill of Rights outlines that each resident has the right to:
1.08 / Exercise their freedom of choice of religion, culture and language; prev 1.5 a / 1.8 / d) Residents are free to choose the personal items to be kept in their rooms, when space permits;
1.09 / Communicate with, have contact with and have visits to and from friends, family and others, in private if desired; prev 1.6 b / 1.9 / e) Select the clothing to be worn each day;
1.10 / Choose their recreational activities prev 1.7 c / 1.10 / f) Residents are afforded reasonable privacy while being treated and cared for;
1.11 / Choose the personal items to be kept in their rooms, when space permits prev 1.8 d / 1.11 / g) Residents are to be provided with a safe and clean environment;
1.12 / Select the clothing to be worn each day; prev 1.9 e / 1.12 / h) Residents may communicate and meet with their legal representative as often as necessary and in private if desired.
1.13 / Be provided reasonable privacy while being treated and cared for prev 1.10 f / 1.13 / There is evidence that the personal care home respects and promotes the bill of rights:
a) The bill of rights is included in staff orientation;
1.14 / Be provided with a safe and clean environment, and; prev 1.11 g / 1.14 / b) Staff’s acknowledgement of the bill of rights is documented;
1.15 / Communicate and meet with their legal representative as often as necessary and in private, if desired. Prev 1.12 h / 1.15 / c) Facility policies are compatible with the bill of rights;
There is evidence that the PCH respects and promotes the bill of rights, as follows:
1.16 / Facility policies are compatible with the bill of rights, and; prev 1.15 c / 1.16 / d) Audits are conducted of how staff incorporate the bill of rights into their interactions with residents;
1.17 / Audits of how staffs incorporate the bill of rights into their daily interactions with residents are completed at least annually. Prev 1.16 d / 1.17 / e) The bill of rights is annually reviewed with staff.
The audit results:
1.18 / Are reported; / NEW
1.19 / Are reviewed and analyzed; / NEW
1.20 / Recommendations are made, as required, from the audit analysis, and; / NEW
1.21 / Recommendations are implemented/followed up. / NEW
Scoring methodology:
  • The bolded measures (1.01, 1.02, 1.03 & 1.04) are pass/fail performance measures. If they are not met, the standard is not met. If they are met, the other measures are considered before assigning an overall rating to the standard.
  • Of the 17 other measures:
  • If ≥14 measures are met, the standard is met
  • If ≥10 and <14 measures are met, the standard is partially met
  • If <10 measures are met, standard is not met.

Standard 2: Resident Council
Reference: Personal Care Homes Standards Regulation Sections 5 & 6
Resident Council
The operator shall ensure that reasonable assistance is given to residents and their designates to help them establish and maintain a resident council.
The purpose of the resident council is to provide a forum where issues, that concern residents, can be discussed including the services provided to residents in the PCH.
The resident council may consist of residents, their designates and any other persons that the council considers appropriate.
Suggestions and concerns raised by the council
The operator shall ensure that a concern raised by the resident council is addressed, including an investigation of the concern if necessary, and that a response, or preliminary response, is provided to the council at or before its next meeting.
The minutes of the council’s meetings must be posted in standard CNIB (Arial font, sixe 14 or larger) in a location that is prominent and easily accessible by residents and staff.
Expected Outcome: Residents have a forum to freely discuss their concerns and issues, and management of the home responds to the same forum.
Performance Measures
2.01 / There is evidence that the resident council meets, at a minimum, five times per year. / 2.1 / There is evidence that the resident council meets at a minimum five times per year.
2.02 / Terms of Reference of the resident council meetings provide evidence that residents are encouraged and supported in bringing forward issues and concerns. / 2.2 / Minutes of the meetings of the resident council provide evidence that residents are encouraged and supported in bringing forward issues and concerns.
Minutes of the resident council meetings provide evidence that the residents’ issues and concerns are:
2.03 / Documented; / 2.3 / Minutes of the meetings of the resident council provide evidence that the residents’ issues and concerns are:
a) Documented:
2.04 / Investigated; / 2.4 / Investigated; and
2.05 / Responded to at the next resident council meeting; and / 2.5 / c) Responded to in a timely fashion.
2.06 / Followed-up on in a timely fashion
Scoring methodology:
  • The bolded measure (2.01) is a pass/fail performance measure. If it is not met, the standard is not met. If it is met, the other measures are considered before assigning an overall rating to the standard.
  • Of the 5 other measures:
  • If ≥ 4 measures are met, standard is met
  • If 3 measures are met, standard is partially met
  • If ≤ 2 measures are met, standard is not met.

