Purpose

The purpose of this document is to provide licensees of long-term care homes, as defined in the Long-Term Care Homes Act, 2007 (the Act), with general information on requirements set out by the Province of Ontario with respect to the covid 19 pandemic, including those set out in Directive #3 (PDF), issued by the Chief Medical Officer of Health (CMOH) and to help homes in developing approaches for operating safely while providing the greatest possible opportunities for maximizing resident quality of life.

This document is to be followed in conjunction with any applicable legislation, directives and orders and is not intended as a substitute and does not constitute legal advice. This document should be followed unless there are reasonable health and safety reasons to exercise discretion or as ordered by the local public health unit. Where homes are undertaking covid 19 measures that exceed the requirements in this document or the associated legislation, directives and orders, it is expected that the home will consult with their local public health unit, the Residents’ Council and Family Council prior to implementation.

In the event of any conflict between this document and any legislation, directive or order, the legislation, directive or order prevails. Additionally, this document is not intended to take the place of medical advice, diagnosis, or treatment.

For the purpose of interpreting this document, “fully vaccinated” against covid 19 has the same meaning as the current version of covid 19 Fully Vaccinated Status in Ontario (gov.on.ca) (PDF).

Layers of protection against COVID-19

SARS-CoV-2, the virus which causes covid 19, primarily spreads from one person to another when an infected person breathes, talks, coughs, or sneezes and releases respiratory emissions of different sized virus-laden particles into the air.

There is not one specific measure that will prevent SARS-CoV-2 transmission. However, the use of multiple layers of prevention provides the best protection, especially when people cannot avoid closed spaces, crowded places, and close contact.

Omicron variant of concern

Since February, Ontario has experienced a decrease of covid 19 cases. However, the Omicron variant remains a concern and emerging evidence suggests a greater risk of covid 19 re-infections with the Omicron variant.

Up-to-date information and evidence regarding variants of concern can be found on Public Health Ontario’s website.

COVID-19 Vaccination

The goal of the provincial covid 19 immunization program is to protect Ontarians from covid 19. Vaccines minimize the risk of severe outcomes, including hospitalizations and death, due to covid 19, and may help reduce the number of new cases.

All vaccines provided as part of Ontario’s vaccine rollout are safe and effective. Vaccines provide high levels of protection against hospitalization and death from covid 19.

Provision of fourth doses to long-term care residents

There continues to be an increased risk for severe outcomes as a result of covid 19 in the elderly population due to age and underlying medical conditions, particularly in shared living spaces like long-term care homes. Based on recommendations from the Ontario Immunization Advisory Committee, residents of long-term care homes are now eligible for a fourth dose of an mRNA vaccine if at least three months have passed since their third dose. Based on when residents received their third dose, many long-term care residents are now around three months from their third dose and are likely becoming increasingly susceptible to covid 19 infection due to waning immunity.

Any mRNA vaccine product is acceptable as a fourth dose, although data suggest that the Moderna Spikevax covid 19 vaccine may provide a more robust immune response. Home administrators are asked to encourage residents to receive their fourth dose.

Mandatory vaccination requirements

For matters related to covid 19 vaccination requirements in long-term care homes, refer directly to:

All individuals are highly encouraged to get their third doses as soon as they are eligible (in advance of the mandatory deadlines set out in the Minister’s Directive: Long-term care home covid 19 immunization policy).

Infection prevention and control (IPAC)

The importance of ongoing adherence to strong and consistent IPAC processes and practices cannot be overstated. It is critical that homes strive to prevent and limit the spread of covid 19 by ensuring that strong and consistent IPAC practices are implemented and continuously reviewed. Appropriate and effective IPAC practices must be carried out by all people attending or living in the home, at all times, regardless of whether there are cases of covid 19 in the home or not, and regardless of the vaccination status of an individual.

IPAC audits

Per Directive #3 (PDF), homes must be completing IPAC audits every two week unless in outbreak. When a home is in outbreak IPAC audits must be completed weekly.

Homes are reminded that IPAC audits should be rotated across shifts, including evenings and weekends.

At minimum, homes must include in their self-audit the Public Health Ontario's (PHO) covid 19: Self-Assessment Audit Tool for Long-Term Care Homes and Retirement Homes (PDF).

Results of the IPAC self-audit should be kept for at least 30 days and shared with inspectors from Public Health Unit, Ministry of Labour, Training and Skills Development, and Ministry of Long-Term Care for long-term care homes upon request.

General IPAC requirements

As a reminder, licensees are subject to section 86 of the Long-Term Care Homes Act, 2007, which requires that every home have an IPAC program. Additionally, section 229 of Ontario Regulation 79/10 under the Act contains additional requirements, including that homes are to follow an interdisciplinary team approach in the coordination and implementation of the IPAC program and that every long-term care home must have an IPAC coordinator in place. The importance of ongoing adherence to strong IPAC processes and practices cannot be overstated.

