CCAC Client Services Policy Manual Chapter 11 Admission to Long-Term Care Homes

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1 11.1 Introduction Community Care Access Centres (CCACs) are the designated placement co-ordinators under the Nursing Homes Act (NHA), Charitable Institutions Act (CIA) and Homes for the Aged and Rest Homes Act (HARHA), and are therefore required to comply with the relevant provisions of these statutes and their regulations. As placement co-ordinators, management of admissions to long-term care (LTC) homes is one of the key functions of the CCAC. In some CCACs, case managers carry out placement co-ordination, while other CCACs have dedicated placement co-ordinators. The terms case manager and placement co-ordinator are often used interchangeably in reference to the persons carrying out the placement function. The term placement co-ordinator is used throughout this chapter for purposes of consistency. This chapter sets out the requirements that the CCAC must adhere to in order to determine a person s eligibility for admission to a LTC home, and for those determined eligible, authorizing their admission to the LTC home of their choice. The requirements for short-stay and long-stay clients are dealt with separately in this chapter. (See prioritization criteria and waiting list management in chapter #12 in this manual.) All legislative references in this chapter, unless stated otherwise, are to the NHA and regulation 832 of the NHA. However, similar provisions can be found in the CIA and HARHA, and their regulations. It should be noted that the CCAC does not determine eligibility or authorize admissions to group homes, rest homes and retirement homes, or to acute, complex continuing care and psychiatric hospitals Responsibilities of the CCAC with Respect to LTC Home Admissions All persons seeking admission to a LTC home must contact the placement co-ordination service (PCS) of the CCAC in the person s area. The CCAC, through its placement function, is responsible for: determining eligibility for admission to LTC homes; September

2 for those persons determined eligible, requesting the LTC home s approval for admission to the home; determining priority for admission and placing all eligible applicants in the appropriate prioritization categories on the waiting lists when beds are not immediately available; keeping and managing the waiting lists for admission to LTC homes; and authorizing admissions to LTC homes. If an application is made for a LTC home in another area of the province, the local CCAC where the person is living at the time of application is responsible for the determination of eligibility, but will transfer the assessment and eligibility information to the out-of-area CCAC where the LTC home is located. In this situation, the two CCACs co-ordinate their activities and the local CCAC acts as liaison with the person. When a person requests admission to a LTC home, the CCAC will conduct an interview with the applicant or if the applicant is incapable of making the admission decision, with his or her authorized substitute decision-maker (SDM). Here the CCAC will explain the assessment and admission processes and will gather information to determine the applicant s needs and whether the needs can be met through CCAC in-home services or community services or whether the applicant requires LTC home admission. The CCAC must have detailed information about the LTC homes, publicly-funded community services, retirement homes and other alternative services in its area. The information for each home should include programming available, unique features, in-house staffing, number of beds, and compliance with standards, policies, criteria, regulations and legislation. This information is necessary because the placement co-ordinator must consider the following: whether the person s care requirements can be met in a LTC home (rather than in the person s home or in the community); the person s care expectations and personal preferences; and the person s ethnic, spiritual, linguistic, familial and cultural preferences. The placement co-ordinator must also assess the person s ability to understand the service options that are available and appropriate to address the person s needs, and assist the person or if the person is incapable of making the admission decision, the SDM s ability to access these services History PCSs were initially pilot tested in Ontario in the1970s. In 1993 the Long-Term Care Statute Law Amendment Act, 1993 (LTCSLAA) made amendments to the NHA, CIA and HARHA. These amendments enabled the Ministry of Health and Long-Term Care (MOHLTC) to designate one or more persons, classes of persons, or other entities as placement co-ordinators. By 1994, PCSs were fully implemented across the province. Between 1996 and 1998, PCSs and Home Care Programs were consolidated to form the new CCACs with the purpose of providing simplified access for persons seeking in-home services or placement in LTC homes. September

3 This manual supersedes the previous Placement Coordination Services Manual issued in 1994 and its subsequent updates. Further information about MOHLTC policies with respect to LTC homes can be found in the Long-Term Care Facilities Program Manual, 1993, Revisions 1995, 1998 available from the MOHLTC Long-Term Care Homes Branch or any regional office of MOHLTC. September

