Public Accounts Committee — oagreport personalcarehomesmar 26 2025 — 26 March 2025

2025-03-26

Newfoundland and Labrador — Committees

Personal Care Homes Independent Auditor's Report April 2025

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Audit Overview 1 Why this Audit is Important Personal care homes serve a vulnerable sector of the population. There are approximately 4,400 people residing in personal care homes in Newfoundland and Labrador. The government projects that between 2023 and 2043, the 65 plus population is expected to increase significantly. As the need for personal care homes grows, more residents and their families will rely on the government to ensure personal care homes provide safe, holistic care to meet their needs.

It is critical that the Department of Health and Community Services (the department) and Newfoundland and Labrador Health Services (NLHS) have appropriate standards and processes in place to ensure resident health, safety and care in personal care homes. Conclusions We have serious concerns about the oversight and program delivery of the Provincial Personal Care Home Program. The department has failed in its responsibilities to maintain modern operational standards, given they have not been comprehensively updated since 2007 and may not adequately reflect the needs of the current personal care home population.

The department has increasingly distanced itself from oversight responsibilities for the program. We are concerned that the department is not truly delivering on the commitments made in the standards, particularly given the lack of oversight. Neither the department nor NLHS disclose the nature or number of personal care home instances of non-compliance publicly. There also appears to be a culture of acceptance within the department and NLHS towards the ongoing backlog of overdue resident care reassessments.

Sadly, our Office has highlighted these issues before – they remain outstanding recommendations from our 2015 report on Personal Care Home Regulation. Incidents and compliance violations are pervasive in the province’s personal care homes. Relicensing of personal care homes is too subjective, and personal care homes are often relicensed while carrying unresolved compliance issues.

Summary of Recommendations We recommend the department: Update, implement, effectively communicate and regularly review the Provincial Personal Care Home Program Operational Standards ensuring alignment with best practices and addressing any gaps identified in this audit. Review all personal care home serious incidents, ensuring that they are addressed in a timely manner with documented resolutions.

Enhance publicly available information regarding personal care homes, including posting inspection results, non-compliance information, licensure status and retain a history of the information for each home for a minimum of two years. We recommend the department in collaboration with NLHS: Develop and implement formal and consistent oversight processes for personal care homes, including the establishment of key performance indicators, reporting requirements, documentation standards, and serious incident protocols. Implement a formal and comprehensive complaint management process for personal care homes.

We recommend NLHS: Ensure that kitchen and dining facilities, staff, and serving routines in personal care homes follow the operational standards and that they are monitored to ensure consistency across the province. Ensure personal care home staffing levels are appropriate, that staff have satisfied hiring requirements before starting their employment, and that staff have the necessary training to comply with all aspects of the operational standards.

Review the licensing and re-licensing processes for personal care homes, including the clear definition and communication of consequences for non-compliance determined from quarterly monitoring and/or annual inspections. Ensure that initial personal care home resident assessments and reassessments are completed in a timely manner and any changes in care needs are addressed appropriately. Implement an internal quality control process to ensure that personal care home operating standards compliance monitoring is completed consistently across the province.

Objectives To determine whether Newfoundland and Labrador Health Services, in conjunction with personal care homes, delivers appropriate care to residents and whether there is appropriate oversight of the Personal Care Home Program. Audit Period April 1, 2022, to September 30, 2024 Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

What We Found Program Delivery Staffing There were 43 of 65 employees (66 per cent), from 12 of 13 homes (92 per cent), that had at least one instance of non- compliance with hiring requirements per the operational standards. Three of 65 employees (five per cent) had negative results on their Certificate of Conduct, including assault charges. Staff Training There were 42 of 59 employees (71 per cent) from six of 13 homes (46 per cent) that received minimal training. Medication Storage and Administration There were medication storage non-compliances in four of 13 homes we visited (31 per cent).

Nine of 33 (27 per cent) employees who administered medications were non-compliant in their mandatory three-month review of medication policies, as required by the operational standards. Twelve of 13 homes (92 per cent) had medication-related incidents since March 1, 2024. Food Quality and Service Meals did not match the posted menu approved by NLHS in seven of 13 (54 per cent) personal care homes we visited. There was no evidence to support that these meals met Canada’s Food Guide requirements.

Resident food allergies and preferences were not clearly posted and updated in four of 13 homes (31 per cent) we visited. Licensing Conditional licences were issued to 22 of 34 homes (65 per cent) we sampled at least once within our audit period. These homes operated under a conditional licence for an average of three months. Multiple conditional licenses were issued to 17 of the 22 homes (77 per cent) between April 2022 and September 2024.

One of the 34 homes sampled (three per cent) had 105 instances of non-compliances that resulted in it operating under a conditional licence for 27 of 30 months (90 per cent) within our audit period. Not all instances of non-compliance had been corrected by the required deadline for 10 of the 22 homes (45 per cent) that had been issued conditional licences. For five of those 10 homes, their licence was reinstated by NLHS even though there was no evidence to suggest that all corrective action plans had been fully addressed.

For 11 of 34 homes (32 per cent) we sampled a full licence was granted despite multiple instances of noncompliance with the operational standards. Two homes in the province had their licences revoked during our audit period. There were 18 of 34 homes (53 per cent) we sampled that did not have all inspection reports on file required for relicensing, including facilities, fire and life safety, and food premises inspections completed by the Department of Digital Government and Service NL.

For eight of those 18 homes (44 per cent), a full licence was granted for the duration of our audit period despite not having the required inspection reports. Resident Care Assessments Initial Assessments There were 28 of 60 residents (47 per cent) we sampled who waited over 100 days from the date their initial assessment was submitted to when it was approved. Reassessments There were 39 of 144 annual reassessment samples (27 per cent) between one and 334 days overdue. This equated to an average of 56 days overdue.

There was no comprehensive historical database capturing the number of overdue resident reassessments. Operational Standards Status of Operational Standards Since 2007, the department did not complete the required biennial comprehensive review of the operational standards including the NLHS monitoring methods. New standards have been in draft form since 2022 and have yet to be implemented. We found changes (addendums and memos) to the operational standards were issued reactively, generally after an incident had occurred.

Provincial Comparisons Newfoundland and Labrador standards were the most out of date when compared to the Atlantic provinces and Alberta; Newfoundland and Labrador’s personal care home monitoring results were not publicly available. 2 Audit Overview Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Program Oversight Oversight Processes The department did not have formal processes, including periodic checks, to ensure NLHS consistently followed the requirement to license and monitor personal care homes for compliance with standards. The department failed to enforce quarterly reporting requirements for NLHS, as required by the operational standards. There were no quarterly monitoring reports or inspections received or requested by the department from January 1 to September 30, 2024.

The department did not provide any evidence of follow up to the monitoring reports, or inspections it received from NLHS between April 2022 and September 2024. Inquiries and Incidents Oversight The department had no internal written policies, procedures, or processes to handle inquiries, including complaints or serious incidents. The department received notification of eight serious incidents between April 2022 and September 2024; six of these eight incidents (75 per cent) had no documented follow up action by the department.

One of the serious incidents that had evidence of follow-up occurred via email approximately two months after the incident took place. Compliance Compliance Monitoring In 69 of 173 quarterly monitoring reports (40 per cent), there was insufficient or no evidence to support some of the conclusions drawn by NLHS. Instances of Non-Compliance None of the homes were fully compliant for all five quarterly report samples. The majority of reports, 148 of 173 reports (86 per cent), contained instances of non-compliance with operational standards.

Persistent Instances of Non-Compliance There were six of 35 homes (17 per cent) we sampled that had persistent violations of the operational standards but were not issued a conditional licence. There were no specific timelines for action in the operational standards or in NLHS procedures to address persistent violations of the standards. Issuing a conditional licence or revoking a licence was done at the discretion of NLHS. Monitoring of Evictions NLHS reported 254 resident evictions to the department during our audit period. This quantity equates to 85 evictions per year on average.

It was reported that 91 residents (36 per cent) were sent to the emergency department and not accepted back by the personal care home. This practice was known and not addressed by the department and NLHS. 3 After reading this report, you may want to ask the following questions of government: 1. When will the updated personal care home operational standards be implemented? 2. How will government ensure that resident care assessments and reassessments are done in a timely manner? 3.

Will government publicly disclose the results of personal care homes compliance inspections, like they do for child care centre violations and food premises inspections reports? Audit Overview Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

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Table of Contents 07Background 13Findings - Program Delivery 19Findings - Licensing 35 Recommendations Appendix I - About This Audit 5 Conclusions 09Summary of Key Findings 36 38 Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes 23Findings - Resident Care Assessments 25Findings - Operational Standards 28Findings - Program Oversight 34Subsequent Events Appendix II - List of Personal Care Homes in operation between April 1, 2022 and September 30, 2024 41 31Findings - Compliance

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Background 7 The Personal Care Home Regulations under the Health and Community Services Act provide the Minister of the Department of Health and Community Services with the authority to establish polices and guidelines for the province’s personal care home program; the department developed Provincial Personal Care Home Program Operational Standards (operational standards) as a result. The standards cover governance, licensing, resident care and rights, as well as administration, and responsibilities are outlined for operators, residents, the department, and the health authority.

Under the provincial regulations, a personal care home is defined as a premises, place, or private residence in which personal care is provided for remuneration, to five or more adults. They are privately owned and operated by licensees (known as operators). These facilities accept seniors and other adults, who need assistance with their daily living requirements and may require the services of visiting healthcare professionals. Residents may pay privately to live in a personal care home, or they may be provincially subsidized, based on a financial assessment to determine their eligibility.

If approved for a financial subsidy, it is payable directly to the operator from government. On April 1, 2023, four regional health authorities, and the Newfoundland and Labrador Centre for Health Information, merged into Newfoundland and Labrador Health Services; five regional zones were created (Eastern - Urban, Eastern – Rural, Central, Western and Labrador-Grenfell).

The Department of Health and Community Services requires Newfoundland and Labrador Health Services (NLHS) to license and monitor personal care homes in compliance with the Health and Community Services Act, Personal Care Home Regulations, operational standards, and any other applicable policies or guidelines established or adopted by the Minister.

A Memorandum of Understanding exists between the departments of Health and Community Services and Digital Government and Service NL to establish responsibilities and accountabilities for a variety of inspection programs under the authority of Health and Community Services, including personal care homes. The Department of Digital Government and Service NL completes various personal care home inspections in accordance with operational standards, including environmental health, fire and life safety, and food premises inspections.