Specific requirements for long-term care homes in the context of the covid 19 pandemic are also set out in the Required Infection Prevention and Control (IPAC) Practices section of Directive #3 (PDF).

Long-term care homes are reminded that they must be in compliance with current requirements under the Long-Term Care Homes Act, 2007 as well as covid 19 related directives.

Everyone in a long-term care home, whether staff, student, volunteer, caregiver, support worker, general visitor or resident, has a responsibility to ensure the ongoing health and safety of all by practising these measures at all times.

Licensees should ensure that they have adequate stock levels of all supplies and materials required on a day-to-day basis regardless of outbreak status.

Further IPAC requirements including personal protective equipment (PPE) can be found in Directive #1, Directive #3 (PDF) and Directive #5 issued by the CMOH.

For further guidance or elaboration on best practices related to IPAC, refer to the following Public Health Ontario websites:

Physical distancing

Consistent with Directive #3 (PDF), homes must ensure that physical distancing (a minimum of two metres or six feet) is practiced by all individuals at all times, except for the purposes of providing direct care to a resident or when the following exceptions apply:

  • for residents to have brief physical contact with their visitors, regardless of visitors’ vaccination status
  • between residents, either one-on-one or in small group settings
  • between fully vaccinated visitors and fully vaccinated residents
  • for the purposes of compassionate or end-of-life visits
  • while providing personal care services (for example, haircutting). Please note that personal care services must be in accordance with all applicable laws including regulations under the Reopening Ontario (A Flexible Response to covid 19) Act, 2020

Universal masking

  • Homes must ensure that all staff and essential visitors wear a medical mask for the entire duration of their shift or visit, both indoors (including in the residents’ room) and outdoors, regardless of their immunization status.
  • General visitors must wear a medical mask for the entire duration of indoor visits (including in the resident’s room). Additionally, a medical or non-medical mask is required for the entire duration of an outdoor visit.
  • Removal of masks for the purposes of eating should be restricted to only areas designated by the home.

For residents: Homes are required to have policies regarding masking for residents. While there is no requirement for residents to wear a mask inside of the home, a home's policies must set out that residents must be encouraged to wear, or be assisted to wear, a medical mask or non-medical mask when receiving direct care from staff, when in common areas with other residents (with the exception of meal times), and when receiving a visitor, as tolerated.

Exceptions to the masking requirements are:

Homes must also have policies for individuals (staff, visitors, or residents) who:

  • have a medical condition that inhibits their ability to wear a mask
  • are unable to put on or remove their mask without assistance from another person

Personal protective equipment (PPE)

Requirements
  1. Long-term care homes must follow the precautions described in the applicable directives issued by the Chief Medical Officer of Health.
  2. Homes must provide training on PPE to all people regularly attending a home, including staff (permanent or temporary), student placements, volunteers, visitors, and service providers coming to the home from a third party (for example, an agency).

Grouping staff

To the extent possible, staff should be cohorted to work on consistent floors or areas of a home, including during breaks, even when the home is not in an outbreak. Staff gatherings should be limited in size and only when necessary, and where possible, virtual meetings are encouraged.

Activities

Communal dining

Communal dining is an important part of many homes’ social environment.

All long-term care homes may provide communal dining with the following precautions:

  • during regular dining, residents should continue to be grouped in their cohorts and homes should ensure physical distancing (a minimum of two metres or six feet) is maintained between the tables
  • when not eating or drinking, residents should be encouraged to wear a mask where possible or tolerated
  • fully vaccinated caregivers may accompany a resident for meals to assist them with eating; however, the caregiver should remain masked at all times and not join in the meal
  • frequent hand hygiene of residents, and staff, caregivers and volunteers assisting residents with eating must be undertaken

Unless otherwise directed by a local public health unit, homes may offer buffet or family-style service, including during regular daily meals and as part of special occasions or celebrations (for example, to celebrate a holiday).

Group activities: organized events and social gatherings

Homes are to provide opportunities for residents to gather for group activities including for social purposes, physical activities, hobbies and crafts, celebrations such as for birthdays, and religious ceremonies or practices consistent with licensees’ requirement to ensure that there is an organized program for the home to ensure that residents are given reasonable opportunity to practice their religious and spiritual beliefs, and to observe the requirements of those beliefs, pursuant to section 14 of the Long-Term Care Homes Act, 2007.

  • Residents should be cohorted, in small groups with consistent membership, no cross pollinating or mixing of groups to reduce the risk of transmission across the home during high risk activities (singing, dancing, etc.).
  • Homes should avoid large gatherings (more than 10) for organized events and social gatherings.

Fully vaccinated caregivers who have passed and completed all required screening and surveillance testing requirements in accordance with applicable laws and directives and who are in a home per the home’s visitor policy may join residents during activities in all homes, both indoors and outdoors, unless otherwise directed by the local public health unit.

