Purpose

The purpose of this document is to provide licensees of long-term care homes, as defined in the Fixing Long-Term Care Act, 2021 (the Act), with general information on enforceable requirements set out by the Province of Ontario with respect to the COVID‑19 pandemic, including those set out in the Minister’s Directive issued by the Minister of Long-Term Care, 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 as ordered by the local public health unit.

Where homes are undertaking COVID‑19 measures that exceed the requirements in this document or the applicable legislation, directives and orders, it is expected that the home will consult with their local public health unit, their Residents’ Council and Family Council prior to implementation.

In the event of any conflict between this document and any applicable 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.

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.

COVID‑19 vaccination

Vaccination policies

With the high vaccine uptake among residents, the availability of safe and effective antivirals, and high immunity in the general community, the risk of severe outcomes to residents has significantly decreased.

Long-term care homes that have retained their proof-of-vaccination requirements are strongly recommended to revisit their policies, with consideration to the current context of the pandemic and the Residents’ Bill of Rights, including the residents’ right to receive visitors of their choice. Specifically, while continuing to promote the uptake of boosters, homes are encouraged to consider permitting entry to visitors and qualified staff, regardless of their vaccination status. Licensees should engage with their residents’ council, family council, and local public health unit to inform the review of their policies to ensure revisions are supported by the most current clinical evidence. Licensees are also encouraged to seek independent legal advice as appropriate.

Long-term care licensees continue to retain the ability to impose vaccination requirements for existing and new staff, students, volunteers, support workers, caregivers and general visitors provided they are consistent with the Fixing Long-Term Care Act, 2021, including the Residents’ Bill of Rights and section 5 (right to a safe and secure home), as well as O. Reg. 246/22 under the Act, and comply with all other applicable laws including the Human Rights Code.

However, vaccination requirements shall not apply to residents. For clarity, homes cannot deny admission to a resident due to their vaccination status. In addition, vaccination policies must not apply to outdoor visitors, children under the age of five, or to those visiting residents who are receiving end-of-life care.

To augment continued vaccination policies, long-term care homes are strongly encouraged to consider best practices regarding promoting awareness of the benefits of vaccination, ensuring up to date information regarding booster eligibility is available, and offering on site vaccination (including setting up for independent administration by the home).

Best practices

Promoting awareness of the benefits of vaccination

There continues to be a 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. Getting vaccinated and staying up to date with your COVID‑19 vaccines is the best way to remain protected from the most serious effects of COVID‑19.

Vaccination has been shown to be very effective against severe illness and outcomes. Staying up-to-date with recommended doses restores protection that wanes over time. More specifically, booster doses help increase protection against symptomatic infection and severe outcomes, such as hospitalization and ICU admission.

Regardless of a home’s specific vaccination policy, all individuals living in, working in or visiting long-term care homes, are strongly encouraged to get vaccinated and stay up-to-date as per the Ministry of Health’s COVID‑19 Vaccine Guidance (PDF). All vaccines provided as part of Ontario’s vaccine rollout are safe and effective. Additional information about COVID‑19 vaccination can be found at COVID‑19 vaccines for Ontario.

Onsite vaccination

Onsite vaccine administration by homes remains the preferred approach to ensure vaccines can get to residents, caregivers and staff as quickly as possible. Homes that are set up for independent administration of COVID‑19 vaccines should work with their local public health units to request vaccine and relevant ancillary supplies for administering vaccine doses to residents, staff and caregivers onsite.

Homes that are not yet set up for independent administration are asked to either take the necessary steps to onboard for independent administration, or consider other avenues for administering vaccines onsite, working with their local public health unit.

Onsite vaccine administration should include residents, staff and caregivers regardless of whether the home is administering or another partner. Notwithstanding the benefits of onsite administration, homes should also continue to strongly encourage staff and caregivers to leverage resources available in the community to get their booster dose as soon as they are eligible.

Staff and caregivers can book booster appointments on the provincial COVID‑19 vaccination portal, by calling the Provincial Vaccine Contact Centre at 1-833-943-3900, or through select pharmacies and primary care settings. Homes are also encouraged to support staff and remove any barriers to getting a COVID‑19 vaccine (such as, supporting paid time to go to a vaccine appointment).

Infection prevention and control (IPAC) practices

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.

Licensees are required to implement requirements of the Infection Prevention and Control Standard for Long-Term Care Homes for IPAC programming, in addition to the requirements outlined in this guidance document.

IPAC audits

Per section 1.1 of the Minister’s Directive, licensees, in consultation with their joint health and safety committees or health and safety representatives, if any, shall ensure measures are taken to prepare for and respond to a COVID‑19 outbreak, including ensuring the development and implementation of a COVID‑19 Outbreak Preparedness Plan. This plan must, among other things, include conducting regular IPAC audits in accordance with this guidance document.

Homes must complete IPAC audits at least quarterly, in alignment with the requirement under the IPAC standard. When a home is in COVID‑19 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 audit the PHO's COVID‑19: Self-Assessment Audit Tool for Long-Term Care Homes and Retirement Homes (PDF).

Results of the IPAC audit should be kept for at least 30 days and shared with inspectors from the public health unit, Ministry of Labour, Immigration, Training and Skills Development, and Ministry of Long-Term Care upon request.

General IPAC requirements

As a reminder, licensees are subject to section 23 of the Act, which requires that every home have an IPAC program. Details of IPAC program requirements can be found in the Infection Prevention and Control Standard for Long-Term Care Homes. Section 102 of O. Reg. 246/22 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 a designated IPAC lead.