4 11.2 Eligibility Criteria Eligibility Criteria for Long-Stay Applicants Section 130 of the Nursing Homes Act (NHA) regulation outlines eligibility criteria for a person seeking long-stay placement in a long-term care (LTC) home: s. 130(1) An applicant shall be determined to be eligible for admission to a nursing home if, and only if, (a) the applicant is at least 18 years old; (b) the applicant is an insured person under the Health Insurance Act; (c) the applicant meets at least one of the conditions set out in subsection (2); (d) the applicant meets at least one of the conditions set out in subsection (3); and (e) the applicant's care requirements can be met in a nursing home. (2) The following are the conditions referred to in clause (1) (c): 1. The applicant requires that nursing care be available on-site 24 hours a day. 2. The applicant requires assistance each day with activities of daily living. 3. The applicant requires, at frequent intervals throughout the day, on-site supervision or onsite monitoring to ensure his or her safety or well-being. 4. The applicant is at risk of being financially, emotionally or physically harmed if the applicant lives in his or her residence. 5. The applicant is at risk of suffering harm due to environmental conditions that cannot be resolved if the applicant lives in his or her residence. 6. The applicant may harm someone if the applicant lives in his or her residence. (3) The following are the conditions referred to in clause (1) (d): 1. None of the publicly-funded community-based services available to the applicant while the applicant lives in his or her residence and none of the other caregiving, support or companionship arrangements available to the applicant while the applicant lives in his or her residence are sufficient, in any combination, to meet the applicant's requirements. 2. None of the publicly-funded community-based services available to the applicant in the area to which the applicant plans to move and none of the other caregiving, support or companionship arrangements available to the applicant in the area to which the applicant plans to move are sufficient, in any combination, to meet the applicant's requirements. (4) Revoked: O. Reg. 121/02, s. 7. (5) Revoked: O. Reg. 121/02, s. 7. (6) This section does not apply to an applicant who is applying for a determination respecting his or her eligibility for admission to a nursing home as a short-stay resident in the respite care or supportive care program Discussion of the Eligibility Criteria for Long-Stay Applicants As indicated in the regulatory provisions of the NHA referenced above, the criteria for determining an applicant s eligibility for admission to a LTC home are: September

5 1. the applicant must be at least 18 years old; 2. the applicant must be an insured person under the Health Insurance Act (HIA); 3. the applicant must meet at least one of the following criteria: requires nursing care be available on-site 24 hours a day; requires assistance each day with activities of daily living; requires, at frequent intervals throughout the day, on-site supervision and monitoring to ensure his or her safety or well-being; at risk of being financially, emotionally or physically harmed if the applicant lives in his or her residence; at risk of suffering harm due to environmental conditions that cannot be resolved if the applicant lives in his or her residence; or applicant may harm someone if the applicant lives in his or her residence; 4. publicly-funded community-based services available to the applicant and caregiving, support or companionship arrangements available where the applicant lives or intends to live are insufficient to meet the applicant s requirements; and 5. applicant s care requirements can be met in a LTC home. For greater clarity, additional information and discussion of each of these requirements is provided below. 1. The applicant is at least 18 years old. Persons under the age of 18 years cannot be admitted to LTC homes on either a short or long-term basis. Persons aged 18 years and over may be served in a LTC home. Of course, all community-based service options should be explored with all applicants. Some younger persons may prefer community-based services over placement in a LTC home, as the majority of persons who seek admission to LTC homes are seniors. 2. The applicant is an insured person under the HIA. The Community Care Access Centre (CCAC) must ensure that the applicant has valid Ontario Health Insurance Plan (OHIP) coverage. (For additional information on OHIP coverage, see chapter #3 in this manual.) 3. The applicant meets at least one of the following criteria. s. 130(2)1 The applicant requires that nursing care be available on-site 24 hours a day. People seeking admission to LTC homes should not require the constant presence of registered nursing staff: this level of care is only available in a hospital. However, the applicant who requires frequent intervention and monitoring of a condition by a nurse throughout the day, which would be difficult to provide in a community-based setting, would meet this criterion. s. 130(2)2 The applicant requires assistance each day with activities of daily living. September

6 The applicant requires assistance with some or all of the following activities each day that would be difficult to provide in a community-based setting. These activities include but are not limited to the following: washing/bathing/showering/bed bath; mouth care; hair care; preventive skin care; routine hand/foot care; menstrual care; transferring/positioning/turning; exercises (rehabilitation/ambulation); dressing/undressing; assistance with eating; toileting (including empty/change leg bag, catheterization); bowel routines; assistance with taking pre-measured medications; changing non-sterile dressings; and care and maintenance of equipment. In addition, an applicant who is of such frailty that he or she requires ongoing assistance with a number of activities of daily living such as meal preparation, ordinary housework, managing finances, managing medications and shopping on a daily basis may be in need of admission to a LTC home. s. 130(2)3 The applicant requires, at frequent intervals throughout the day, on-site supervision and monitoring to ensure his or her safety or well-being. The need for a supervised, safe physical environment is the reason for admission in this case as opposed to the applicant s need for nursing or personal care. The applicant requires frequent monitoring or on-site supervision to ensure his or her safety and well-being throughout the day. For example, a secure setting may be required to prevent wandering, or for applicants who experience considerable agitation and distress living in an environment where they would be alone for long periods of time. s. 130(2)4 The applicant is at risk of being financially, emotionally or physically harmed if the applicant lives in his her residence. There is reason to believe that the applicant is at risk of harm or abuse if he or she is left in his or her existing living situation. In the case of abuse, it could be physical, psychological September