What happens in an outbreak?

In the event of a covid 19 outbreak, residents should be cohorted for all non-essential activities including communal dinning, organized events and social gatherings. Different cohorts are not to be mixed, and residents from different cohorts should not visit one another.

What happens when a resident is isolating or fails screening?

Residents in isolation or who fail screening are not to join in group organized events, activities or social gatherings. However, homes should attempt to have these residents join-in virtually where possible to provide these residents with an alternative to in-person social interaction.

Personal care services

Personal care services such as hairdressing and barber services are permitted in long-term care homes in accordance with all applicable laws including regulations under the Reopening Ontario (A Flexible Response to covid 19) Act, 2020.

Residents should be encouraged to wear masks where possible or tolerated.

Screening

Refer to Directive #3 (PDF) for requirements related to active screening.

Staffing

In recognition of the staffing challenges that long-term care homes are experiencing the ministry has put in place a number of measures to help homes in times of serious staffing shortages that cannot be filled by other means including staffing agencies. Homes not in outbreak have the ability to implement these measures based on their own assessment. When a home is in outbreak, they should work with the PHU when implementing these measures.

Operational flexibility

Homes are reminded that the following regulations are in place to provide operational flexibility to homes under the Reopening Ontario (A Flexible Response to covid 19) Act, 2020, specifically:

Homes should read the applicable regulations for a full understanding of all requirements. Please see Appendix for a reference guide.

Multiple work locations when in outbreak

Based on the advice from the Office of the Chief Medical Officer of Health (OCMOH), the ministry is removing the policy under the O. Reg 146/20: Limiting Work to a Single Long-Term Care Home that restricts fully vaccinated staff from only working in one location when a home is in outbreak. In these circumstances if a staff member is critically required to work in another facility while working in an outbreak facility, this should be done in consultation with the public health unit and homes should ensure the following:

  • the staff member working in an area of outbreak at one home or health care facility also works in an area of outbreak at the other work location
  • staff have received all recommended doses of the vaccine (third dose for those eligible, otherwise two doses)
  • the staff member has not had a known high-risk contact with a case
  • the home(s) or health care facility and staff member maintain excellent IPAC practices including appropriate PPE
  • the staff member be actively screened every day and be rapid antigen tested every day, the same as those under test-to-work who have an ongoing exposure in an outbreak (see below)

Test-to-work or return to work

The Ministry of Health, in consultation with the Chief Medical Officer of Health, has updated its covid 19 testing and isolation guidelines to ensure publicly funded testing and case and contact management resources are available to focus on the highest-risk settings and protect the most vulnerable including those in long-term care.

This includes testing and isolation requirements specific to health care workers returning to work in settings such as long-term care, that differ from the general public’s requirements, as well as a risk-based framework to advise homes on return to work.

All staff, student placements, volunteers and caregivers who are covid 19 positive, have covid 19 symptoms or are a high-risk close contact with someone who is covid 19 positive should notify the home right away and follow the steps below:

  • be PCR tested and where delays in PCR testing exist also be rapid antigen tested to confirm if they are covid 19 positive
  • isolate for five days (or longer if remain symptomatic) and do not return to the home for 10 days.

Return-to-work risk-based framework

In circumstances of serious staffing shortages homes may have fully vaccinated staff return, prior to the 10 days. The options below are for staff who are high risk close contacts with someone who is covid 19 positive or who are covid 19 positive. This framework outlines testing and isolation requirements for various risk of transmission levels (lowest risk, moderate risk and highest risk). Homes are to evaluate their own circumstances to determine the best risk option to apply; however, homes are encouraged to use the lowest risk option whenever possible.

Note: PCR test referenced below includes laboratory based and rapid antigen testing.

Staff who are fully vaccinated, who are high risk close contacts with someone who is COVID-19 positive

Lowest risk

If applying the lowest risk option, staff can return to work either:

  • after a negative PCR test collected on, or after, day seven from last exposure
  • on day seven after two negative rapid antigen tests on day six and seven, taken 24 hours apart, after last exposure

Moderate risk

If applying the moderate risk option, staff must continue daily rapid antigen tests until end of the isolation period (10 days) or the individual meets testing requirements under the lowest risk option and can return to work:

  • after an initial negative PCR test or after two negative rapid antigen tests taken 24 hours apart

Highest risk

If applying the highest risk option, staff must continue daily rapid antigen tests until end of isolation period (10 days), or until the individual meets criteria under the lowest risk testing option and may return to work:

  • after a single negative rapid antigen test

Staff who are fully vaccinated, who are COVID-19 positive, or have COVID-19 symptoms

Lowest risk

If applying the lowest risk option, staff can return to work if symptoms have been improving for 24 hours (or 48 hours if vomiting or diarrhea) and either:

  • after 10 days from symptom onset or positive test (whichever is earliest), or
  • after a single negative PCR or two negative rapid antigen tests collected 24 hours apart any time prior to the 10 day isolation requirement

Moderate risk

If applying the moderate risk option, staff can return to work, if symptoms have been improving for 24 hours (or 48 hours if vomiting or diarrhea):

  • on day seven from symptom onset or positive test (whichever is earlier) and they are only providing care for covid 19 positive residents

Note: This can only be employed where there is a serious staffing shortage and positive residents are grouped together closely to enable care for only this group.