The department also provides copies of their inspection reports to NLHS, which is expected to take results into consideration when determining a personal care home’s licensure status. Eligibility for personal care home admission is done through a single-entry system where NLHS completes a comprehensive clinical assessment by using a standardized assessment tool that determines an individual’s care need and appropriate services. Individuals are assigned to a scale of Level I, II, Enhanced Care, III or IV.

Individuals with low care needs, requiring minimal assistance with daily living activities, are considered Level I or II care. Individuals are classified as Enhanced Care when they have higher care needs but are medically stable enough to not need continuous supervision or frequent intervention by nursing staff. Personal care homes admit residents who have been assessed as Level I, Level II, or Enhanced Care. Personal care home residents may be reassessed as Level III and may remain in a personal care home while waiting for a long-term care placement.

Level III care requires additional care, with a minimum of three hours of nursing care and/or supervision in a 24- hour period. There were 95 personal care homes in operation within our audit period April 1, 2022, to September 30, 2024; six homes were permanently closed by the operators, one home was temporarily closed for renovations, and two homes were closed by NLHS and their licences to operate were revoked. As of September 30, 2024, there were 86 personal care homes operating in the province with 5,208 available beds.

Figure 1 shows the percentage of available beds, broken down by subsidized, private pay, and vacant beds. Auditor General o f Newfoundland and Labrador - April 2025 - Personal Care Homes

Figure 1: Provincial Personal Care Home Beds As of September 2024 Source: Prepared by the Office of the Auditor General based on information provided by Newfoundland and Labrador Health Services, unaudited. Private pay rates vary by home; information on private pay personal care home residency was not included in this audit.

Private Pay: 8% Vac ant: 16% Subsidized: 76% Private Pay Vacant Subsidized Level of Care Monthly Subsidy Rate (per bed) April 1, 2022 – August 31, 2022 September 1, 2022 – March 31, 2023 April 1, 2023 – July 31, 2023 August 1, 2023 – September 30, 2024 Level I $2,375 $2,490 $2,500 $2,837 Level II $2,375 $2,505 $2,515 $2,972 Enhanced Care $3,430 $3,580 $3,590 $4,157 Level III $3,510 $3,680 $3,690 $4,465 Background 8 Our audit work started in December 2023 and covered April 1, 2022, to September 30, 2024.

It included two lines of inquiry: 1. to determine whether Newfoundland and Labrador Health Services, in conjunction with personal care homes, delivers appropriate care to residents; and 2. to determine whether there is appropriate oversight of the Personal Care Home Program. Nine criteria were established to assess these lines of inquiry. We completed audit procedures on 35 personal care homes, including site visits to 13 homes; Appendix II lists all personal care homes active within our audit period.

Our office completed an audit of personal care homes in 2015, and we note that two (100 per cent) recommendations issued to the Department of Health and Community Services and three of 20 (15 per cent) recommendations issued to the former regional health authorities remained outstanding as of April 2023. This audit is being conducted for and will be submitted to the House of Assembly’s Public Accounts Committee. On December 14, 2023, the Committee, pursuant to

section 22 of the Auditor General Act, 2021, requested a special assignment audit of personal care homes, in part due to outstanding recommendations from our 2015 audit. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes The total provincial expenditure for personal care home subsidies for the 2022-23 fiscal year was $49.8 million; for 2023-24 it was $83.6 million. The Department of Health and Community Services made multiple subsidy rate increases to the Personal Care Home Program during our audit period, as illustrated in Figure 2.

Figure 2 Monthly Provincial Subsidy Rate Increases for Personal Care Homes From April 1, 2022 to September 30, 2024 Source: Prepared by the Office of the Auditor General based on information provided by the Department of Health and Community Services, unaudited. 810 451 3947

Summary of Key Findings Program Delivery Staffing All 13 personal care homes had compliant staffing levels at the time of our 2024 visits. Operators did not always ensure staff had the minimum qualifications to work in a personal care home, as required in the operational standards. There were 43 of 65 employees (66 per cent), from 12 of 13 homes (92 per cent), that had at least one instance of non-compliance with hiring requirements per the operational standards.

The most common instance of non-compliance was missing tuberculin skin test results, which occurred in 19 of 65 employees (29 per cent) in 10 of 13 homes (77 per cent). Three of 65 employees (five per cent) had negative results on their Certificate of Conduct, including assault charges; they continued to work at a personal care home despite these results. All three employees were working at the same home during our September 25, 2024, visit.

Nine of 65 employees (14 per cent) from six of 13 homes (46 per cent) could not provide some of the documentation for hiring requirements, such as official immunization records; the personal care homes accepted self-declarations or affidavits in lieu of the required documentation, which was not permitted in the standards. Staff Training There was no consistency in the training provided to employees at the personal care homes we visited. The operational standards did not specify the amount or frequency of training operators or NLHS should provide to personal care home staff.

There were 42 employees (71 per cent) from six of 13 homes (46 per cent) that received minimal training. One home (eight per cent) did not offer any training to employees, while three of 13 homes (23 per cent) offered only one training session. For two employees, there was no documented support for their orientation training. Medication Storage and Administration Personal care homes did not consistently follow the operational standards for the storage and administration of resident medications. There were medication storage non-compliances in four of 13 homes we visited (31 per cent).

In three of 13 homes we visited (23 per cent), medication carts were left unlocked and/or unattended. Nine of 33 (27 per cent) employees who administered medications were non-compliant in their mandatory three-month review of medication policies, as required by the operational standards. There were 51 of 289 incident reports (18 per cent) related to medications. Twelve of 13 homes (92 per cent) had medication-related incidents since March 1, 2024. Food Quality and Service Meals did not match the posted menu approved by NLHS in seven of 13 (54 per cent) personal care homes we visited.

There was no evidence to support that these meals met Canada’s Food Guide requirements. Three of 13 homes (23 per cent) were missing vegetables from lunchtime meals. Resident food allergies and preferences were not clearly posted and updated in four of 13 (31 per cent) homes we visited. One home (8 per cent) did not have a 3-day food supply available at the time of our visit. Two homes (15 per cent) did not have clean and/or organized kitchen, storage, and/or refrigeration/freezer facilities. 9Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Summary of Key Findings Licensing NLHS often relicensed personal care homes when instances of non-compliance with the operational standards existed. Conditional licences were issued to 22 of 34 homes (65 per cent) we sampled at least once within our audit period. These homes operated under a conditional licence for an average of three months. Multiple conditional licenses were issued to 17 of the 22 homes (77 per cent) between April 2022 and September 2024.

One of the 34 homes sampled (three per cent) had 105 instances of non-compliances that resulted in it operating under a conditional licence for 27 of 30 months (90 per cent) within our audit period. Non-compliances included concerns of sexual assault of a resident by staff, staff being abusive toward residents, multiple medication errors, unsanitary room conditions, mold on windows in resident rooms, food safety issues, inadequate staffing levels, and missing hiring requirements.

Not all instances of non-compliance had been corrected by the required deadline for 10 of the 22 homes (45 per cent) that had been issued conditional licences. For five of those 10 homes, their licence was reinstated by NLHS even though there was no evidence to suggest that all corrective action plans had been fully addressed. One of these homes eventually had their licence revoked by NLHS. One home was issued a conditional licence by NLHS for a full year; normally conditional licences are issued for a period of 3 to 6 months but there is no defined period of time required in the Standards.

We were unable to confirm if one home operated with a valid license in April 2024, as NLHS did not provide a letter of licensure to the home, and the evidence of interim license was not signed. For 11 of 34 homes (32 per cent) we sampled a full licence was granted despite multiple instances of non- compliance with the operational standards. Two homes in the province had their licences revoked during our audit period. Neither NLHS nor the Department of Health and Community Services posted the notice of the revoked licence to their websites.

There were 18 of 34 homes (53 per cent) we sampled that did not have all inspection reports on file required for relicensing, including facilities, fire and life safety, and food premises inspections completed by the Department of Digital Government and Service NL. For 10 of 18 (56 per cent) of those homes, inspections were missing for more than one annual relicensing period. For eight of those 18 homes (44 per cent), a full licence was granted for the duration of our audit period despite not having the required inspection reports.

Resident Care Assessments Initial Assessments There were 28 of 60 residents (47 per cent) we sampled who waited over 100 days from the date their initial assessment was submitted to when it was approved. There were 11 of 60 residents (18 per cent) we sampled approved for admittance over 100 days before being admitted to a home. Reassessments Newfoundland and Labrador Health Services did not always ensure resident reassessments were completed in a timely manner in accordance with the operational standards. There were 39 of 144 annual reassessment samples (27 per cent) between one and 334 days overdue.

This equated to an average of 56 days overdue. There was no comprehensive historical database capturing the number of overdue resident reassessments. Operational Standards Status of Operational Standards The Department of Health and Community Services did not complete the required biennial comprehensive review of operational standards, including NLHS monitoring methods. Operational standards have not been comprehensively updated since 2007. New standards have been in draft form since 2022 and have yet to be implemented.

In the absence of proactive review and updates, we found changes (addendums and memos) to the operational standards were issued reactively, generally after an incident had occurred. 10 Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Summary of Key Findings Provincial Comparisons Newfoundland and Labrador standards were the most out of date when compared to the Atlantic provinces and Alberta; Newfoundland and Labrador did not require a professional certification for staff to work in a personal care home, while there was one jurisdiction we reviewed that required personal care home staff to have a professional certification, such as a Personal Care Attendant diploma; Newfoundland and Labrador’s personal care home monitoring results were not publicly available.

The vast majority of other Atlantic provinces, along with Alberta, Ontario, British Columbia, Manitoba, and Saskatchewan, publicly disclosed monitoring results. Program Oversight Oversight Processes The Department of Health and Community Services did not have formal processes, including periodic checks, to ensure NLHS consistently followed the requirement to license and monitor personal care homes for compliance with standards. The department failed to enforce quarterly reporting requirements for NLHS, as required by the operational standards.

We found there were no quarterly monitoring reports or inspections received or requested by the department from January 1 to September 30, 2024. The department did not provide any evidence of follow up to the monitoring reports and inspections it received from NLHS between April 2022 and September 2024. Inquiries and Incidents Oversight The Department of Health and Community Services had no internal written policies, procedures, or processes to handle inquiries, including complaints. The department received 197 inquiries during our audit period which equated to approximately seven inquiries per month.