7 or emotional, financial abuse or exploitation, sexual abuse, medication abuse, violation of civil/human rights or neglect/self-neglect. 1 Another example of where an individual may be at risk for financial or emotional harm occasionally occurs when a person is left on his or her own as a result of his or her spouse s/partner s admission to a LTC care home. s. 130(2)5 The applicant is at risk of suffering harm due to environmental conditions that cannot be resolved if the applicant lives in his or her residence. The applicant may be living in a home that is no longer fit for habitation or living in a remote area where there are limited health and community services to assist the applicant to remain in his or her current setting. s. 130(2)6 The applicant may harm someone if the applicant lives in his or her residence. Family members, caregivers or neighbours may be at risk if the applicant is prone to assaultive behaviour because of an illness or a cognitive impairment. 4. The community-based services, caregiving, support or companionship arrangements available where the applicant lives or intends to live are insufficient to meet the applicant s requirements. s. 130(1)(d) The applicant meets at least one of the conditions set out in subsection (3): (3) 1. None of the publicly funded community-based services available to the applicant while the applicant lives in his or her residence and none of the other caregiving, support or companionship arrangements available to the applicant while the applicant lives in his or her residence are sufficient, in any combination, to meet the applicant s requirements. 2. None of the publicly-funded community-based services available to the applicant in the area to which the applicant plans to move and none of the other caregiving, support or companionship arrangements available to the applicant in the area to which the applicant plans to move are sufficient, in any combination, to meet the applicant s requirements. If the applicant s needs can be met through the community-based services described above, the applicant is not eligible for admission to a LTC home. The CCAC may declare an applicant ineligible if the CCAC placement co-ordinator believes that the communitybased services the applicant is receiving or could receive are adequate to meet his or her needs. The CCAC may not, however, declare an applicant ineligible on the grounds that the applicant has the financial resources to live in a retirement home or to make private care arrangements that exceed the amount of service available through publicly-funded or voluntary community-based services. 1 British Columbia Coalition to Eliminate Abuse of Seniors Fact Sheet #1. September

8 If an applicant refuses to accept community-based services that have been determined by the CCAC to be available and appropriate to meet the applicant s needs, the applicant is not eligible for LTC home admission. 5. The applicant s care requirements can be met in a LTC home. The CCAC must ensure that the applicant s assessed care needs: may be reasonably met within the LTC home; are within the scope of what a LTC home provides; or can be provided by a LTC home with the support and assistance of other institutional or home resources in the community Determination of Ineligibility Pursuant to LTC home legislation, if an applicant is determined ineligible for admission to a LTC home, the CCAC must provide the applicant and the person, if any, who applied for the determination on behalf of the applicant, with written notice outlining: s. 20.5(1)the determination of ineligibility; the reasons for the determination, and the applicant s right to apply to the Health Services Appeal and Review Board (Appeal Board) for a review of the determination. The CCAC should advise applicants to contact the CCAC for a re-determination of eligibility should their condition or circumstances change. If the applicant is a hospital inpatient, the CCAC may advise the hospital of the CCAC s determination of ineligibility, subject to the provisions of the Personal Health Information Protection Act, 2004 (PHIPA) Other Alternatives Subsection 20.1(16) of the NHA provides that the CCAC placement co-ordinator must suggest alternative services or make appropriate referrals on behalf of an applicant if it is determined that the applicant is either not eligible for admission to a LTC home or is determined eligible for admission to a LTC home but not authorized for immediate admission Spousal/Partner Accompaniment by a Well Spouse/Partner A spouse/partner who does not have care requirements of his or her own, but who wishes to enter a LTC home to be with his or her spouse/partner who has been determined eligible as a result of care needs, or who is already residing in a LTC home, may be admitted to a LTC home as long as he or she meets the following criteria: September