Highest risk

Long-term care homes cannot take an approach that is high risk in this category.

For further information on the risk-based framework, please refer to covid 19 Interim Guidance: Omicron Surge Management of Critical Staffing Shortages in Highest Risk Settings (PDF). Homes should review the covid 19 Integrated Testing & Case, Contact and Outbreak Management Interim Guidance: Omicron Surge and encourage all staff, students, volunteers, and caregivers to review as well. The testing and isolation requirements for residents are set out in Directive #3 (PDF) and the Ministry of Health covid 19 Guidance: Long-Term Care Homes and Retirement Homes for Public Health Units (PDF) and are not impacted by these updates.

Key principles for reducing risk:

  • The fewest number of high-risk exposed healthcare workers should be returned to work to allow for business continuity and safe operations in clinical and non-clinical areas.
  • Those who have received three doses should be prioritized to return before those who have received only two doses.
  • Staff should avoid working with immunocompromised individuals.
  • Only bring back asymptomatic individuals. Exposed individuals should have a daily negative rapid antigen test.
  • Early return of a high-risk contact with negative test is preferred to early return of a known case.
  • Those greater than five days from last exposure to a case are preferred to those less than or equal to five days from exposure.
  • Those with a high-risk contact in the community are preferred to those with a household contact.
  • Returning to work in an outbreak area is preferred to working in a non-outbreak area.

Staffing resources available across the system are extremely limited. Facilities must rely upon their business continuity plans and system partners to support wherever possible. In the event that challenges continue after exhausting your contingency plans, staffing agency partnerships, community partners, and corporate or municipal supports (where applicable) homes should escalate to Ontario Health.

Admissions and transfers

For admissions and transfers as well as applicable isolation and testing requirements for long-term care homes, refer directly to Directive #3 (PDF) and the Ministry of Health covid 19 Guidance: Long-Term Care Homes and Retirement Homes for Public Health Units (PDF), specifically Appendix E: Algorithm for Admissions and Transfers for Long-Term Care Homes and Retirement Homes.

Absences

Requirements

All long-term care homes must establish and implement policies and procedures in respect of resident absences, which, at a minimum set out the definitions and requirements and conditions described below.

For all absences, residents must be:

  • provided with a medical mask when they are leaving the home
  • provided a handout that reminds residents and families to practice public health measures such as physical distancing and hand hygiene when outside of the home
  • actively screened upon their return to the home

There are four types of absences:

  1. medical absences are absences to seek medical or health care and include:
    • outpatient medical visits and a single visit (less than or equal to 24 hours in duration) to the emergency department
    • all other medical visits (for example, admissions or transfers to other health care facilities, multi-night stays in the emergency department)
  1. compassionate and palliative absences include, but are not limited to, absences for the purposes of visiting a dying loved one
  1. short term (day) absences are absences that are less than or equal to 24 hours in duration. There are two types of short term (day) absences:
    • essential absences include absences for reasons of groceries, pharmacies, and outdoor physical activity
    • social absences include absences for all reasons not listed under medical, compassionate or palliative, or essential absences that do not include an overnight stay
  1. temporary absences include absences involving two or more days and one or more nights for non-medical reasons

Effective February 21, 2022, all residents (regardless of vaccination status) may resume social short term (day) absences. Residents who have had at least three covid 19 vaccine doses are able to resume temporary absences. However, homes should continue to encourage residents to:

  • limit their contact with others, including avoiding large social gatherings
  • physically distance and only be in close contact with people who have had three doses of a covid 19 vaccine, especially when eating

Temporary absences are currently paused for all residents who have not had at least three covid 19 vaccine doses.

As per Directive #3 (PDF), homes cannot restrict or deny absences for medical or palliative or compassionate reasons at any time. This includes when a resident is in isolation or when a home is in an outbreak.

Isolation and testing requirements for residents when returning from absences

The following are the testing and isolation requirements for residents who go on day and overnight absences. Please note that residents are exempt from these requirements if they are within 90 days from a covid 19 infection that occurred since December 20, 2021 assuming they do not have symptoms.