Inquiries related to resident placement (34 per cent), financial questions (29 per cent), quality of care and treatment (25 per cent), staffing levels, qualifications or training (3 per cent), and food quality and service (3 per cent). The department had no internal written policies, procedures, or processes to handle serious incidents. The department exercised a lack of oversight regarding serious incidents that occurred at personal care homes.

The department received notification from NLHS of eight serious incidents between April 2022 and September 2024; six of these eight incidents (75 per cent) had no documented follow up action by the department. One of the serious incidents that had evidence of follow-up occurred via email approximately two months after the incident took place. Compliance Compliance Monitoring There were issues with how NLHS documented their compliance monitoring. In 69 of 173 quarterly monitoring reports (40 per cent), there was insufficient or no evidence to support some of the conclusions drawn by NLHS.

In 10 of 13 monitoring reports (77 per cent) completed by NLHS, we did not find supporting staffing calculations. Timesheets from 12 of 13 homes we visited did not match the staffing schedules that were reviewed by NLHS. Instances of Non-Compliance None of the homes we tested were fully compliant for all five quarterly report samples. The majority of reports, 148 of 173 reports (86 per cent), contained instances of non-compliance with operational standards.

We found 32 of 173 quarterly monitoring reports (18 per cent) indicated homes did not investigate, follow up, or document complaints and incidents in at least one quarter, which represented 16 of 35 homes (46 per cent) we sampled. There were 13 of 173 reports (eight per cent) where it was noted that homes did not respond to complaints and incidents within seven days as required by the operational standards. They also did not document the outcome in at least one quarter, which represented 10 of 35 homes (29 per cent) we sampled. 11Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Summary of Key Findings Instances of non-compliance related to staff qualifications and training, food quality and service, staffing levels, and medication administration from the reports we reviewed. Persistent Instances of Non-Compliance Newfoundland and Labrador Health Services did not consistently take appropriate steps when personal care homes were persistently non-compliant with operational standards. Actions that could be taken included issuing a conditional licence or revoking a licence.

We found six of 35 homes (17 per cent) we sampled had persistent violations of the operational standards but were not issued a conditional licence. We found five of 35 homes (14 per cent) we sampled were issued a conditional licence due to non-compliance, which equated to eight of 173 reports (five per cent). There were no specific timelines for action in the operational standards or in NLHS procedures to address persistent violations of the standards. Issuing a conditional licence or revoking a licence was done at the discretion of NLHS.

Monitoring of Evictions Newfoundland and Labrador Health Services reported 254 resident evictions to the department during our audit period. This quantity equates to 85 evictions per year on average. It was reported that 91 residents (36 per cent) were sent to the emergency department and not accepted back by the personal care home. This practice was known and not addressed by the department and NLHS. Five of 254 evicted residents (two per cent) were evicted without consultation with NLHS.

Newfoundland and Labrador Health Services did not maintain a record of resident evictions other than the monthly eviction statistics that are required to be reported to the department. Personal care home residents were not protected by the Residential Tenancies Act. Performance Evaluation Newfoundland and Labrador Health Services did not have established key performance indicators to evaluate the performance of the Provincial Personal Care Home Program. 12 Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Findings - Program Delivery Criteria 8 Personal care homes have appropriate staffing levels to meet resident care needs as required by the Provincial Personal Care Home Program Operational Standards. Objective What We Expected We expected personal care home operators would follow the operational standards pertaining to staff / resident ratios and resident care needs. We expected that operators would maintain adequate staffing levels to meet the operational standards.

We expected personal care home operators would ensure staff at their homes were qualified to meet resident care needs as per the operational standards. We expected that operators, in conjunction with NLHS, would provide relevant training to their staff to enable them to meet the care needs of residents. We also expected that the same or similar training courses would be provided for all personal care home staff in all homes. We expected operators would ensure their staff follow the operational standards pertaining to storage and administration of resident medications.

We expected personal care homes would follow the operational standards regarding nutrition and food service. We also expected homes would have protocols in place to address any food-related concerns or risks. Finally, we expected personal care home residents would be satisfied with food offerings at their respective care homes.

To determine whether Newfoundland and Labrador Health Services, in conjunction with personal care homes, delivers appropriate care to residents. 13 Criteria 6 Personal care homes have qualified and adequately trained staff as required by the Provincial Personal Care Home Program Operational Standards. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes Criteria 9 Personal care homes appropriately administer medication to residents as per the Provincial Personal Care Home Program Operational Standards.

Criteria 7 Personal care homes provide food quality and service to residents as required by the Provincial Personal Care Home Program Operational Standards.

Program Delivery 14 Staffing We found all 13 personal care homes had compliant staffing levels at the time of our 2024 visits. Operational standards require minimal staffing coverage, based on the number of personal care home residents and their levels of care. Figure 3 outlines personal care home staffing requirements according to the standards.

Daily Hours Number of Residents 1-10 11-15 16-20 21-25 26-30 8-4 1.0 staff 1.5 staff 2.0 staff 2.0 staff 3.0 staff 4-12 1.0 staff 1.5 staff 1.5 staff 2.0 staff 2.0 staff 12-8 1.0 staff 1.0 staff 1.0 staff 2.0 staff 2.0 staff Figure 3 Personal Care Home - Staffing Requirements Source: Adapted from an excerpt of the Provincial Personal Care Home Program Operational Standards What We Learned Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes Homes with more than 30 residents will ensure: 1. a minimum of two staff on duty at all times; 2. sufficient staff to provide 1.5 hours of care and supervision per day depending on resident needs; and 3. adequate domestic, security and administrative staff as evidenced by outcomes.

Homes with more than 60 residents will ensure: 1. a minimum of three staff on duty at all times; 2. sufficient staff to provide 1.5 hours of care and supervision per day depending on resident needs; and 3. adequate domestic, security and administrative staff as evidenced by outcomes. Enhanced Care residents require 3.5 hours of care and supervision per day, and level III residents require 3.9 hours of care and supervision per day. We found some operators indicated they used overtime to address staffing issues.

In our interviews with personal care home operators and staff, we found five of 13 homes (38 per cent) reported frequently having to use overtime to meet operational standards staffing ratios. Three of 13 homes (23 per cent) also indicated they experienced challenges recruiting staff in rural locations. We found operators did not always ensure staff had the minimum qualifications to work in a personal care home, as required in the operational standards.

According to the standards, personal care home operators are supposed to ensure, prior to hiring, that employees meet the employment requirements, as shown in Figure 4.

The operator will ensure, prior to hiring, that employees have the following: a medical assessment for all persons providing resident care and or supervision; pre-employment tuberculin skin test and chest x-ray if indicated by the physician; a record of immunization; a certificate of conduct from the Royal Newfoundland Constabulary or Royal Canadian Mounted Police (it is the responsibility of the operator to ensure the individuals working in the home pose no threat to the residents); a pledge of confidentiality; and a first aid certificate.

Figure 4: Employment Hiring Requirements per Operational Standards Source: Adapted from an excerpt of the Provincial Personal Care Home Program Operational Standards

The Department of Health and Community Services issued a memo in 2020 which advised of a change in the medical assessment for employment form, including that the pre-employment medical assessment must be completed within 30 days of starting work, and relaxed requirements for a two-step tuberculin test owing to challenges with access to testing during the COVID-19 pandemic.

We sampled five active employee files at the 13 homes we visited and found 43 of 65 employees (66 per cent), from 12 of 13 homes (92 per cent), each had at least one instance of non-compliance with hiring requirements per the operational standards.

We found the most common instances of non-compliance for missing hiring requirements were: 19 of 65 employees (29 per cent), in 10 of 13 homes (77 per cent), were missing tuberculin skin test results; 11 of 65 employees (17 per cent), in five of 13 homes (38 per cent), were missing medical assessments; 13 of 65 employees (20 per cent), in six of 13 homes (46 per cent), were missing immunization records; 11 of 65 employees (17 per cent), in nine of 13 homes (69 per cent), were missing first aid certificates; and, two of 65 employees (three per cent), in two of 13 homes (15 per cent), were missing certificates of conduct (criminal records check).

We found one home was missing medical assessments for all five of the staff we selected for testing. We found three of 65 employees (five per cent) had negative results on their certificate of conduct, one of which included assault charges; they continued to work at a personal care home despite these results. All three employees were working at the same home during our September 25, 2024, visit. We also found four of 65 employee first aid certificates (six per cent) were expired at the time of our visit.

We also found the standards did not specify the level of first aid certification personal care home staff were required to have. In March 2023, the Department of Health and Community Services issued a memo stating staff must have first aid training delivered by a qualified person; however, the memo did not specify the level or type of first aid required.

We found nine of 65 employees (14 per cent) from six of 13 homes (46 per cent) could not provide some of the documentation for hiring requirements, such as official immunization records; the personal care homes accepted self-declarations or affidavits in lieu of the required documentation, which was not permitted in the standards. Staff Training We found no consistency in the training provided to employees at the personal care homes we visited. Some employees received at least one training session every three months, while other employees did not receive any training.

We found operational standards did not specify the amount or frequency of training operators or NLHS should provide to personal care home staff. We found the same training was not provided consistently to personal care home staff at all homes we visited. We found the most common types of training provided was resident care (25 per cent), human resources (16 per cent), infection prevention and control (14 per cent), medication administration (13 per cent), and food quality and service (12 per cent).

Of note, 79 per cent of the training sessions we reviewed were provided internally by the homes we visited, while 21 per cent of training sessions were provided by NLHS. We also found six of 13 personal care homes (46 per cent) stated NLHS did not offer accessible or proactive training. During our onsite visits, we reviewed training documentation for five employees at each home. We found six employees were newly hired at the time of our visit; of the remaining 59 employees, we found 42 (71 per cent) from six of 13 homes (46 per cent) received minimal training.

We found one home (eight per cent) did not offer any training to employees, while three of 13 homes (23 per cent) offered only one training session within our audit period of April 2022 to September 2024. 15 Program Delivery Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Within our sample of 65 employees, two did not have documented support for their orientation training. Operational standards state operators are required to provide orientation to all new employees and an orientation checklist and description of activities should be included in staff records. Medication Storage and Administration We found personal care homes did not consistently follow the operational standards for the storage and administration of resident medications. Per the standards, operators are required to ensure medications are administered and stored according to departmental standards and policies.