Standard 3: Eligibility for Admission
Reference: Personal Care Homes Standards Regulation Section 7
Who is eligibility for Admission
If a bed is available in a personal care home, any person who meets the eligibility requirements described in clause 3(a) and (b) of The Personal Care Services Insurance and Administration Regulation is entitled to be admitted, unless it can be demonstrated that safe and adequate care cannot be provided to the person in the home.
When determining whether safe and adequate care can be provided, the needs of the person must be considered, as well as the staffing and physical facilities of the personal care home.
The person’s needs are those described in the completed Application and Assessment Form and as determined by any contact between the staff of the personal care home and
  1. The person and his or her designate or legal representative; and
  2. Any other person or entity that has provided health care to the person.
A bed designated for short-term respite care is not available under subsection (1).
Expected Outcome: Residents are assessed and placed in the most appropriate setting, according to their needs.
3.01 / There is evidence in the resident’s health record that eligibility for admission has been determined by an assessment panel independent of the personal care home; / 3.1 / There is evidence in the resident’s health record that eligibility for admission has been determined by an assessment panel independent of the personal care home.
3.02 / The admission process is guided by specific documented criteria developed by the facility/Regional Health Authority to determine its ability to meet the needs of the prospective resident. / 3.2 / The admission process is guided by specific documented criteria developed by the facility to determine its ability to meet the needs of the prospective resident
3.03 / There is documented evidence on the resident’shealth record of pre-admission contact between staff of the facility and the prospective resident, the resident’s representative and/or any other person or entity that has provided health care to the prospective resident. / 3.3 / There is documented evidence of pre-admission contact between staff of the facility and the prospective resident, the resident’s representative and any other persons or entity that has provided health care to the person.
Scoring methodology:
  • Each of the measures is bolded (3.01, 3.02, 3.03) and are therefore pass/fail performance measures. If any one of the measures is not met, the standard is not met.