Day absences (medical, compassionate, or short term)

  • Rapid antigen test and PCR test on day five following the absence. No isolation is required unless a positive result is received. If a timely PCR test is not available, two rapid antigen tests 24 hours apart may be used as an alternative.
    • residents who go on absences on a daily or frequent basis are to have a laboratory-based PCR test and rapid antigen test, on the same day, two times per week (for example, PCR and rapid antigen test on Tuesday; and PCR and rapid antigen test on Friday)
  • If a resident has a known exposure to a case while on their absence, they must be treated as a high-risk contact as per the Ministry of Health covid 19 Guidance: Long-Term Care Homes and Retirement Homes for Public Health Units (PDF), which would require:
    • residents vaccinated with at least three doses of a covid 19 vaccine to isolate until a PCR test on day five is negative
    • residents who are not vaccinated or do not have their third dose of the covid 19 vaccine to isolate for 10 days with a PCR test on day five

Overnight absences (temporary, medical or compassionate)

For residents with at least three doses of a covid 19 vaccine:

  • If returning from a hospital that is not in outbreak:
    • take PCR or rapid antigen test prior to or when returning home and isolate until a negative test result can be obtained
  • If returning from the community:
    • screen and isolate on arrival at the home until negative PCR or rapid antigen test result obtained from day five testing
    • if timely PCR results are unavailable, perform two rapid antigen tests separated by 24 hours on day 5 and day 6
  • If a resident has a known exposure to a case while on their absence, they must be treated as a high-risk contact as per the Ministry of Health covid 19 Guidance: Long-Term Care Homes and Retirement Homes for Public Health Units (PDF), which would require a resident to isolate until a PCR test on day five is negative (if the resident is vaccinated with at least three doses).

For residents who are not vaccinated or do not have their third dose of the covid 19 vaccine:

  • Screen and isolate for 10 days with a PCR test on day five.
  • If the resident has been exposed to a known covid 19 case during their absence, they must be tested for covid 19 with a PCR test or rapid antigen test on return to the home and must isolate for 10 days. A second negative covid 19 PCR test result collected on day five is required.

For further information, please refer to the Ministry of Health covid 19 Guidance: Long-Term Care Homes and Retirement Homes for Public Health Units, specifically Appendix E: Algorithm for Admissions and Transfers for Long-Term Care Homes and Retirement Homes (PDF).

Residents leaving home for extended absences

Residents who may wish to leave a long-term care home due to covid 19 will be discharged and the bed may then be available for occupancy by another person.

  • Before the resident leaves the long-term care home, the licensee is required to provide specified information, including information on the resident’s care requirements and that the resident (or the resident’s substitute decisionmaker, if applicable) assumes full responsibility for the care, safety and wellbeing of the resident.
  • During the time the person is away, the bed will be available for occupancy by another person.
  • The process for returning to the home they were discharged from differs according to the time the resident was away from the home:
    • For absences that are three months or less, the resident would be deemed eligible and accepted for admission by the licensee, and simply placed into the “re-admission” category (this category is the highest-ranking category for vacant beds; it ranks higher than the “crisis” category).
    • Longer absences require a truncated assessment by the placement coordinator with the ability for the licensee to refuse the admission if the circumstances for refusing an admission in the LTCHA exist. If accepted, the person would be placed into the “re-admission” category for that long-term care home.

Off-site excursions

Off-site group excursions (for example, to an attraction) are considered social absences and are permitted to reflect the reopening of attractions, music/theatre venues, etc.

Where an off-site excursion involves transporting residents in a vehicle, cohorting of residents and physical distancing should be maintained to the maximum extent possible during travel in the vehicle, including during the use of public transportation.

Homes should also encourage consistent seating in vehicles and maintain seating records.

For all off-site group excursions, residents must be:

  • provided with a medical mask when they are leaving the home
  • reminded to practice public health measures such as physical distancing and hand hygiene when outside of the home
  • actively screened per Directive #3 (PDF) upon their return to the home

Testing and isolation rules under isolation and testing requirements for residents when returning from absences will apply.

Visitors

Required visitor policy

All homes are required to establish and implement a visitor policy that complies with this document and Directive #3 (PDF) (as amended from time to time) in addition to all other applicable laws.

Homes are reminded that residents have a right under the Long-Term Care Homes Act, 2007, to receive visitors and homes should not develop policies that unreasonably restrict this right.