We found medication storage non-compliance in four of 13 homes we visited (31 per cent). For example, we found medication carts were left unlocked and/or unattended in three of 13 visits (23 per cent). In one home (eight per cent), we found medication carts were untidy and unorganized, containing several empty pill packs with confidential information that should have been discarded. We sampled 33 employees responsible for administering medication and found nine of 33 (27 per cent) were non- compliant in their mandatory three-month review of medication policies, as required by the operational standards.

We found numerous medication-related incidents in our sample, with 51 of 289 incident reports (18 per cent) related to medications. We found 12 of 13 homes (92 per cent) had medication-related incidents since March 1, 2024. We found the most common incident required to be recorded was medication refusals by residents (12 of 51 incidents - 24 per cent).

We also found 16 medication administration incidents were attributable to staff error: staff administered the wrong medication to residents (eight of 16 or 50 per cent); staff administered an incorrect dosage (five of 16 or 31 per cent); or missed medications (three of 16 or 19 per cent). We found follow-up actions by the operators did not meet operational standards in two of 51 medication incident reports (four per cent) we reviewed, and that NLHS was not notified of these incidents. One incident report stated that 87 narcotic count sheets were not signed but all narcotics were accounted for.

The incident report did not note any action taken and was missing an employee signature. An employee refused to administer morning medications because they were ‘tired,’ and failed to administer medications the night before. Supervisory staff monitored residents and reviewed resident rights with the employee, but no long-term recommendations were written on the incident report form. 16 Program Delivery Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Food Quality and Service We found personal care homes did not always follow the operational standards with regard to food quality and service. Operational standards require personal care homes to provide residents with a safe and supportive meal service that meet Canada’s Food Guide requirements. We found meals did not match the posted menu approved by NLHS in seven of 13 (54 per cent) of personal care homes we visited. There was also no evidence to support that these meals met Canada’s Food Guide requirements. Three of 13 homes (23 per cent) were missing required vegetables from lunchtime meals.

We also found resident food allergies and preferences were not clearly posted and updated in four of 13 (31 per cent) homes we visited. In some smaller homes, staff stated they did not need to post this information because they could remember resident allergies and preferences; however, operational standards do not state any exceptions to this policy related to home size. In one home, food allergies and preferences were not posted; a cook we interviewed stated there were no resident allergies but was corrected by another staff member, who indicated there was in fact one allergy at the home.

We found one home (8 per cent) did not have a 3-day food supply available at the time of our visit. We also found two homes (15 per cent) did not have clean and/or organized kitchen, storage, and/or refrigeration/freezer facilities. Another home was in the process of completing renovations and we found its kitchen and storage areas were disorganized with numerous tripping hazards throughout. We also reviewed complaints and incidents related to food quality and service.

We found residents were not always satisfied with food offerings at their respective care homes and a total of five food-related complaints in four of 13 (31 per cent) visits were documented. Complaints included cold food, raw food, and lack of evening snack availability for diabetic residents. We found a total of four food-related incidents in three of 13 (23 per cent) visits. We found two incidents at one home where the same kitchen worker was rude to residents, which caused distress for a resident.

The incident reports did not show evidence that NLHS was notified or consulted about the worker as per operational standards, and it was not noted in the corresponding quarterly report. 17 Program Delivery Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Why It Matters Approximately 4,400 adults in the province reside in a personal care home, some of whom are the most vulnerable members of society. The public should be assured that their loved ones are receiving quality care provided by competent, compassionate personal care home staff. It is important that personal care homes maintain appropriate staffing levels to meet the specific needs of each resident. Inadequate staffing levels can lead to lack of supervision and care of vulnerable residents, which can have dire consequences such as missing residents, injury, and death.

Unsatisfied hiring requirements and accepting negative certificates of conduct not only conflict with the standards, they put residents at risk. Without adequate and appropriate training for its staff, the personal care home operators are not sufficiently mitigating the risks associated with caring for their residents. Medication errors have the potential to cause critical injuries and death to personal care home residents. Personal care home staff are not required to have specific medication training upon hiring, and the amount and quality of training provided within the home is not consistent.

Again, this environment puts residents at risk. Food quality and service is an integral part of creating a safe and supportive social environment that feels like home for residents of personal care homes. As a licenced food premise, operators should ensure their kitchen and dining facilities, serving staff, and serving routines are following food safety and nutrition guidelines consistently.

Non- compliance with the standards related to food quality and service has the potential to cause harm to residents, such as complications from malnutrition, allergic reactions, and choking hazards. 18 Program Delivery Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Findings - Licensing 19 Newfoundland and Labrador Health Services licences and relicenses personal care homes in accordance with the Provincial Personal Care Home Program Operational Standards.Criteria 4 Objective What We Expected We expected NLHS would have and follow standard processes and controls to ensure each personal care home is licensed and relicensed according to the standards. We expected NLHS would complete relicensing in a timely manner. We expected NLHS to ensure homes operated with a valid licence and grant conditional licensure to a home that did not meet all licensing requirements.

We also expected the Department of Health and Community Services would publicly report an updated licensure status of each personal care home in a timely manner. To determine whether Newfoundland and Labrador Health Services, in conjunction with personal care homes, delivers appropriate care to residents. We found Newfoundland and Labrador Health Services often relicensed personal care homes when instances of non-compliance existed. Standards provide the requirements for licensing new personal care homes and the requirements for annual relicensing.

Licensing and relicensing requirements ensure homes are safe and comfortable residences.

There are four distinct types of licences issued to personal care homes: Licenced: Compliant with regulations and standards at the time of monitoring or inspection; Interim Licence: Expired licence but information is not available to inform renewal; Conditional Licence: Not compliant with regulations and standards at the time of monitoring and inspection but the non‐compliance issues identified do not significantly affect resident safety or quality of care and a corrective action plan with timelines has been provided to the personal care home; or, Revoked Licence: No licence in place due to significant and/or sustained non‐compliance with the regulations and standards.

In the case of a revoked licence, the department’s website is supposed to post this status for three months which is one reporting period. We reviewed the supporting evidence for relicensing of 34 personal care homes between April 2022 to September 2024 to determine whether NLHS relicensed the homes per operational standards. We found all 34 homes tested for relicensing had at least one non-compliance with the operational standards. We found operating under a conditional licence is permissible under the operational standards.

We found 22 of 34 homes (65 per cent) were issued a conditional licence at least once within our audit period. These homes operated under a conditional licence for an average of three months. We found 17 of the 22 homes (77 per cent) were issued multiple conditional licences between April 2022 and September 2024. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes What We Learned

Figure 5 outlines examples of non-compliance we found from homes issued a conditional license between April 2022 and September 2024. We also note the number of months each home operated under a conditional licence within our audit period. 20 *This list is meant to provide some selected examples of non-compliances that contributed to conditional licenses. Source: Prepared by the Office of the Auditor General based on information provided by Newfoundland and Labrador Health Services, unaudited.

Licensing Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes Examples of Non-Compliances noted in Quarterly Monitoring Reports * Number of Months Home Operated Under a Conditional Licence Issues with medication administration process. Approved menu not consistently followed, and client information not posted in kitchen as required. Staff noted to be yelling at residents. Issues with domestic services including cleanliness of resident rooms. Not appropriately reporting an infection outbreak in the home. Fire and life safety issues.

This home closed temporarily in 2024 for renovations. 11 Insufficient staffing to provide supervisory care as the one staff working was sleeping when a resident sustained a fall. Failure of the home to notify NLHS regarding missing resident. 9 Multiple non-compliances dating back to 2009, including: Residents reported being hungry and cold. Staff were waking residents up at 5:00am for breakfast without their consent. Some residents were told they could not shower more than once a week. Residents reported the owner was disrespectful to them and they were fearful of bringing concerns forward.

Residents were financially abused by owner. Issued multiple conditional licenses prior to having their license revoked in 2023. 15 Residents had concerns of abuse by staff, including sexual abuse. A resident’s room had a large amount of smeared feces on the wall and doorframe outside bathroom. Cleaning by staff was inadequate and feces was left on the wall. Concerns with medication administration, documentation of incidents and resident care plans. Residents not receiving medical assessments in a timely manner. 27 Resident choked and dietician or case manager not notified.

Resident care plan not updated. 4 A resident was left unattended while toileting and had to unsafely transfer to a wheelchair. 13 Resident admitted during an infection outbreak and Infection Prevention and Control not consulted. Incident reports missing. Dietician not notified of resident weight loss and decreased food intake. 19 Multiple incidents in a three month-period, including Adult Protection Act concerns that were not reported to the adult protection on-call service.

Other examples included a resident not bathed for two weeks; a missed referral to the dietician; missing fire and life safety training; and a resident not receiving required medical attention. 13 Four undocumented and unreported incidents where residents went missing from a home, all within 10 days of each other. 4 Forty-one medication incidents in a three-month period, which included incidents such as a needle being left on an insulin pen, narcotic miscounts, and missing benzodiazepine. 3 A resident was advised to lay down while enduring a headache after staff administered too much medication. 6 Figure 5 Examples of Non-Compliance and Length of Conditional License for April 2022 to September 2024 Further, we found one of the 34 homes sampled (three per cent) had 105 instances of non-compliances that resulted in it operating under a conditional licence for 27 of 30 months (90 per cent) within our audit period.

Non-compliances included concerns of sexual assault of a resident by staff, staff being abusive toward residents, multiple medication errors, unsanitary room conditions, mold on windows in resident rooms, food safety issues, inadequate staffing levels, and missing hiring requirements.

Once non-compliance is identified by monitoring staff, they may issue a written corrective action plan that outlines the details of the non-compliance and a time limit for compliance with the plan. We found that not all instances of non-compliance had been corrected by the required deadline for 10 of the 22 homes (45 per cent) that had been issued conditional licences. We found five of those 10 homes had their licence reinstated by NLHS even though there was no evidence to suggest that all corrective action plans had been fully addressed. One of these homes eventually had their licence revoked by NLHS.

Further, we found one home was issued a conditional licence by NLHS for a full year; normally conditional licences are issued for a period of 3 to 6 months but there is no defined period of time required in the operational standards. We were unable to confirm if one home operated with a valid license in April 2024, as NLHS did not provide a letter of licensure to the home, and the evidence of interim license was not signed. We also found 11 of 34 homes (32 per cent) that had multiple instances of non-compliance were granted a full licence within our audit period.