9 s. 132 Despite section 130, an applicant shall be determined to be eligible for admission to a nursing home as a long-stay resident if, (a) the applicant's spouse or partner is, (i) a long-stay resident, or (ii) a person who has been determined by a placement co-ordinator to be eligible for admission to a nursing home as a long-stay resident; (b) the applicant is at least 18 years old; (c) the applicant is an insured person under the Health Insurance Act; and (d) the applicant's care requirements can be met in a nursing home. Notes: The term spouse is defined in subsection 1(1) of the NHA regulation as: s. 1(2) a person, (a) to whom the person is married, or (b) with whom the person is living, or was living immediately before one of them was admitted to a nursing home, in a conjugal relationship outside marriage, if the two persons, (i) have cohabited for at least one year, (ii) are together the parents of a child, or (iii) have together entered into a cohabitation agreement under section 53 of the Family Law Act. The term partners is defined in subsection 1(2) of the NHA regulation as: s. 1(2) Two persons are partners for the purpose of this Regulation if they have lived together for at least one year and have a close personal relationship that is of primary importance in both persons' lives. A spouse/partner entering a LTC home to join his or her spouse/partner must provide the same assessment and personal information required for any applicant. An accompanying spouse/partner who is admitted to a LTC home may continue to reside in the LTC home after the death of his or her spouse/partner even if the surviving person does not require LTC home services. The rationale for allowing this person to remain in the home is that the survivor is unlikely to have a home in the community to which he or she can return. If the spouse/partner in the LTC home dies while the accompanying person is on a waiting list, the CCAC must reassess the eligibility of the person. If the person does not meet the eligibility criteria for admission set out in section 130(1) of the NHA regulation, the person must be removed from the waiting list. The CCAC should explain this situation to prospective applicants who wish to join a spouse/partner in a LTC home and are not eligible for home admission on the basis of their own care and support requirements. If there is a strong indication that a well spouse/partner will want to accompany his or her spouse/partner into a LTC home, the CCAC should strongly encourage the well spouse/partner to apply for admission at the same time as his or her spouse/partner. This will ensure the earliest possible date for ranking of the well spouse within prioritization category 2 of the waiting list. (The spouse with the care needs will receive higher prioritization in category 1A1. See subsection #12.3 in this manual for additional information on prioritization criteria in category 1A1.) September

10 Eligibility of Individuals Already Resident in a LTC Home Section 133 of the NHA regulation exempts existing residents of LTC homes from a redetermination of their eligibility for admission to another LTC home by stating: s. 133 Despite section 130, the following applicants shall be determined to be eligible for admission to a nursing home as long-stay residents: 1. A long-stay resident requesting a transfer to another nursing home as a long-stay resident. 2. A long-stay resident under the Homes for the Aged and Rest Homes Act or the Charitable Institutions Act requesting a transfer to a nursing home as a long-stay resident. Note: This exemption extends only to the eligibility requirements in section 130 of the NHA regulation. It does not exempt the CCAC from obtaining an applicant s consent for admission to another LTC home, which is required for authorization of admission. The requirement for consent is contained in subsection 20.1(13) of the NHA. (See subsection #11.4 in this manual for additional information on the requirement for consent.) Although the eligibility for admission of a person who is seeking a transfer to another LTC home cannot be re-determined, there may be situations where a transfer is being requested because the person s needs can no longer be met in a LTC home. In these cases, it is imperative that the LTC homes to which the person is seeking a transfer receive comprehensive and up-todate information about the person s condition, including physical and mental health, functional status and behaviours in order to determine whether to grant or refuse admission. In some instances new assessments may be appropriate when an applicant is transferring from one home to another Eligibility of Veterans With the exception of the requirement that they be an insured person under the HIA, veterans are also exempt from the eligibility criteria set out in section 130 of the NHA regulation. Section provides for the eligibility of veterans as follows: s Despite section 130, an applicant who is a veteran shall be determined eligible for admission to a nursing home as a long-stay resident if the applicant is an insured person under the Health Insurance Act. September

11 11.3 Application Process for Long-Stay Eligibility Determination Section 134 of the Nursing Homes Act (NHA) regulation sets out the application process for a determination of eligibility: s. 134(1) To apply for a determination respecting his or her eligibility for admission to a nursing home, a person shall establish that he or she is at least 18 years old and shall provide to a placement co-ordinator, (a) a request by the person for a determination of his or her eligibility, in the form provided by the Minister; (b) proof that the person is an insured person under the Health Insurance Act; (c) an up-to-date health assessment of the person, in the form provided by the Minister, signed by, (i) a member of the College of Physicians and Surgeons of Ontario, or (ii) a registered nurse who holds a general certificate of registration or an extended certificate of registration in accordance with the regulations made under the Nursing Act, 1991; (d) an up-to-date functional assessment of the person conducted by a health or social service provider approved by the placement co-ordinator; and (e) such additional information and documentation as is necessary to enable the placement coordinator to determine whether the person meets the eligibility requirements set out in this Regulation. (1.1) Despite subsection (1), a veteran who wishes to apply for a determination of his or her eligibility for admission to a nursing home is not required to establish that he or she is 18 years old or to provide his or her request for a determination respecting his or her eligibility in the form provided by the Minister. (2) Despite subsection (1), the following persons are not required to establish that they are at least 18 years old and are not required to comply with clauses (1) (b), (c) and (d): 1. A long-stay resident applying for a determination of eligibility for the purpose of transferring to another nursing home as a long-stay resident. 2. A long-stay resident under the Homes for the Aged and Rest Homes Act or the Charitable Institutions Act applying for a determination of eligibility for the purpose of transferring to a nursing home as a long-stay resident. (3) Despite subsection (1), a person described in a paragraph of subsection (2) who is applying for a determination of eligibility for the purpose of transferring to a related temporary nursing home, a re-opened nursing home or a replacement nursing home as a long-stay resident is not required to provide his or her request for a determination respecting his or her eligibility in the form provided by the Minister, if he or she is a long-stay resident of the original nursing home or was a long-stay resident of the original nursing home immediately before the closure of his or her bed in the home. September

