Ontario government oversight of long-term care homes 'largely collapsed' during pandemic, ombudsman finds (CTV News)

September 7, 2023

7 September 2023

The Ministry of Long-Term Care’s oversight mechanisms “largely collapsed” when the COVID-19 pandemic hit, with on-site inspections of long-term care homes grinding to a halt for nearly two months during the first wave of the pandemic, according to an investigation by Ontario’s ombudsman.

Codi Wilson
This link opens in a new tabCTV News
September 7, 2023

The Ministry of Long-Term Care’s oversight mechanisms “largely collapsed” when the COVID-19 pandemic hit, with on-site inspections of long-term care homes grinding to a halt for nearly two months during the first wave of the pandemic, according to an investigation by Ontario’s ombudsman.

The report by Ontario Ombudsman Paul Dubé, which was released Thursday, focuses on the Ministry of Long-Term Care’s inspections-related activity at homes during the initial stages of the pandemic. It found that over a seven-week period during the initial wave of the pandemic, the ministry’s inspections branch “simply stopped conducting on-site inspections.”

In Hamilton, no on-site inspections occurred for three straight months.

“What we uncovered was an oversight system that was strained before the pandemic, and proved to be wholly incapable and unprepared to handle the additional stresses posed by COVID-19,” the report read.

In one case reviewed by the ombudsman’s office, one man complained to the Ministry four times between April 6 and May 5, 2020 about “disturbing conditions” in his mother’s long-term care home.

“None of his concerns were inspected until October 2020, many months after his mother had already died from COVID. In total, 53 residents died at that same long-term care home during the first wave,” the report continued.

In April 2020, the report notes, a woman complained to the ministry about the conditions at her parents’ long-term care home, indicating that it was “severely” short-staffed and residents were not being cleaned, fed, or given their medications. One of the woman’s parents had died of COVID-19 and the other was sick with the virus, the report read.

“A ministry inspector ‘reassured’ (the woman) over the phone and then closed the file without taking any action. Thirty-three residents died at that long-term care home during the first wave,” the report continued.

“It’s impossible to know what might have happened if the ministry inspectors had diligently followed up on complaints… when they were received.”



Inspections, the report said, were not carried out as inspectors were "not trained on infection prevention and control" and the ministry did not provide the inspections branch with a supply of personal protective equipment (PPE).

"Once inspections resumed, and for much of the first wave, only inspectors who volunteered were sent to homes experiencing COVID outbreaks,” the report read.

“Consequently, some areas of the province had as few as three or four inspectors to conduct on-site work, when there would normally be 20 to 25.”

Instead of on-site inspections at Ontario's more than 600 long-term care homes, which comprise of nearly 80,000 resident beds, the branch “monitored and supported” homes by making “periodic” telephone calls to the facilities.

"Many were directed to contact long-term care homes by phone and take on more of a supportive role than an investigative one. They relied entirely on self-reporting by the homes. We discovered that extremely serious COVID-related issues… were not inspected in a timely manner, or at all," Dubé said during a news conference on Thursday morning.

"Even when the inspections resumed and violations of the law were found, the inspections branch often took the least severe enforcement action available, even in serious situations. Homes were given many months to fix significant issues that posed a serious risk of harm to residents."

Inspection reports were slow to be completed when inspections resumed, Dubé said.

"For more than two months during the first wave, the inspections branch stopped issuing any inspection reports, even for completed inspections that pre-dated the pandemic," the report states.

In a statement sent out Thursday, SEIU Healthcare, the union representing 60,000 frontline health-care workers in the province, said the report proves that the province did not do enough to protect workers during the COVID-19 pandemic.

“The Ombudsman’s investigation revealed what we’ve known for years: that there was, and still is, a lack of protection for residents and staff, and virtually no penalties levied against negligent nursing home corporations that break their obligation to keep people safe," the statement read.

"Ontario should be a place with high standards and real accountability, but we have neither, and that continues to put seniors and staff at risk."

There were close to 2,000 COVID-related deaths in long-term care during the first wave of the pandemic, which occurred between January 15, 2020 and August 2, 2020. During the seven-week inspection hiatus, Dubé said 720 long-term care residents died.

"Although long-term care residents represent a tiny fraction of Ontario’s population, they account for nearly one-third of the province’s COVID death toll," the report notes.

The ombudsman launched his investigation on June 1, 2020 after military personnel revealed shocking conditions inside several long-term care homes where they had been called in to help.

He said his office received 269 complaints and inquiries from families, employees of long-term care homes and other stakeholders. His team conducted more than 90 interviews and reviewed thousands of emails and documents.



Dubé said much more needs to be done to deal with the "serious lapses in oversight" that have been uncovered.

"The direct result of the lack of inspections, reports, and enforcement, was a lack of protection for residents and staff and a lack of accountability for the system," he added.

In the report, the ombudsman made 76 recommendations, all of which have been accepted by the ministry, he said.

The recommendations include ensuring inspectors are always available to do on-site inspections, clarifying when off-site inspections are appropriate during any future pandemic or other type of emergency, and ensuring the ministry brief its inspectors on emerging threats.

The Ombudsman also called for revising legislation to improve whistleblower protection and ensuring the inspections branch has adequate staffing levels.

According to the Ombudsman’s Office, the Ministry has agreed to report back every six months on its progress in implementing the recommendations.

Ontario's Long-Term Care Minister Stan Cho said the province has made progress on more than 50 per cent of the ombudsman's recommendations so far.

"This includes investing $72.3 million to double the number of new long-term care inspection staff, enhancing compliance and enforcement measures in the Fixing Long-Term Care Act to ensure residents receive the highest levels of care, and launching a new proactive investigations regime to address complaints and critical incidents promptly," a statement from Cho's office read.

"COVID-19 was an unprecedented global event with devastating impacts on long-term care homes around the world. The lessons learned from this have ensured we take action by creating a new investigations unit that can refer charges when necessary and introducing new monetary penalties for bad actors. We will use this report to build on this work to ensure safe, high-quality care is delivered to seniors in long-term care homes across the province."

MPP Wayne Gates, the NDP critic for Long-Term Care, said the report shows how the safeguards meant to protect vulnerable seniors “failed entirely.”

“Under this government’s watch, inspectors did little or nothing to hold these homes accountable. And thousands of our friends, parents and grandparents died,” Gates said in a news release issued Thursday.

"This was preventable. And there need to be immediate consequences."

John Fraser, interim leader of the Ontario Liberals, said inspectors should have continued to conduct on-site inspections throughout the pandemic.

“Everybody was concerned about the risks during the pandemic. There were PSWs that went in there everyday, nurses that went in there everyday, doctors that went in there everyday, administrative people that went in there everyday,” he told reporters. “I think it would be appropriate for inspectors to go in there everyday.”

Dubé said it is essential that lessons are learned from the tragedy in long-term care to prevent this from happening in the future.

“The next pandemic could come sooner than we think and be even deadlier than the COVID-19 pandemic,” the report read.

“Effective preparedness and strong oversight are absolutely essential to mitigating risk.”