The operational standards outlined the approach for licence revocation, requiring a home and NLHS to work on a corrective action plan to avoid residents being displaced. NLHS indicated that a revoked licence only occurs after a prolonged period of persistent and serious violations with little to no evidence of corrective action.

Figure 6 outlines examples of homes that remained fully licenced despite having multiple incidents of non-compliance. 21 Non-Compliance with Operational Standards Staff did not advise management of verbal abuse against a vulnerable resident by another resident, and the resident continued to experience abuse. 87 incidents during a three-month period, including a case of sexual harassment and abuse. Medication was signed off on resident records ahead of administration time and records were replaced when error was found.

An enhanced care resident was taken outside and left unmonitored, where he left the property on his own, fell and was found by a community member. NL Health Services was not notified. An employee did not wear a mask after testing positive for COVID-19 after returning to work. Figure 6 Examples of Homes that Remained Fully Licensed Despite Multiple Incidents of Non-Compliance Source: Prepared by the Office of the Auditor General based on information provided by NLHS, unaudited.

Licensing Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes We found two homes in the province each had their licence revoked during our audit period. Neither NLHS nor the Department of Health and Community Services posted notice of the revoked licences to their websites. We also found issues with how NLHS used the Department of Digital Government and Service NL inspections to relicense personal care homes.

In support of NLHS licensing and relicensing responsibilities, the Department of Digital Government and Service NL completed various inspections in accordance with operational standards and the Memorandum of Understanding that exists between the two departments. We found 18 of 34 homes (53 per cent) did not have all inspection reports on file required for relicensing, including facilities, fire and life safety, and food premises inspections completed by the Department of Digital Government and Service NL.

We found of those 18 homes missing inspections for relicensing, 10 of 18 homes (56 per cent) were missing inspections for more than one annual relicensing period. We also found eight of 18 homes (44 per cent) were granted a full licence for the duration of our audit period despite not having the required inspection reports. We found three newly licenced homes and two homes that came under new ownership were licenced in accordance with operational standards.

Why It Matters 22 Licensing Lack of collaboration and communication between NLHS and Digital Government and Service NL contributes to confusion and errors in the relicensing process, potentially also increasing the risks to residents. Further, the current public reporting of licensure status is simplistic and does not contain details by home of instances of non- compliance with operating standards. This approach indicates a lack of transparency and accountability from government, making it difficult for residents seeking a placement in a personal care home to make an informed decision. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Findings - Resident Care Assessments 23 Newfoundland and Labrador Health Services ensures resident care assessments and re-assessments were completed in accordance with the Provincial Personal Care Home Program Operational Standards. Criteria 5 Objective What We Expected We expected NLHS would ensure personal care home resident assessments and reassessments would be completed in compliance with the standards and in a timely manner. We expected that NLHS would have a comprehensive historical database to manage the workflow of overdue resident reassessments.

To determine whether Newfoundland and Labrador Health Services, in conjunction with personal care homes, delivers appropriate care to residents. Initial Assessments A key step prior to the approval, return for additional information, or rejection of a resident’s assessment is a formal review and decision by NLHS. We found NLHS did not have established timelines for the placement decisions to approve the resident assessments through the single-entry system, and there was no requirement in the operational standards.

NLHS completed initial clinical assessments to determine an individual’s care needs and suitability for a personal care home. We selected a sample of 60 residents from the total population in the province at the time (approximately one per cent) and tested the timeliness on the initial assessments completed through the single-entry system within our audit period. We found 28 of 60 residents (47 per cent) waited over 100 days from the date their initial assessment was submitted to when it was approved.

We found the Central zone of NLHS had the largest percentage of residents (11 of 28, 39 per cent) whose initial assessments were not approved for over 100 days. We found 11 of 60 residents (18 per cent) were approved for admittance over 100 days before being admitted to a home. We found the Eastern Urban zone of NLHS had the largest percentage of residents (five of 21, 24 per cent) whose initial assessments were approved for over 100 days before being admitted to a home. Residents can choose to delay moving into a placement, preferring to wait for their home of choice or other reasons.

Reassessments We found NLHS did not always ensure reassessments were completed in a timely manner in accordance with standards. We note that this was also an outstanding recommendation from our 2015 audit of personal care home regulations. Operational standards require NLHS to complete an annual reassessment of a resident’s health status and assess quality of care. We selected a sample of 60 residents from across the province and tested the timeliness of their reassessments (144 reassessments in total within our audit period).

We found 39 of 144 annual reassessment samples (27 per cent) were between one and 334 days overdue. This equated to an average of 56 days overdue. See Figure 7 for the average of overdue resident reassessments by zone. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes What We Learned

Why It Matters Initial assessments and reassessments are a way to ensure residents are appropriately assigned to the residential setting that best meets their needs. Care needs can change quickly for residents waiting for their initial assessments to be approved, or for reassessments to be completed.

Further complicating the issue is the number of level III residents in personal care homes waiting for a long-term care bed. 24 NLHS Zone Average # of Days Reassessments were Overdue Range of # of Days Reassessments were Overdue Eastern - Urban 35 1 - 103 Eastern - Rural 32 1 - 153 Central 41 1 - 85 Western 135 29 - 334 Labrador-Grenfell 10 6 - 14 Provincial 56 1 - 334 Source: Prepared by the Office of the Auditor General based on information provided by Newfoundland and Labrador Health Services, unaudited.

The Department of Health and Community Services and NLHS acknowledged this backlog, and the department provided funding for additional human resources to support this work in September 2023, but the backlog remains. We also found there was no comprehensive historical database capturing the number of overdue resident reassessments. In addition to overdue reassessments, we found 238 personal care home residents who had been reassessed as requiring level III care and thus applied for placement in a long-term care home.

Figure 7: Overdue NLHS Resident Reassessments Resident Care Assessments Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Findings - Operational Standards 25 The Department of Health and Community Services maintains up-to-date Provincial Personal Care Home Program Operational Standards.Criteria 1 Objective What We Expected We expected the department would complete a comprehensive review, including NLHS monitoring methods, every two years as per the standards, in addition to reviewing and revising standards any time it is deemed necessary. We expected the department would have a formal process to develop and communicate addendums to the standards and memos to operations.

We also expected the department would make publicly available any changes to the standards. We expected all personal care homes models of operating would align to the operational standards. Finally, we expected the operational standards would be comparable with similar personal care home standards in other provinces and territories. To determine whether there is appropriate oversight of the Personal Care Home Program.

Status of Operational Standards We found the Department of Health and Community Services did not complete the required biennial comprehensive review of operational standards, including NLHS monitoring methods. We found operational standards have not been comprehensively updated since 2007. This was also an outstanding recommendation from the Office of the Auditor General’s 2015 report on Personal Care Home Regulation. We also found new standards have been in draft form since 2022 and have yet to be implemented.

We note that three groups consulted in the drafting of the revised standards were concerned with the delay in implementation; one noted that since 2021, when they last provided their submission to the department, they had received minimal feedback. We found the department, on occasion, made changes to operational standards in consultation with NLHS, and in response to feedback from stakeholders and communicated those changes through written addendums (additions) and memos that were not publicly available.

Addendums were issued as an official update or change to the 2007 operational standards, and memos were issued for important reminders.

We found the department issued nine updates via addendums to the standards since 2007: Changes to the Operational Standards (2009); Emergency Preparedness (2015); Enhanced Care (2016); Supplemental Rate to Support Personal Care Home Residents Waiting for Long Term Care Placement (2017); Behaviour Management Services (2020); Eviction of a Resident (2020); Use of Microwaves in Rooms (2020); Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes What We Learned

26 Use of Cooktops in Rooms (2021); and, Amendments to the Personal Care Home Regulations for Licensing (2024). The department also issued eight memos pertaining to standards since 2007: Personal Care Home Eligibility and New Initiatives (2018); Medical Assessment for Employment for Home/Personal Support Workers (2020); Clinically Ineligible Residents (2021); Serious Incident Reporting (2022); Subsidy Increase and New Programs (2022); Monthly Subsidy Rate Increase (2023); Clarification First Aid Requirements; and, Hiring Requirements and Internationally Recruited Workers (2024).

In the absence of proactive review and updates, we found changes (addendums and memos) to the operational standards were issued reactively, generally after an incident had occurred.

For example: Eviction of a Resident (February 1, 2020): addendum was developed after NLHS identified concerns with the number of residents evicted from personal care homes; Behaviour Management Services (February 1, 2020): addendum was developed to support residents with behavioural challenges, as identified during the drafting of the 2020 eviction addendum; Medical Assessment for Employment for Home/Personal Support Workers (2020): memo advised of a change in the medical assessment for employment form, including that the pre-employment medical assessment must be completed within 30 days of starting work, and relaxed requirements for a two-step tuberculin test owing to challenges with access to testing during the COVID-19 pandemic; Serious Incident Reporting (June 28, 2022): memo developed based on review of the Patient Safety Act, the required reporting outlined within the Act, and the reporting challenges being encountered.

We noted that following a serious medication incident in May 2022, this memo was issued, approximately one month later; and Hiring Requirements and Internationally Recruited Workers (September 16, 2024): memo developed to provide clarification regarding documentation of international workers. We noted the hiring memo was issued after we asked the department for clarification regarding hiring requirements for internationally recruited workers during our audit.

We noted the current operational standards do not consider addendums or memos, but rather state a requirement for a comprehensive standards review every two years. We also found only one personal care home’s initial assessment criteria required a mental health diagnosis to be submitted for residents. There was no reference to requiring a mental health diagnosis in the operational standards and no corresponding addendum or memo to reflect such a requirement. Provincial Comparisons We compared the 2007 operational standards to similar standards in the Atlantic provinces and Alberta.

Due to differences in terminology and frameworks, we could not confirm that the standards were complete when compared to other jurisdictions.