12 (4) If a person applying for a determination of eligibility is going to be placed in category 1A under section 143, the person is not required to comply with clauses (1) (c) and (d) if there is insufficient time to comply with them. (5) The placement co-ordinator shall assist the person in obtaining the information and documentation that the person is required to provide to the placement co-ordinator under this section Discussion of the Application Process for Determination of Eligibility The application process begins when a person requests admission to a long-term care (LTC) home. The placement co-ordinator conducts an interview with the applicant or if the applicant is incapable of the admission decision, with his or her authorized substitute decision-maker (SDM). (For information on identifying the SDM, see subsection #4.5.3 in this manual.) In the interview, the placement co-ordinator will explain the assessment and admission processes and will gather information to determine the applicant s needs, whether the needs can be met through Community Care Access Centre (CCAC) in-home services or community services. If the client s needs cannot be met by in-home services or community services, then the assessment continues to determine whether the client s needs can be met by LTC home services. The placement co-ordinator will review the following information with the applicant or the SDM: the criteria for determining eligibility; the type of information that is collected during the eligibility determination process, including personal information; the process for admission to a LTC home, which includes authorizing admission to a LTC home and the LTC home s ability to withhold approval for the person s admission under certain circumstances; (i.e., the home lacks the physical facilities or nursing expertise necessary to meet the person s care requirements); the process for determining a person s priority for admission and what the waiting list involves; the person s rights to appeal any determination of being incapable of making an admission decision and the right to appeal a determination of ineligibility for admission to a LTC home; and resident charges in a LTC home. If the person agrees to proceed with the determination of eligibility, the placement co-ordinator works with the person and/or the person s SDM in obtaining the information and documentation required by the regulation under subsection 134(5) of the NHA. In all cases, the outcome of this interview must be documented and retained for future reference. September

13 Establishing that an Applicant is at Least 18 Years Old Subsection 134(1) of the NHA provides that to apply for admission to a LTC home, a person must establish that he or she is at least 18 years old. Since many individuals seeking admission to LTC homes are seniors, specific verification of age through the provision of identification that includes a date of birth is generally not required. If a situation arises where a placement co-ordinator is in doubt that a prospective applicant is at least 18 years old, the placement co-ordinator must request proof of age. This proof could include a birth certificate, passport, or any other government identification that provides date of birth. Exemptions: Under subsections 134 (1.1), (2) and (3) of the NHA regulation, veterans and persons already resident in a LTC home who are transferring to another LTC home are not required to establish that they are at least 18 years old. (For long-stay residents of a LTC home applying for a determination of eligibility in order to transfer to a related temporary, re-opened or replacement LTC home, see Streamlined Admission Process in subsection # in this manual.) A Written Request for Determination of Eligibility for Admission to a LTC Home A further requirement, in subsection 134(1)(a) of the NHA, is the provision of a written request for determination of eligibility for admission to a LTC home, which is contained in the Ministry of Health and Long-Term Care (MOHLTC) consent form, Consent for Placement Coordination Services to Collect, Keep on File, and Release Information form (# ), available at: [ DR&TAB=PROFILE&ENV=WWE&NO= ]. When completed and signed, this form provides the written request for eligibility determination. Exemptions: Under subsections 134 (1.1) and (3) of the NHA regulation, veterans and long-stay residents of a LTC home applying for a determination of eligibility in order to transfer to a related temporary, re-opened or replacement nursing home are not required to provide their requests for eligibility determination in the form provided by the MOHLTC. (In the latter case, see Streamlined Admission Process in subsection # in this manual.) This does not mean that these applicants are exempt from making the request, but rather that the request does not have to be in the form provided by the MOHLTC (i.e., the request can take another form such as an oral request). September