Requirements

  1. Every long-term care home must have and implement a visitor policy that, at a minimum:
    • reflects the following guiding principles:
      • safety – any approach to visiting must balance the health and safety needs of residents, staff, and visitors, and ensure risks are mitigated
      • emotional well-being – welcoming visitors is intended to support the mental and emotional well-being of residents by reducing any potential negative impacts related to social isolation
      • equitable access – all residents must be given equitable access to receive visitors, consistent with their preferences and within reasonable restrictions that safeguard residents
      • flexibility – the physical or infrastructure characteristics of the home, its workforce or human resources availability, whether the home is in an outbreak and the current status of the home with respect to personal protective equipment (PPE) are all variables to consider when setting home-specific policies
      • equality – residents have the right to choose their visitors. In addition, residents or their substitute decision-makers have the right to designate caregivers
    • sets out the parameters, requirements, and procedures prescribed in the current version of this document with respect to visitors, including but not limited to:
      • the definitions of the different types of visitors;
      • the requirement to designate caregivers;
      • restrictions with respect to visitors in the event of an outbreak or when a resident is isolating; and
      • non-compliance by visitors of the home’s visitor policy.
    • includes provisions around the home’s implementation of all required public health measures as well as infection prevention and control practices.
    • reflects the requirements related to the active screening, and surveillance testing of visitors, consistent with Directive #3 (PDF), the current Minister of Long-Term Care’s Directive covid 19: Long-term care home surveillance testing and access to homes, the vaccination requirements set out in the Minister’s Directive: Long-term care home covid 19 immunization policy and this guidance document, as applicable.
  1. Per Directive #3 (PDF), homes must maintain visitor logs of all visits to the home. The visitor log must include, at minimum:
    • the name and contact information of the visitor
    • time and date of the visit
    • the purpose of the visit (for example, name of resident visited)

    These visitor logs or records must be kept for a period of at least 30 days and be readily available to the local public health unit for contact tracing purposes upon request

  1. Homes must ensure that all visitors have access to the home’s visitor policy.
  1. Homes must provide education or training to all visitors about physical distancing, respiratory etiquette, hand hygiene, IPAC practices, and proper use of PPE.

The home’s visitor policy should include guidance from the following Public Health Ontario resources to support IPAC and PPE education and training:

Types of visitors

Not considered visitors

Long-term care home staff (as defined under the Long-Term Care Homes Act, 2007), volunteers, and student placements are not considered visitors as their access to the home is determined by the licensee. Infants under the age of one are also not considered visitors and are excluded from testing and vaccination requirements.

Essential visitors

A home’s visitor policy must specify that essential visitors are persons visiting a home to meet an essential need related to the residents or the operations of the home who could not be adequately met if the person does not visit the home.

There are no limits on the total number of essential visitors allowed to come into a home at any given time.

Essential visitors are the only type of visitors allowed when there is an outbreak in a home or area of a home or when a resident has failed screening, is symptomatic or in isolation.

There are four types of essential visitors:

  • people visiting very ill or palliative residents who are receiving end-of-life care for compassionate reasons, hospice services, etc.
  • government inspectors with a statutory right of entry. Government inspectors who have a statutory right to enter long-term care homes to carry out their duties must be granted access to a home in accordance with the applicable legislation. Examples of government inspectors include inspectors under the Long-Term Care Homes Act, 2007, the Health Protection and Promotion Act, the Electricity Act, 1998, the Technical Standards and Safety Act, 2000 and the Occupational Health and Safety Act.
  • support workers: support workers are persons who visit a home to provide support to the critical operations of the home or to provide essential services to residents. Essential services provided by support workers include but are not limited to:
    • assessment, diagnostic, intervention or rehabilitation and counselling services for residents by regulated health professionals such as physicians and nurse practitioners
    • Assistive Devices Program vendors – for example, home oxygen therapy vendors
    • moving a resident in or out of a home
    • social work services
    • legal services
    • post-mortem services
    • emergency services (for example, such as those provided by first responders)
    • maintenance services such as those required to ensure the structural integrity of the home and the functionality of the home’s HVAC mechanical, electrical, plumbing systems and services related to exterior grounds and winter property maintenance
    • food or nutrition, and water or drink delivery
    • Canada Post mail services and other courier services
    • election officials or workers
  • caregivers: A caregiver is a type of essential visitor who is visiting the home to provide direct care to meet the essential needs of a particular resident. Caregivers must be at least 16 years of age and must be designated by the resident or his or her substitute decision-maker. Direct care includes providing support or assistance to a resident that includes providing direct physical support (for example, eating, bathing and dressing) or providing social and emotional support.
    • Examples of direct care provided by caregivers include but are not limited to the following:
      • supporting activities of daily living such as bathing, dressing and eating assistance
      • providing cognitive stimulation
      • fostering successful communication
      • providing meaningful connection and emotional support
      • offering relational continuity assistance in decision-making
    • Examples of caregivers include:
      • friends and family members who provide meaningful connection
      • a privately hired caregiver
      • paid companions
      • translator

An important role of the caregiver is that of providing meaningful connection and emotional support. A person should not be excluded from being designated as a caregiver if they are unable to provide direct physical support.