Focusing on areas of our audit criteria, we found: Operational Standards Newfoundland and Labrador standards were the most out of date when compared to the Atlantic provinces and Alberta; Newfoundland and Labrador did not require a professional certification for staff to work in a personal care home, while there was only one jurisdiction we reviewed that required personal care home staff to have a professional certification, such as a Personal Care Attendant diploma; There was no consistency across the jurisdictions regarding a timeline for review and revision to standards; There was no consistency across jurisdictions regarding staffing ratios; Newfoundland and Labrador was the only province that required a medical and tuberculosis test for employees; Similar to all but one jurisdiction, Newfoundland and Labrador required resident reassessments to be completed annually or earlier if care needs changed; Medication administration standards were similar across jurisdictions; Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Newfoundland and Labrador Health Services’ process to address persistent standards violations was included in the standards, while there was no language in the other standards we compared. However, additional sources from the other jurisdictions provided direction on repeated instances of non-compliance; and Newfoundland and Labrador’s quarterly personal care home monitoring inspections may be announced or unannounced, while one province required inspections to be unannounced. We compared how all provinces and territories disclose their monitoring results.

We found Newfoundland and Labrador’s personal care home monitoring results were not publicly available. The vast majority of other Atlantic provinces, along with Alberta, Ontario, British Columbia, Manitoba, and Saskatchewan, publicly disclosed monitoring results. 27 Operational Standards Why It Matters The operational standards are critical to the regulation of the personal care home industry. The standards outline the baseline expectations for personal care homes, residents, health authorities and the department, including the residents’ rights to independence, privacy, and freedom of choice.

Therefore, the standards should be current and informed by best practices, to ensure quality of services and care provided for personal care home residents. As the population ages and the number of people likely requiring the use of a personal care homes increases, it is even more important that standards are updated and maintained to meet the demands of the resident population. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Findings - Program Oversight 28 The Department of Health and Community Services monitors the delivery of the Personal Care Home Program.Criteria 2 Objective What We Expected We expected the Department of Health and Community Services would mandate NLHS to monitor and report key performance indicators related to personal care homes. We also expected the department would have and follow quality control processes to ensure NLHS are monitoring and reporting on the delivery of the personal care home program, including timely and accurate reporting of serious incidents.

We expected the department would use the information from incidents to enhance the creation and implementation of policies and procedures to prevent, detect and mitigate risks. To determine whether there is appropriate oversight of the Personal Care Home Program. Oversight Processes We found the Department of Health and Community Services did not have formal processes, including periodic checks, to ensure NLHS consistently followed the requirement to license and monitor personal care homes for compliance with standards.

We found the department failed to enforce quarterly reporting requirements for NLHS, as required by the operational standards. The standards state that NLHS report quarterly to the department, specifically on complaints and incidents, resident care requirements and provision, and staffing. The department indicated this practice was stopped in 2017 because the reporting lacked information on the context of monitoring and the details of non-compliance. Since 2017, the department requested quarterly monitoring reports at random from NLHS for various reasons.

There was no official addition to the operational standards to reflect this change. We found he Department of Health and Community Services received a total of 20 individual home quarterly monitoring reports, and 31 inspection reports from NLHS from April 2022 to September 2024. Of those 51 reports and inspections, 38 of 51 (75 per cent) were from 2022, and 13 of 51 (25 per cent) were from 2023. We found there were no quarterly monitoring reports or inspections received or requested by the department from January 1 to September 30, 2024.

Further, the Department of Health and Community Services did not provide any evidence of follow up to the monitoring reports and inspections it received from NLHS between April 2022 and September 2024. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes What We Learned

Figure 8: Inquiries Received by the Department of Health and Community Services about the Provincial Personal Care Home Program Source: Prepared by the Office of the Auditor General based on information provided by the Department of Health and Community Services, unaudited. 29 Program Oversight Inquiries and Incidents Oversight We found the department had no internal written policies, procedures, or processes to handle inquiries, including complaints. Inquiries included both questions and concerns about the personal care home program.

We found the department received 197 inquiries during our audit period, which equated to approximately seven inquiries per month. We found inquiries related to resident placement (34 per cent), financial questions (29 per cent), quality of care and treatment (25 per cent), staffing levels, qualifications or training (3 per cent), and food quality and service (3 per cent). Six per cent of inquiries were related to items not included in our scope.

Examples of what the department heard included homes not being able to meet client needs, inadequate care, quality of food, and delays in resident assessments and reassessments. Figure 8 shows categories of inquiries received by the Department of Health and Community Services during our audit period. Placement: 34% Sta ng: 3% Financial: 29% Food Quality & Service: 3% Quality of Care & Treatment: 25% Other: 6% PlacementSta ng FinancialFood Quality & Service Quality of Care & TreatmentOther We found the department exercised a lack of oversight regarding serious incidents that occurred at personal care homes.

Serious incidents were not defined in the 2007 operational standards; however, in 2022, the Department of Health and Community Services issued a memo that defined serious incidents as an ‘event or circumstance that potentially threatens the well-being and safety of residents.’ Serious incidents could include a missing resident, suspected neglect, a suspicious death, medication error resulting in significant harm, fire, flood, or labour dispute. This memo also states NLHS was responsible to report serious incidents to the department as soon as they became aware of the incident.

We found the department had no internal written policies, procedures, or processes to handle serious incidents. The department received notification from NLHS of eight serious incidents between April 2022 to September 2024. However, we found six of these eight incidents (75 per cent) had no documented follow up action by the department. We found specific follow up actions for two of eight serious incidents (25 per cent). However, one of these follow-ups happened via email approximately two months after the incident took place.

Examples of serious incidents reported to the department included: A resident did not return from a routine walk and was found deceased later that day; A resident went missing due to wandering/dementia; A resident was injured after falling down an embankment behind a home; and A resident was administered multiple medications of another resident and died as the result of accidental overdose. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

30 Program Oversight Why It Matters As the oversight authority for the Provincial Personal Care Home Program, the Department of Health and Community Services has a responsibility to ensure that NLHS is appropriately monitoring the delivery of the program and that the health and safety needs of personal care home residents is met. Without formalized processes, a department is unable to provide effective oversight. Further, lack of clear parameters on reporting requirements could leave the department unaware of significant issues within the program.

Instances of non-compliance and serious incidents can happen at any time. Routine reporting and communication between NLHS and the department is a critical factor in effective oversight. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Findings - Compliance 31 Newfoundland and Labrador Health Services monitors personal care homes for compliance with the Provincial Personal Care Home Program Standards.Criteria 3 Objective What We Expected We expected that NLHS would have and follow a process to monitor personal care homes compliance with the standards, including maintaining appropriate documentation. We also expected that NLHS would take appropriate steps when personal care homes are not in compliance, as per the non-compliance protocols outlined in the standards.

We expected NLHS would track, measure, and report key performance indicators related to personal care homes for performance evaluation purposes. We expected that NLHS would have a well established process for managing complaints. We expected NLHS would report quarterly to the department on complaints and incidents as per the standards. We expected NLHS would have a comprehensive process in place to address persistent violations of the standards. Finally, we expected NLHS, in collaboration with the personal care home operators, would follow the standards with respect to evicted residents.

To determine whether there is appropriate oversight of the Personal Care Home Program. Compliance Monitoring We found issues with how NLHS documented their compliance monitoring. NLHS were responsible to follow the operational standards and NLHS guidelines by completing at least one monthly unannounced visit and announced quarterly visits, and producing quarterly monitoring reports. We reviewed 173 quarterly monitoring reports from a sample of 35 homes throughout the province to determine whether NLHS ensured homes were in compliance with standards.

We found, in 69 of 173 quarterly monitoring reports (40 per cent), there was insufficient or no evidence to support some of the conclusions drawn by NLHS. Examples included blank file audit sections, blank sections of the report, unclear or incorrect staffing level calculations, lack of detail including missing non-compliance items, and contradictory information. As an additional procedure, we also compared NLHS’ quarterly monitoring reports corresponding to the times of our visits.

We found all 13 homes were compliant with staffing requirements per the standards; however, we found 10 of 13 monitoring reports (77 per cent) completed by NLHS did not include supporting staffing calculations. Furthermore, we obtained timesheets from each home corresponding to our visits and found 12 of 13 timesheets (92 per cent) did not match the staffing schedules that were reviewed by NLHS.

Examples of discrepancies in the timesheets and staffing schedules included: Staff missing from either the timesheet or the staffing schedule; Hours noted for some employees did not match; Total number of hours per the timesheet did not match with the total number of hours per the schedule; Homes provided copy of staffing

schedule as timesheet; Total employees per the timesheet did not match with the total employees per the schedule; Home did not include regular shift staff within the timesheet; and In the schedule, instead of number of hours, ‘D,’ ‘N’,’CA’ was mentioned for day shift, night shift and casual, respectively. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes What We Learned

32 Compliance Instances of Non-Compliance We reviewed NLHS quarterly monitoring reports to gain insights into the quantity and the types of non-compliance occurring at personal care homes. We found none of the homes we tested were fully compliant for all five quarterly report samples. We found 148 of 173 reports (86 per cent) contained instances of non-compliance with operational standards. We also found 11 of 173 reports (6 per cent) noted the personal care home did not provide NLHS with required monthly status reports.

We found four of 35 homes (11 per cent), that were marked as missing these reports more than once, were all located in the Central zone. We found 32 of 173 quarterly monitoring reports (18 per cent) indicated homes did not investigate, follow up, or document complaints and incidents in at least one quarter, which represented 16 of 35 homes (46 per cent). We found 13 of 173 reports (eight per cent) where homes did not respond to complaints and incidents within seven days per operational standards and did not document the outcome in at least one quarter, which represented 10 of 35 homes (29 per cent).

We also found non-compliance related to staff qualifications and training, food quality and service, staffing levels, and medication administration from the reports we reviewed: Staff qualifications and training – 99 of 173 reports (57 per cent); Food quality and service – 38 of 173 reports (22 per cent); Staffing levels – 31 of 173 reports (18 per cent); and Medication administration – 110 of 173 reports (64 per cent). Persistent Instances of Non-Compliance Across zones, NLHS did not consistently take appropriate steps when personal care homes were persistently non-compliant with operational standards.

Actions that could be taken included issuing a conditional licence or revoking a licence. We found six of 35 homes (17 per cent) had persistent violations of the standards but were not issued a conditional licence. We found five of 35 homes (14 per cent) were issued a conditional licence due to instances of non-compliance, which equated to eight of 173 reports (five per cent). We found there were no specific timelines for action in the operational standards to address persistent violations of the standards.

As previously stated, we found issuing a conditional licence or revoking a licence was done at the discretion of NLHS. Monitoring of Evictions An addition to the operational standards, Eviction of a Resident, was introduced by the Department of Health and Community Services in 2020. For example, it stated NLHS was responsible to assist displaced residents find an alternate residential option, and that NLHS must report the number of resident evictions to Health and Community Services. We found NLHS reported 254 resident evictions to the department during our audit period.