14 Proof that the Person is an Insured Person Under the Health Insurance Act A person seeking admission to a LTC home must provide proof that he or she is an insured person under the HIA. The CCAC must ensure that the applicant s Ontario Health Insurance Plan (OHIP) coverage is valid by verifying coverage through the OHIP validation systems. (For information on the verification process, see subsection #3.2 in this manual.) Exemptions: Under subsections 134(2) and (3) of the NHA regulation, persons who are already residents in a LTC home who are transferring to another LTC home are not required to provide proof of OHIP coverage. (For long-stay residents of a LTC home applying for a determination of eligibility in order to transfer to a related temporary, re-opened or replacement LTC home, see Streamlined Admission Process in subsection # in this manual.) Also see Residency Requirements for OHIP Coverage in subsection #3.3 in this manual. Up-to-date Health and Functional Assessments A further requirement for a determination of eligibility for LTC home admission is the provision of an up-to-date health assessment and an up-to-date functional assessment of the applicant in all cases, including crisis situations. Purpose of Assessments The purpose of the assessments is to: identify and evaluate the person s needs, strengths and preferences; identify potential risks; determine the person s eligibility; and determine the most appropriate level of care to address the person s requirements. Health Assessment An up-to-date health assessment of the person is required in all cases, including crisis situations. The information for the health assessment is provided in the MOHLTC Health Report form (# ) which is available at: [ T=RDR&TAB=PROFILE&ENV=WWE&NO= ]. This form seeks information about the person s medical diagnosis, health history, special needs, treatment and medication requirements. The form must be signed by a member of the College of Physicians and Surgeons of Ontario, or a registered nurse who holds a general certificate of registration or an extended certificate of registration, as required by section 134(1)(c) of the NHA regulation. September

15 Applicants cannot be charged for completion of this form by a physician if the completion of the form is a common element of an insured service provided by the physician (under the OHIP Schedule of Benefits). Functional Assessment Under subsection 134(1)(d) of the NHA regulation, an up-to-date functional assessment carried out by a health or social services provider approved by the CCAC is required in all cases, including crisis situations. Since March 2004, functional assessments are carried out using the Resident Assessment Instrument-Home Care (RAI-HC) assessment tool, the use of which the MOHLTC has mandated. In the past, functional assessments were frequently contracted out to hospitals and service providers; however, since the introduction of the RAI-HC in all CCACs, these assessments are now carried out almost exclusively by CCAC case managers or placement coordinators who are either healthcare or social work professionals. This assessment has become an activity internal to the CCAC as a result of the proficiency requirements associated with the assessment tool. However, there is nothing to preclude the CCAC from contracting out the provision of this assessment so long as the health or social service providers they select are, and remain, proficient in the use of the RAI-HC. Note: Subsection 134(1)(d) of the NHA regulation provides that although the functional assessment that contributes to the eligibility determination may be delegated to a health or social services professional in the employ of a service provider or service agency, an applicant s eligibility for admission to a LTC home shall be determined only by the CCAC as provided by subsection 20.1(9) of the NHA. The RAI-HC provides for a standardized assessment process and terminology that is applicable throughout the province. Standardized assessments ensure greater consistency in outcomes based on data collected from applicants. It also ensures LTC homes throughout the province receive the same type of reports and information for consideration when deciding on admission of an applicant. The RAI-HC assessment tool consists of the Minimum Data Set for Home Care (MDS-HC) and Client Assessment Protocols. The MDS-HC is the screening component that enables a home care provider to assess multiple key areas of a client s function, health, social support, and service use. The RAI-HC report function known as the Personal Health Profile provides a standard summary document of the information generated by the RAI-HC tool that homes use to help decide whether to approve an application for admission. Exemptions: Under subsections 134(2) and (3) of the NHA regulation, persons who are already longstay residents in a LTC home who are transferring to another LTC home are exempt from the requirements for an up-to-date health assessment and up-to-date functional assessment. (For long-stay residents of a LTC home applying for a determination of September

16 eligibility in order to transfer to a related temporary, re-opened or replacement nursing home, see Streamlined Admission Process in subsection # in this manual.) Additionally under subsection 134(4) of the NHA regulation, applicants who are going to be placed in category 1A (crisis) of the waiting lists of their chosen LTC homes are not required to provide up-to-date health and functional assessments at this point of the admissions process if there is insufficient time to comply with these requirements. Any Additional Information Necessary for the CCAC to Determine Whether the Person Meets the Eligibility Requirements Set Out in the Regulations Additional information and documentation may be requested if required to enable the placement co-ordinator to determine whether an applicant meets the eligibility requirements in the regulations. September