Designating a caregiver

  • Caregivers must be designated and must be at least 16 years of age.
  • The maximum number of designated caregivers per resident is four (unless designated before December 15, 2021).
  • A resident or their substitute decision-maker may change a designation in response to a change in the:
    • resident’s care needs that is reflected in the plan of care
    • availability of a designated caregiver, either temporary (for example, illness) or permanent.
  • A resident or their substitute decision-maker may not continuously change a designation in order to increase the number of people able to enter the home.
  • As of February 21, 2022, all caregivers are required to be fully vaccinated in order to enter the home.

The decision to designate an individual as a caregiver is the responsibility of the resident or their substitute decision-maker and not the home. The designation of a caregiver should be made in writing to the home. Homes should have a procedure for documenting caregiver designations.

Caregivers – scheduling, length and frequency of visits

Homes may not require scheduling or restrict the length or frequency of visits by caregivers. However, in the case where a resident resides in an area of the home in outbreak, is symptomatic or isolating under additional precautions, only one caregiver may visit at a time.

A caregiver should not visit any other home for 10 days after visiting another:

  • resident who is self-isolating, including those experiencing symptoms of covid 19 and are being assessed
  • home or area of a home affected by an outbreak

Recognizing there are caregivers who want to volunteer to support more than one resident, in the event of an outbreak, caregivers may support up to two residents who are covid 19 positive, provided the home obtains consent from all involved residents (or their substitute decision makers). Caregivers may also support more than one resident in non-outbreak situations, with the same expectation regarding resident consent.

All homes need to create safe opportunities for caregivers who are fully vaccinated to spend time with residents in areas outside the resident’s room including:

  • lounges
  • walks in hallways (without going outdoors)
  • outdoor gardens and patios (if available)

General visitors

A general visitor is a person who is not an essential visitor and is visiting to provide non-essential services related to either the operations of the home or a particular resident or group of residents. General visitors include those persons visiting for social reasons as well as visitors providing non-essential services such as personal care services, entertainment, or individuals touring the home.

Homes should prioritize the mental and emotional well-being of residents and strive to be as accommodating as possible when scheduling visits with general visitors.

Access to homes

Effective February 21, 2022, all general visitors five years of age and older who provide proof of being fully vaccinated against covid 19 may resume visits to long-term care homes.

  • Children under five years of age are restricted from entering a long-term care home, except for infants 12 months or younger.
  • Up to three visitors (including caregivers) per resident may visit at a time.
  • With the resumption of general visitors being permitted to enter homes, this will also allow for the resumption of adult day programs, entertainers and personal care services (where the person is not a staff member) in the homes. Social group activities should remain as small groups (that is, up to 10).
  • Outdoor visits:
    • The vaccination requirements outlined in the Minister’s Directive: Long-term care home covid 19 immunization policy do not apply to outdoor visits by visitors.
    • It is the discretion of the home to decide if outdoor visits are permittable in the winter months depending on the weather. Recognizing that not all homes have suitable outdoor space, outdoor visits may also take place in the general vicinity of the home.
  • Caregivers must meet the vaccination requirements outlined in the Minister’s Directive: Long-term care home covid 19 immunization policy in order to gain entry to the home.
  • When a resident is symptomatic or isolating, only one caregiver may visit at a time.

Homes should ensure physical distancing (a minimum of two metres or six feet) is maintained between groups.

Where permitted general visitors younger than 14 years of age must be accompanied by an adult and must follow all applicable public health measures that are in place at the home (for example, active screening, vaccination requirements, physical distancing, hand hygiene, masking for source control).

Restrictions during outbreaks or when a resident is isolating

Essential visitors

Essential visitors are the only type of visitors allowed when a resident is isolating or resides in a home or area of the home in an outbreak.

General visitors

General visitors are not permitted:

  • when a home or area of a home is in outbreak
  • to visit an isolating resident
  • when the local public health unit so directs

Direction from the local public health unit

In the case where a local public health unit directs a home in respect of the number of visitors allowed, the home is to follow the direction of the local public health unit.

Surveillance testing

All staff, students, volunteers, support workers, visitors and caregivers, regardless of vaccination status, must be tested in accordance with the Minister’s Directive. Refer directly to the Minister of Long-Term Care’s Directive covid 19: Long-term care home surveillance testing and access to homes for requirements related to surveillance testing.

Residents’ councils

Residents' councils play an important role in every long-term care home. As a reminder:

  • licensees are not to interfere with the meetings or operation of the residents' council per section 65 under the Long-Term Care Homes Act, 2007
  • licensees are to co-operate with the residents' council, appoint an assistant, and respond to council concerns and recommendations per section 57(2) of the Long-Term Care Homes Act, 2007 within 10 days

All homes need to ensure that the residents' council is provided an opportunity to meet. When in-person meetings of the residents' council are possible, it is expected that the residents' councils will be provided with the appropriate PPE and adequate space to meet so that physical distancing can be maintained and IPAC guidelines can be followed. Homes are to accommodate the continuation of residents' council meetings when in-person meetings are not possible.