This quantity equates to 85 evictions per year on average. The department indicated they have taken some actions to address evictions, such as the Home First Initiative (2018 and 2021), implementing a Behaviour Management Services policy (2019), and revising its funding model (2023). However, even with these additional supports, we found 91 residents (36 per cent) were sent to the emergency department and not accepted back by the personal care home within our audit period. We note that this practice was known and not addressed by the department and NLHS.

We found five of 254 evicted residents (two per cent) were evicted without consultation with NLHS. Figure 9 shows the combined total number of evicted residents by zone that was reported to the department on a monthly basis. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

33 Figure 9 Resident Evictions from April 1, 2022, to September 30 2024 Source: Prepared by the Office of the Auditor General based on information provided by the Department of Health and Community Services, unaudited. 1 Central zone and Western zone indicated there were gaps in their reported data. 2 Nine months, January to September. Compliance Why It Matters We found NLHS did not maintain a record of resident evictions, other than the monthly eviction statistics that are required to be reported to the department.

NLHS was unable to provide our audit team with sufficient evidence so that we could test compliance with the evictions addendum. We found personal care home residents were not protected by the Residential Tenancies Act. Despite the eviction’s addendum introduced in 2020, our Office received two submissions expressing concerns regarding the number of evictions per year, and cases of misinterpretation or misuse of the eviction addendum by operators. Performance Evaluation We found NLHS did not have established key performance indicators to evaluate the performance of the Provincial Personal Care Home Program.

We found there was no mention of key performance indicators in the operational standards. When NLHS was asked what were the key performance indicators for the program, officials listed five indicators, including reporting to the department on care indicators: 1. licensure and compliance, 2. incident reporting, 3. staffing levels, 4. corrective actions, and 5. after-hours reporting. However, NLHS could not provide evidence these indicators had been compiled and reported on separately, and noted data limitations due to lack of integration, aggregate metrics and trend analysis between personal care homes and NLHS.

Year Evicted by Personal Care Home and transferred to another Care Home Evicted and NLHS Consulted Evicted & NLHS engaged in transition plan Evicted without NLHS consult Sent to Emergency Department and not accepted back by Personal Care Home Total % of Total 20221 14 19 5 0 33 71 28% 20231 29 33 19 3 34 118 46% 20242 17 12 10 2 24 65 26% TOTAL 60 64 34 5 91 254 Percentage 24% 25% 13% 2% 36% NLHS has the responsibility of ensuring personal care homes follow the operational standards and are thus meeting the health and safety needs of residents.

NLHS should have processes in place that safeguards residents throughout the province, not just in certain zones or homes. This would include timely and consistent follow up actions when homes are not complying with the standards. Monitoring, addressing, and reporting on compliance issues should be more consistent and effective across zones and personal care homes. A lack of consistency indicates weaknesses in the monitoring processes. Further, detailed monitoring results for personal care homes are not available to the public, which indicates a lack of transparency and accountability.

Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Subsequent Events 34 On February 5, 2025, the Provincial Government released the Long-Term Care and Personal Care Home Review Report. The report was developed by an expert advisory panel and makes 23 recommendations on improving long- term care homes and personal care homes for residents and staff. The report is a result of Health Accord NL recommendations to improve the quality and availability of long-term care homes and personal care homes.

This report was independent of our audit, and we have reviewed their findings and recommendations where our scope of work is similar (food quality and service, staff qualifications and training, and staffing levels). Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Conclusions 35 We have serious concerns about the oversight and program delivery of the Provincial Personal Care Home Program. The Department of Health and Community Services has failed in its responsibilities to maintain modern operational standards, given they have not been comprehensively updated since 2007 and may not adequately reflect the needs of the current personal care home population.

As a fundamental component of the department’s residential care system, the provincial government has stated in the standards that it is committed to offering personal care home residents a high quality of holistic, resident- centered care within a home-like environment. But since 2017, the Department of Health and Community Services has increasingly distanced itself from oversight responsibilities for the program. We are concerned that the department is not truly delivering on the commitments made in the standards, particularly given the lack of oversight.

Our audit indicates there are deficiencies with the monitoring processes performed by Newfoundland and Labrador Health Services which ensure personal care homes are delivering resident care and safety in accordance with the operational standards. Neither the Department of Health and Community Services nor Newfoundland and Labrador Health Services discloses the nature or number of personal care home instances of non-compliance publicly. Sadly, our Office has highlighted this issue before – it remains an outstanding recommendation from our 2015 report on Personal Care Home Regulation.

Relicensing of personal care homes is too subjective, and personal care homes are often relicensed while carrying unresolved compliance issues. There also appears to be a culture of acceptance within the Department of Health and Community Services and Newfoundland and Labrador Health Services towards the ongoing backlog of overdue resident care reassessments. Our 2015 report also included a recommendation to address overdue reassessments but remains outstanding.

If reassessments are not timely, individuals may be living in personal care homes where their individual care needs are not appropriately met, creating risks for themselves and others in the home and in their communities. Incidents and compliance violations are pervasive in the province’s personal care homes. This was evident through our review of documentation and observed by our staff while completing onsite visits of personal care homes.

Some of the most concerning examples of non-compliance included staff permitted to care for residents without the minimum hiring requirements including appropriate medical or code of conduct clearances; inadequate food quality and service; and inappropriate storage and administration of medications. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

36 Recommendations Recommendation 1 The Department of Health and Community Services should update, implement, effectively communicate and regularly review the Provincial Personal Care Home Program Operational Standards, ensuring alignment with best practices and addressing any gaps identified in this audit. Response: The Department of Health and Community Services accepts this recommendation Recommendation 2 The Department of Health and Community Services should review all personal care home serious incidents, ensuring that they are addressed in a timely manner with documented outcomes.

Response: The Department of Health and Community Services accepts this recommendation. Recommendation 3 The Department of Health and Community Services should enhance publicly available information regarding personal care homes, including posting inspection results, non-compliance information, licensure status and retain a history of the information for each home for a minimum of two years. Response: The Department of Health and Community Services accepts this recommendation.

Recommendation 4 The Department of Health and Community Services should work with Newfoundland and Labrador Health Services to develop and implement formal and consistent oversight processes for personal care homes, including the establishment of key performance indicators, reporting requirements, documentation standards, and serious incident protocols. Response: The Department of Health and Community Services accepts this recommendation. Newfoundland and Labrador Health Services accepts this recommendation.

Recommendation 5 The Department of Health and Community Services should work with Newfoundland and Labrador Health Services to implement a formal and comprehensive complaint management process for personal care homes. Response: The Department of Health and Community Services accepts this recommendation. Newfoundland and Labrador Health Services accepts this recommendation. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

37 Recommendations Recommendation 6 Newfoundland and Labrador Health Services should ensure that kitchen and dining facilities, staff, and serving routines in personal care homes follow the operational standards and that they are monitored to ensure consistency across the province. Response: Newfoundland and Labrador Health Services accepts this recommendation.

Recommendation 7 Newfoundland and Labrador Health Services should ensure personal care home staffing levels are appropriate, that staff have satisfied hiring requirements before starting their employment, and that staff have the necessary training to comply with all aspects of the operational standards. Response: Newfoundland and Labrador Health Services accepts this recommendation.

Recommendation 8 Newfoundland and Labrador Health Services should review the licensing and re-licensing processes for personal care homes, including the clear definition and communication of consequences for non- compliance, determined from quarterly monitoring and/or annual inspections. Response: Newfoundland and Labrador Health Services accepts this recommendation. Recommendation 9 Newfoundland and Labrador Health Services should ensure that initial personal care home resident assessments and reassessments are completed in a timely manner and any change in care needs are addressed appropriately.

Response: Newfoundland and Labrador Health Services accepts this recommendation. Recommendation 10 Newfoundland and Labrador Health Services should implement an internal quality control process to ensure that personal care home operating standards compliance monitoring is completed consistently across the province. Response: Newfoundland and Labrador Health Services accepts this recommendation. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

38 Why this Audit is Important Personal care homes serve a vulnerable sector of the population. There are approximately 4,400 people residing in personal care homes in Newfoundland and Labrador. The government projects that between 2023 and 2043, the 65 plus population is expected to increase significantly. As the need for personal care homes grows, more residents and their families will rely on the government to ensure personal care homes provide safe, holistic care to meet their needs.

It is critical that the Department of Health and Community Services and Newfoundland and Labrador Health Services have appropriate standards and processes in place to ensure resident health, safety and care in personal care homes. Objectives Objective 1 – Oversight To determine whether there is appropriate oversight of the Personal Care Home Program. Objective 2 – Program Delivery To determine whether Newfoundland and Labrador Health Services, in conjunction with personal care homes, delivers appropriate care to residents.

Criteria The Office of the Auditor General developed criteria based on discussions with personal care home oversight and management representatives; review of relevant documentation; legislation, government policies and procedures; and reviews of literature including reports of other legislative auditors. The Office of the Auditor General defined nine criteria regarding the objectives. The Department of Health and Community Services and Newfoundland and Labrador Health Services representatives accepted the criteria as suitable.

The Office of the Auditor General assessed whether the Department of Health and Community Services and Newfoundland and Labrador Health Services provided appropriate oversight of the Personal Care Home Program against the following criteria: 1. The department maintains up-to-date Provincial Personal Care Home Program Operational Standards; 2. The department monitors the delivery of the Personal Care Home Program; and 3. Newfoundland and Labrador Health Services monitors personal care homes for compliance with the standards.

The Office of the Auditor General assessed whether Newfoundland and Labrador Health Services, in conjunction with personal care homes, delivered appropriate care to residents against the following criteria: 4. Newfoundland and Labrador Health Services licences and re-licences personal care homes in accordance with the standards; 5. Newfoundland and Labrador Health Services ensures resident care assessments and re-assessments are completed in accordance with the standards; 6. Personal care homes have qualified, and adequately trained staff as required by the standards; 7.

Personal care homes provide food quality and service to residents as required by the standards; 8. Personal care homes have appropriate staffing levels to meet resident care needs as required by the standards; and 9. Personal care homes appropriately administer medication to residents as per the standards. Scope and Approach Our audit began in December 2023 and covered the period April 1, 2022, to September 30, 2024.