17 11.4 Consents Required for Long-Stay Placement Consent for Admission People cannot be forced to go into a long-term care (LTC) home or to choose specific homes. The Nursing Homes Act (NHA) states: Applications to placement co-ordinator s. 20.1(6) A person may apply for a determination by a placement co-ordinator respecting the person s eligibility for admission to a nursing home and for authorization of admission with respect to such nursing home or homes as the person selects. Conditions of authorization s. 20.1(13) The placement co-ordinator designated for a nursing home under subsection (3) may authorize the admission of a person to the nursing home only if, (a) the placement co-ordinator or another placement co-ordinator has determined, within the six months preceding authorization, that the person is eligible for admission to a nursing home; (b) the licensee of the nursing home to which the person s admission is to be authorized approves the person s admission to the nursing home; and (c) the person consents to being admitted to the nursing home. While applicants can be encouraged, they cannot be required to choose a specific number of LTC homes or homes with short waiting lists. In addition, they cannot be required to accept a first available bed that is not one of the person s choices. These consumer rights have been a well-established part of the placement co-ordination system since In addition, the Health Care Consent Act, 1996 (HCCA) sets out a comprehensive scheme for obtaining substitute decisions on behalf of persons who are incapable of making the decision about admission to a LTC home. (For information on the provisions of the HCCA concerning consent to admission to a LTC home on behalf of an incapable person, see chapter #4 in this manual.) Consent to Release Personal Information 2 LTC home legislation also requires the placement co-ordinator to obtain a person s consent to share information with the LTC home to which a person is to be admitted. The NHA states: Information to licensee s. 20.2(1) A placement co-ordinator who authorizes a person s admission to a nursing home shall give to the licensee of the nursing home the information mentioned in a paragraph of subsection (2) if, 2 CCACs are health information custodians under the Personal Health Information Protection Act, 2004 (PHIPA). September

18 (a) the placement co-ordinator has the information mentioned in the paragraph; and (b) consent to the disclosure of the information to the licensee is given by, (i) the person whose admission is authorized, or (ii) the person, if any, who was lawfully authorized to consent to admission to the nursing home on behalf of the person whose admission is authorized. Same s. 20.2(2) The information referred to in subsection (1) is the following: 1. Information about assessments of the person whose admission is authorized. 2. Information about the person s medical history. 3. Information about the person s social and other care requirements. 4. The name and address of the person, if any, who was lawfully authorized to consent to admission to the nursing home on behalf of the person whose admission is authorized. Further, requirements under the Personal Health Information Protection Act, 2004 (PHIPA) impose additional obligations on the Community Care Access Centre (CCAC) regarding the maintenance of confidentiality of clients personal health information and the sharing of such information. Personal information gathered by the CCAC must be kept confidential. The CCAC must obtain the consent of the applicant or the applicant s substitute decision-maker (SDM) to collect, use and disclose information. In some instances, PHIPA permits the CCAC to release information without consent. The Ministry of Health and Long-Term Care (MOHLTC) form Consent for Placement Coordination Services to Collect, Keep on File, and Release Information form (# ) is used to obtain client consent for a number of purposes as described below. The placement co-ordinator is responsible for discussing the contents of the form with the applicant, and having the form signed and dated by the applicant or the applicant s SDM before proceeding with the application process. The Consent for Placement Coordination Services to Collect, Keep on File, and Release Information form (# ) is available at: [ DR&TAB=PROFILE&ENV=WWE&NO= ] Types of Consent Different situations require different types of consents to be given by the person or his or her SDM if the person is incapable. The types of consent are outlined below: Consent for the CCAC to request and collect personal information including personal information about the applicant from other organizations Such personal information could include assessments by the applicant s physicians, community-based service providers or informal caregivers. These assessments may provide September

19 information that is necessary to determine the person s eligibility for admission to a LTC home. Consent for the CCAC to disclose personal information about an individual to another CCAC Consent is required to share information with another CCAC when an individual wants to reside in a LTC home outside the catchment area of the CCAC. The person must give consent to the CCAC that will undertake the eligibility determination to disclose personal information to the CCAC that will authorize the person s admission to the LTC home in another area. Consent for the CCAC to disclose personal information to the LTC home(s) to which the person has applied for admission Information about the applicant s medical history, social, health and functional status enables the LTC home to determine whether the home can meet the applicant s care requirements. Consent for the CCAC to send information to the LTC homes to which a resident of a LTC home wishes to transfer Before transferring a person from one LTC home to another, information from the sending LTC home must be sent by the CCAC to the receiving LTC home to obtain the approval of the receiving LTC home to admit the person. September

20 11.5 LTC Home Selection for Long-Stay Applicants If an applicant is declared eligible for admission to a long-term care (LTC) home, the process continues with the selection of the person s preferred LTC home(s). The person has the right to choose the LTC home in which he or she will seek to reside. In order for the applicant to make an informed choice, the applicant needs information about the homes General Information About Homes The Community Care Access Centre (CCAC) can assist a person to make choices about a LTC home by providing information about the services and programs provided by a LTC home, including whether the home has indoor smoking facilities (see #11.6.1, below, in this manual) and answering any questions he or she may have about possible choices. The CCAC must inform the person about home waiting lists so he or she knows how long the wait may be for a specific LTC home. The CCAC may also provide information to persons regarding the performance of the LTC home but should not attempt to influence the person s decision. The CCAC may share the following information with persons interested in different LTC homes: results of the Ministry of Health and Long-Term Care (MOHLTC) inspection of the LTC home; and corrective action plans, if any, that have been identified as part of the inspection. CCACs can also refer applicants to the public reporting website so applicants can review this information themselves (although the CCAC may have a more up-to-date inspection report than is posted on the website). Applicants should be advised if a LTC home has failed to take corrective actions and where sanctions have been applied. If the applicant has additional questions, he or she should be referred to staff of the MOHLTC regional office. The CCAC is also required to maintain up-to-date information with a description of services and programs offered in each LTC home and inform applicants about those services Information About Accommodation Rates The CCAC should provide the following information to persons who are considering choices of LTC homes: the accommodation charges that are required to be paid by the resident; the premium for preferred accommodation; September