The Ontario Association of Residents’ Councils (OARC) has developed a number of resources to help homes facilitate residents' council meetings; please visit OARC's Tools webpage to access these important resources.

Outbreaks

Outbreak definition

For matters related to the definition of an outbreak in long-term care homes, refer directly to Directive #3 (PDF) and the Ministry of Health covid 19 Guidance: Long-Term Care Homes and Retirement Homes for Public Health Units (PDF).

Only the local public health unit can declare an outbreak and declare when it is over. It is not the long-term care home’s responsibility to determine whether cases have an epidemiological link. Local public health units will determine whether cases have a link as part of their investigation, which will inform their decision as to whether they will declare an outbreak.

Outbreak management

Please refer to:

Homes must follow direction from their local public health unit in the event of a suspect or confirmed outbreak.

Reporting outbreaks and cases

covid 19 is a designated disease of public health significance (Ontario Regulation 135/18) and thus confirmed and suspected cases of covid 19 are reportable to the local public health unit under the Health Protection and Promotion Act (HPPA).

Homes must follow the critical incident reporting requirements set out in section 107 of Ontario Regulation 79/10 under the Long-Term Care Homes Act, 2007.

Homes are required to immediately report any covid 19 outbreak (suspect or confirmed) to the Ministry of Long-Term Care using the Critical Incident System during regular working hours or calling the after-hours line at 1-888-999-6973 after hours and on weekends.

Contact information

Resources

General

Infection prevention and control

For information and guidance regarding general IPAC measures (for example, hand hygiene, environmental cleaning), please refer to the following documents:

Signage

Ventilation and air flow

Below is a list of Public Health Ontario knowledge related to the use of portable fans, air conditioning units, and portable air cleaners.

Appendix: Regulation flexibility related to staffing

This quick reference highlights regulations under the Reopening Ontario (A Flexible Response to covid 19) Act, 2020 that may be of particular interest to long-term care (LTC) homes as they continue to meet resident needs while addressing covid 19 related staffing challenges footnote 1 . LTCHA refers to the Long-Term Care Homes Act, 2007.

O. Reg. 95/20: Streamlining Requirements for Long-Term Care homes

Long-term care homes may:

  • fill any staff position with the person who, in their reasonable opinion, has the adequate skills, training and knowledge to perform the duties required of that position
  • use flexible processes for the admission, transfer and discharge of persons if they have the required consent from the persons
  • adopt flexible practices related to the administration of drugs to residents if the practices are consistent with and within the scope of practice of the person administering the drug (nothing prevents a resident from self-administering a drug where they are already permitted to do so under the LTCHA and O. Reg. 79/10)

Note: Under O. Reg. 79/10, where homes are not able to meet the requirement for 24-hour RN coverage as a result of a pandemic, other regulated health professionals (for example RPNs) may fill the role with appropriate supervision.

Long-term care homes are not required to:

  • ensure the minimum number of staffing hours set out in the LTCHA and O. Reg. 79/10 are met for a position if all the care requirements are met
  • meet the screening measures if they adopt other measures that ensure resident care and safety
  • meet the training and orientation requirements set out in the LTCHA and O. Reg. 79/10 as long as they ensure staff and volunteers take measures to ensure resident care and safety
  • hold care conferences at intervals set out in O. Reg. 79/10 if they ensure care conferences take place based on the clinical needs of the resident
  • ensure that a physical examination of a resident occurs annually but must ensure that a physical examination occurs within a reasonable period after the resident’s last examination
  • follow all steps under the LTCHA and O. Reg. 79/10 when seeking approval from the Director to obtain a licence or management contract under the LTCHA, unless otherwise required by the Director

O. Reg 146/20: Limiting Work to a Single Long-Term Care Home

Long-term care employees who are fully vaccinated may work in more than one long-term care home or in a retirement home or other health care setting.

Note: Per the covid 19 guidance document for long-term care homes in Ontario, this includes where one or more of the locations is experiencing an outbreak and it is critical the staff member can work. This should be done in consultation with the public health unit and consideration of how best to mitigate risk. For example:

  • the staff member working in an area of outbreak at one home or health care facility also works in an area of outbreak at the other work location
  • staff have received all recommended doses of the vaccine (third dose for those eligible, otherwise two doses)
  • staff member has not had a known high-risk contact with a case
  • the home(s) or health care facility and staff member maintain excellent IPAC practices including appropriate PPE
  • the staff member be actively screened every day and be rapid antigen tested every day, the same as those under test-to-work who have an ongoing exposure in an outbreak

O. Reg 195/20: Treatment of Temporary covid 19 Related Payments to Employees

Temporarily suspends subsections 11(1) and (2) of the Protecting a Sustainable Public Sector for Future Generations Act, 2019 beginning April 24, 2020.

Long-term care homes may provide temporary covid 19 related payments for work performed during the suspension period.