It examined whether the Department of Health and Community Services and Newfoundland and Labrador Health Services provided appropriate oversight of the Personal Care Home Program as defined by the 2007 Provincial Personal Care Home Program Operational Standards. It also examined whether Newfoundland and Labrador Health Services, in conjunction with personal care homes delivered appropriate care to residents as defined by the 2007 Provincial Personal Care Home Program Operational Standards. Appendix I - About This Audit Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

39 Appendix I - About This Audit We conducted our audit using a risk-based approach based on our understanding of the responsibilities, systems, risk factors and activities of the Department of Health and Community Services and Newfoundland and Labrador Health Services as they relate to the oversight and administration of personal care homes. Our audit procedures included discussions with select representatives of the department, Newfoundland and Labrador Health Services, and owners and employees of personal care homes.

Our audit procedures considered legislation, the standards, guidelines, policies, procedures, and monitoring processes. Our procedures also examined information contained in the electronic records management system, as well as physical records held at personal care homes. Our procedures also included a detailed examination of quarterly and annual monitoring reports, sample menu plans and food inventory reports, dietician reports, resident care assessments and re- assessments, staffing reports, staff qualifications and training records, incident reports, complaints, and complaint follow-up documentation.

We also reviewed clinical information such as resident re-assessment comments, dietician and social work reports, non-compliance reports, committee meeting minutes, organizational charts, incident reports, investigative reports, and other applicable reports and correspondence. We also considered jurisdictional comparisons where appropriate. We also conducted onsite procedures at a sample of thirteen personal care homes from all health zones within the province. The Office of the Auditor General received approval from the homes we visited to take pictures and some of those are included in this report.

We did not include the inspection processes performed by the Department of Digital Government and Service NL. However, our audit procedures included the review of their personal care home inspection reports in relation to licensing and relicensing of personal care homes. We did not include long-term care, assisted living facilities, community care homes, or home support services in this audit.

While assisted living facilities are also private, for-profit businesses that offer levels of care, Newfoundland and Labrador Health Services does not license or place individuals into these facilities, and they are not subject to the same operating requirements or standards. Audit Standards This independent assurance report was prepared by the Office of the Auditor General of Newfoundland and Labrador for the House of Assembly’s Public Accounts Committee.

Our responsibility was to independently audit the Department of Health and Community Services’ and Newfoundland and Labrador Health Services’ oversight and administration of the Personal Care Home Program through our audit objectives and criteria, and to provide objective information and recommendations. The senior management of the Department of Health and Community Services and Newfoundland and Labrador Health Services acknowledged their responsibility for the audit subject matter and the terms of the audit, including audit objective, scope, and approach.

The audit was performed to a reasonable level of assurance in accordance with the Canadian Standard on Assurance Engagements 3001 – Direct Engagements set out by the Chartered Professional Accountants of Canada and under the authority of the Auditor General Act, 2021. The Office applies the Canadian Standard on Quality Management. This standard requires the Office to design, implement and operate a system of quality management, including policies and procedures regarding compliance with ethical requirements, professional standards, and applicable legal and regulatory requirements.

In conducting the audit work, we have complied with the independence and other ethical requirements of the Rules of Professional Conduct of the Association of Chartered Professional Accountants of Newfoundland and Labrador. Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

40 Appendix I - About This Audit Management Representations The Deputy Minister of Health and Community Services confirmed that senior management had provided the Office of the Auditor General with all the information they were aware of that had been requested or that could significantly affect the findings or conclusions of the compliance audit report on behalf of the Department of Health and Community Services.

The Chief Executive Officer of Newfoundland and Labrador Health Services confirmed that senior management had provided the Office of the Auditor General with all the information they were aware of that had been requested or that could significantly affect the findings or conclusions of the compliance audit report on behalf of Newfoundland and Labrador Health Services. Date Conclusion Reached We obtained sufficient and appropriate audit evidence on which to base our conclusions on March 26, 2025 in St. John’s, Newfoundland and Labrador.

DENISE HANRAHAN, CPA, MBA, ICD.D Auditor General Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

41 Appendix II List of Personal Care Homes in operation between April 1, 2022 and September 30, 2024 Central Zone Carmanville Terrace - permanently closed August 2022 Carmanville Hillcrest Manor Musgrave Harbour Gander Bay Retirement Home George's Point Golden Years Estates Grand Falls-Windsor Green Bay Retirement Living Springdale Islandside Manor Leading Tickles Kingsway Living Grand Falls-Windsor Kingsway Living Lewisporte Lanes Retirement Living Botwood Nightingale Manor Gander Oram's Baywatch Manor Glovertown Oram's Bethesda Manor Gander Oram's Bethesda II Gander Oram's Birchview Manor Glovertown Oram's Emmanuel Manor Glovertown Otterbury Manor Wesleyville Pleasantview Manor Lewisporte Riverhead Manor Fogo Robinson's Personal Care Home Bishops Falls Springdale Retirement Centre Springdale Sunset Manor Twillingate The Fountains at Hollett Park Grand Falls-Windsor The Golden Years Estate Gander The Legacy at Hollett Park Grand Falls-Windsor Twilight Manor - permanently closed August 2022 Embree Twin Town Manor Grand Falls-Windsor White Bay Retirement Living Baie Verte White's Family Care Home Porterville Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

Eastern Rural Zone Alderwood Estates Retirement Centre Witless Bay Baccalieu Retirement Living Old Perlican Bay Robert's Retirement Centre Bay Robert's Beachside Manor Placentia Bonavista Retirement Home Bonavista Callingwood Downs Clarke's Beach Clarenville Retirement Home Clarenville Cozy Quarters Retirement Centre Clarenville Eason's Personal Care Home Holyrood Fahey’s Personal Care Home – permanently closed August 2023 Fermeuse Grand Bank Retirement Living Grand Bank Greenwood Personal Care Home – permanently closed February 2023 Musgravetown Hilltop Manor Arnold's Cove Lanes Retirement Living Carbonear Marystown Retirement Centre Marystown Miraquinn Hilltop Manor Hickman's Harbour Lewis Personal Care Home – permanently closed February 2024 Riverhead Shag Rock Manor Whiteway Shirley's Haven Catalina St.

Lawrence Retirement Living St. Lawrence Tobin's Guest Home Holyrood Winter Holme Manor Winterton Woodford's Comfort Manor Holyrood 42 Appendix II Eastern Urban Zone Admiral's Coast Retirement Centre Kelligrews Aurora Estates Conception Bay South Bayview Heights Manor Kelligrews Bishops Garden St. John's Bonaventure Retirement Home – temporarily closed for renovations April 2024 St. John's Cambridge Estates St.

John's Canning's Personal Care Home Long Pond Cherry Lane Manor Manuals CraDea Manor Mount Pearl Essential Personal Care Home – licence revoked by NLHS June 2023 Kelligrews Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

43 Appendix II Source: Prepared by the Office of the Auditor General to show all personal care homes in the province within our audit scope period. We note that we performed testing on a subjective sample of 35 personal care homes and performed on-site visits to 13 personal care homes across the province within that sample. Labrador-Grenfell Zone Harbour View Manor Mary's Harbour Hart Haven Sheshatshiu Ivy Durley Flower's Cove Roddickton House Roddickton Shirley's Haven St.

Anthony Eastern Urban Zone (Continued) Heritage Square Retirement Living Conception Bay South Hillcrest Estates Mount Pearl Karwood Retirement Retreat Paradise Katherine House – licence revoked by NLHS September 2023 St. John's Kelly's Personal Care Home Goulds Kingsway Living Paradise Paradise Lanes Retirement Living St. John's St. John's Linda's Personal Care Home Goulds Meadow Creek Retirement Centre Old Perlican North Pond Manor Torbay Pearl House Mount Pearl Ruby Manor Mount Pearl Westbury Estates St. John's Winslowe Ridge St.

John's Western Zone Acadian Village Stephenville Brake’s Personal Care Home – permanently closed August 2023 Corner Brook Crosswinds Seniors Robinsons Deer Lake Manor Deer Lake Lanes Retirement Living Irishtown Lanes Retirement Living Port Saunders Lohnes Complex Corner Brook Main River Retirement Pollard's Point Mountain Hope Manor Channel-Port Aux Basques Mountain View House Meadows Mountain View Retirement Centre Corner Brook Oceanside Personal Care Home Codroy Silverwood Manor Kippens Westmount Estates Corner Brook Xavier House Corner Brook Auditor General of Newfoundland and Labrador - April 2025 - Personal Care Homes

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Vision Promoting positive change and accountability in the public sector through impactful audits. Mission To promote accountability in government’s management and use of public resources and encourage positive change in its delivery of programs and services. Values Above all else, the Office of the Auditor General must have independence, credibility and integrity. These are essential to everything we do; and critical to our success. The Office of the Auditor General complies with professional and office standards to produce relevant and reliable audit reports.

The Office of the Auditor General’s independence of government, in fact, and in appearance, provides objective conclusions, opinions and recommendations on the operations of government and crown agencies. Our staff work in a professional and ethical manner, ensuring respect, objectivity, trust, honesty and fairness.

Audit Team The Auditor General and the Deputy Auditor General wish to thank the diligent audit team who performed their work with independence, credibility, and integrity: Lindy Stanley, CPA – Assistant Auditor General Adam Lippa, CPA, CISA, CISM – Audit Principal Jillian Roberts, MSW, RSW – Audit Manager Juan Grillo, CPA – Audit Manager Sujin Gu, CPA – Audit Senior Syed Ashraf Abbas Zaidi, ACA (ICAEW), ACCA, CIA – Audit Senior Caitlin Lockyer – Auditor II Marc Blake, CPA – Engagement Quality Reviewer The Auditor General also would like to thank Chrysta Collins, Manager of Communications and Stakeholder Engagement, for report editing and design, as well as stakeholder management.

About Us

Website: Email: Contact Us Mailing Address: Office of the Auditor General Newfoundland and Labrador Box 8700 St. John's, NL, A1B 4J6 Phone: 709-729-2700 www.ag.gov.nl.ca oagmail@oag.nl.ca Follow Us on Social Media

Document details

Collection	Newfoundland and Labrador — Committees
Citation	2025-03-26
Type	committee
Volume / chapter	2025-03-26
Language	en
Format	json
Source	PROVINCIAL
Identifier	232a053c658fd27b5ba07dd305c3cf21bd1ec9a8

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