Standard 4: Information on Admission
Reference: Personal Care Homes Standards Regulation, Section 8
Information for residents on admission
The operator shall give the following information to each resident before admission or, if that is not possible, on admission:
  1. A copy of the residents’ bill of rights;
  2. A copy of the philosophy and mission currently in effect at the PCH;
  3. A description of the ways in which the resident and his or her designate and/or legal representative can participate in assessing, planning, providing, monitoring, and evaluating the resident’s care;
  4. Information about the resident council;
  5. Information respecting the policies relating to complaints, abuse, and restraints;
  6. Financial information, including the availability and administration of residents trust accounts and government financial assistance programs;
  7. An orientation to the facility, including safety and security systems; and
  8. Information respecting health care directives.
If a resident has a legal representative, the operator shall also provide the information under subsection (1) to the legal representative.
Expected Outcome: Residents and their representatives are provided with clear information on the operation of the home.
4.01 / The personal care home has an admission package which is provided to every resident and/or their representative prior to or on admission. / 4.1 / The personal care home has an admission package.
The contents of the admission package are consistent with the requirements of the Personal Care Home Standards Regulation, and include:
4.02 / A copy of the residents’ bill of rights; / 4.2 / The contents of the admission package are consistent with the requirements of the Personal Care Home Standards Regulation, including:
a) A copy of the residents’ bill of rights;
4.03 / A copy of the personal care home’s philosophy and mission; / 4.3 / A copy of the personal care home’s philosophy and mission;
4.04 / A description of the ways in which the resident and his or her designate and/or legal representative can participate in assessing, planning, providing, monitoring, and evaluating the resident’s care; / 4.4 / c) A description of the ways in which the resident and his or her designate and legal representative can participate in assessing, planning, providing, monitoring, and evaluating the resident’s care;
4.05 / Information about the resident council; / 4.5 / d) Information about the resident council;
4.06 / Information respecting the policy on the complaints process; / 4.6 / e) Information respecting the policies on complaints, freedom from abuse, and restraint use;
4.07 / Information respecting the policy on freedom from abuse; prev 4.6 / 4.7 / f) Financial information including the availability and administration of resident trust accounts and government financial assistance programs;
4.08 / Information respecting the policy on restraint use; prev 4.6 / 4.8 / g) An orientation to the facility, including safety and security systems;
4.09 / Financial information including the availability and administration of resident trust accounts and government financial assistance programs; prev 4.7 / 4.9 / h) Information respecting health care directives.
4.10 / Information respecting health care directives, and; prev 4.9 / NEW
4.11 / An orientation to the facility, including safety and security systems. Prev 4.8 / NEW
Scoring methodology:
  • The bolded measure (4.01) is a pass/fail performance measure. If it is not met, the standard is not met. If it is met, the other measures are considered before assigning an overall rating to the standard.
  • Of the 10 other measures:
  • If ≥8 measures are met, standard is met
  • If ≥6 and <8 measures are met, standard is partially met
  • If <6 measures are met, standard is not met.

Standard 5: Right to Participate in Care
Reference: Personal Care Homes Standards Regulation, Section 9 & 10
Resident’s Right to participate in care
The operator shall ensure that a resident and his or her designate and legal representative are given an opportunity to partocopate in assessing, planning, providing for, monitoring and evaluating the resident’s care.
Resident’s Wishes
The operator shall ensure that the resident’s wishes are considered when a care plan is developed or amended.
Expected Outcome: Residents receive care in accordance with their wishes.
Performance Measures:
5.01 / The development of the initial care plan (completed within 24 hours of admission); / 5.1 / There is documented evidence that:
a) The resident and their representative have had the opportunity to participate in the initial care plan;
5.02 / The development of the integrated care plan (completed within eight weeks of admission), and; / 5.2 / b) The resident and their representative have had the opportunity to participate in the development of the integrated care plan;
5.03 / The annual care conferences. / 5.3 / c) The resident and their representative have had the opportunity to participate in the annual care conference.
Scoring methodology:
  • All performance measures (5.01, 5.02, 5.03) are pass/fail measures for the standard. If any one of the measures is not met, the standard is not met.

Standard 6: Communication Previously called Integrated Care Plan.
Reference: Personal Care Homes Standards Regulation, Sections 14
The operator shall ensure that the staff who provide direct care and services to the resident follow the resident’s current care plan.
The operator shall ensure that there are policies and processes in place to guide the sharing of significant information about each resident between and amongst staff, in an effort to limit potential harm to residents. This should include:
  1. A standardization process for transfer of accountability including communication of resident information between staff at change of shift and when a transfer to another unit or facility is required;
  2. A mechanism to review specific residents safety issues;
  3. An opportunity to clarify information prior to transfer of accountability;
  4. The use of a written tool for the exchange of information (minimal reliance on memory), and;
  5. The person in charge has an overview of all current significant information that require monitoring for each resident on the unit(s) for which they are responsible.
The operator shall ensure that the staff who provide direct care and services to the resident:
  1. Follow the resident’s current care plan;
  2. Have, where implemented, an accurate summary of the current care plan to reference (i.e. Activities of Daily Living sheet).
  3. Are aware of current acute issues (i.e. hydration concerns, infections, new behavioral responses, skin breakdown, etc.)
Communications with the physician, Nurse Practitioner and/or Physician Assistant:
The operator shall ensure that there is a standardization process to record all communications with each resident’s physician, nurse practitioner and/or physician assistant in the resident record.