21 that the applicant will be asked by the LTC home to which he or she is admitted to sign an agreement regarding payment of accommodation charges even though the legal requirement for payment is set out in the LTC homes legislation; the services for which the LTC home is responsible and cannot charge residents, and any services the home may make available for which it does charge; income testing procedures for rate reduction (see subsection # in this manual); and reasons for and costs associated with bed holding Information About Rate Reduction Under subsection 116(1) of the Nursing Homes Act (NHA) regulation, rate reduction is only available to long-stay residents in basic accommodation. It is available when a person is unable to pay the full amount of the accommodation fees as a result of limited income. A rate reduction is not available to residents contracting for preferred accommodation. If a person applies for a rate reduction, income testing will be undertaken by the LTC home at the time the person is admitted (or later, if the application for rate reduction is made at a later time). A person applying for a rate reduction must provide a copy of their Notice of Assessment from the Canada Revenue Agency as proof of income for the immediately preceding year. Under subsection 116(2) of the NHA regulation, if the person is not required to file an income tax return with the Canada Revenue Agency, alternative documentation provided by an independent third party may be accepted to prove income for the immediately preceding year (e.g., a confirmation letter from the Income Security Branch of Human Resources Development Canada, or from the applicable social assistance program of the Ministry of Community and Social Services (MCSS)). For a description of the entire process for making an application for a reduction in the basic accommodation rate, refer to section 116 of the NHA regulation Additional Rate Reduction in Basic LTC Home Accommodation Fees Exceptional Circumstances Application Effective July 1, 1995, the regulations under the LTC home legislation were amended to allow residents living in long-stay basic accommodation to apply for an additional reduction to the basic accommodation rate in exceptional circumstances. Section of the NHA regulation sets out the requirements related to this additional rate reduction: s (1) An application may be made to the Director for a reduction in the fee payable by any of the following persons for basic accommodation: 1. A long-stay resident for whom the maximum monthly amount is determined to be $ under section A long-stay resident whose spouse lives outside a nursing home, a home under the Homes for the Aged and Rest Homes Act, an approved charitable home for the aged under the Charitable Institutions Act or a hospital or other facility that is government-funded. September

22 Under subsection 116.1(4) of the NHA regulation, these applications are not processed by the LTC home, but by the MOHLTC directly (i.e., the Director under the LTC homes legislation). Therefore, when a rate reduction is sought under one of these two circumstances, the application must be filed with the MOHLTC regional office for processing. An application may only be filed under one of the above referenced circumstances even when both circumstances apply. An application under the second circumstance referred to above may be made by either the resident or the resident s spouse. The exceptional circumstances application requires residents to provide proof of income for the immediately preceding year. In the case of an application under the second circumstance, proof of the income of the spouse of the resident for the immediately preceding year is also required. Applicants may be requested to provide an explanation of any decrease in their current income from their previous year s income. An applicant who has had a government benefit, entitlement, supplement, or other financial assistance reduced, due to income received or deemed received during the previous year, would in most cases not qualify for the exceptional circumstances rate reduction. MOHLTC regional offices will provide additional information upon request Visits to Homes When circumstances allow, the applicant or substitute decision-maker (SDM) and/or family members should be encouraged to visit the LTC homes in which they have expressed interest before they provide the CCAC with their LTC home choices. The visit to the LTC home provides an opportunity to assess the appropriateness of the LTC home s services and amenities, and to pose questions to LTC home staff. The CCAC is responsible for advising the applicant that when he or she visits the LTC home, the applicant may request to see the following government documents or reports: the Residents Bill of Rights along with information on the procedures for making complaints about the maintenance or operation of the home, the conduct of the staff of the home, or the treatment or care received by a resident in the home; a copy of the service agreement between the LTC home and the MOHLTC; a copy of the most recent inspection report relating to the LTC home (MOHLTC inspections are conducted annually and the report should be dated within 12 months of the date of the visit); and copies of the most recent year-end report and most recent auditor s report for the home. LTC homes legislation requires these documents/reports to be posted in the LTC home or provided by written notice to each resident (or if the resident is incapable, to the SDM). September

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