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.

Masking

Per section 1.2 of the Minister’s Directive, licensees are required to ensure that the masking requirements as set out in this guidance document are followed.

As one of the key defences against the transmission of respiratory viruses, homes must ensure that all staff, students, volunteers and support workers comply with applicable masking requirements at all times.

Staff, students, volunteers and support workers

For staff, students, volunteers and support workers:

Caregivers and visitors
  • Caregivers and visitors are strongly recommended to wear masks in indoor resident areas, except when with the resident in the resident’s room or when eating or drinking with a resident in communal spaces.
Residents in shared rooms
  • If a resident in a shared room is uncomfortable with others  removing their masks, homes are encouraged to provide a designated space where the roommate can receive visitors without the need for masking.

Exceptions

Exceptions to the masking requirements are:

Please note that the masking provisions in the COVID‑19 Guidance for Public Health Units : Long-Term Care Homes, Retirement Homes and other Congregate Living Settings document and in the Ministry of Long-Term Care IPAC Standard have not been updated to reflect the current enhanced masking requirements, as those documents are intended to provide baseline IPAC and outbreak management recommendations and requirements. Long-term care homes are required to follow the enhanced masking requirements set out in this COVID‑19 Guidance Document for Long-Term Care Homes in Ontario.

Eye protection

From an occupational health and safety perspective, regardless of their COVID‑19 vaccination status, appropriate eye protection (for example, goggles or face shield) is required for all staff and essential visitors when providing care to residents with suspected or confirmed COVID‑19 and in the provision of direct care within two metres of residents in an outbreak area. In all other circumstances, the use of eye protection by staff is based on the point-of-care risk assessment when within two metres of a resident.

Physical distancing and cohorting

Currently, there are no COVID-specific requirements or restrictions related to physical distancing or cohorting when not in outbreak.

Areas for isolation

Per section 5.2 of the Minister’s Directive, licensees are required to ensure that the requirements regarding areas for isolation as set out in this guidance document are followed.

Note that per subsection 269(1) of O. Reg. 246/22 under the Act, licensees must ensure that their emergency plan related to COVID‑19 outbreaks identifies an area of the home to be used for isolating residents as required, among other requirements, however homes are no longer required to directly set aside beds for this purpose.

Individuals requiring isolation must be placed in a single room on Additional Precautions. Where this is not possible, individuals may be placed in a room with no more than one (1) other resident who must also be placed in isolation under Additional Precautions, and every effort must be made to allow for adequate space (minimum two metres) between beds. For the purposes of isolation, there should not be more than two (2) residents placed per room, regardless of the number of licensed beds in the room.

Activities

Communal dining

Eating, drinking and sharing meals are important parts of many long-term care homes’ social environments. Caregivers and general visitors may join a resident in sharing a meal or eating and drinking in a communal space without a mask.

There are no COVID-specific requirements or restrictions related to communal dining. IPAC practices, such as hand hygiene, should continue to be followed in communal dining settings.

Group activities: organized events and social gatherings

Homes are to provide opportunities for residents to gather for group activities including:

  • social purposes
  • physical activities
  • hobbies and crafts
  • celebrations such as for birthdays
  • religious ceremonies and practices

Visitors and caregivers may join residents for group activities however they are strongly recommended to wear masks unless eating and drinking with residents. IPAC practices should continue to be followed in communal spaces to promote safety and well-being.

What happens in an outbreak?

In the event of a COVID‑19 outbreak, homes must also follow the direction of the local public health unit, including cohorting practices, as outlined in the COVID‑19 Guidance: Long-Term Care Homes, Retirement Homes, and other Congregate Living Settings for Public Health Units (PDF).  Group activities and communal dining should be conducted such that the outbreak unit is cohorted separately from unexposed individuals. Group activities and communal dining for cohorts (exposed separated from unexposed) may resume. Wherever possible, continuing group activities for exposed cohorts is recommended to support resident mental health and well‑being.

What happens when a resident is isolating or fails screening?

Residents in isolation or who fail screening (such as, daily monitoring as per IPAC Standard section 3) are not to join in group organized events, activities, dining 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.

COVID‑19 screening

Per section 9 of the Minister’s Directive, licensees are required to ensure that the COVID‑19 screening requirements as set out in this guidance document are followed.

The purpose of screening is to provide another preventive layer to identify those who may be infectious, to reduce the potential entry and spread of COVID‑19 within long-term care homes.

Types of screening

Active screening means there is some form of attestation or confirmation of screening. This can be achieved through pre-arrival submission of online screening or in person.

Passive screening means that those entering the setting review screening questions themselves, and there is no verification or reporting of screening results.

Screening requirements

Long-term care home licensees must:

  • establish and communicate an operational plan including guidance for staff, students, volunteers, support workers, caregivers and general visitors to self-monitor for symptoms of COVID‑19 (passive screening)
  • provide individuals with information (for example, screening questions) to monitor their health at home for COVID‑19 symptoms and inform them that they are not permitted to enter the home if they are feeling ill or would otherwise fail screening
    • Homes are not required to request verification or an attestation upon entry to the home (nor are homes required to have staff conduct or verify screening at the door).
  • post signage at entrances and throughout the home that lists the signs and symptoms of COVID‑19, for self-monitoring and steps that must be taken if COVID‑19 is suspected or confirmed in any individual

Homes are not to prohibit visitors for palliative end‑of‑life residents. If these individuals fail screening, they must be permitted entry, but homes must ensure that they wear a medical (surgical or procedural) mask and maintain physical distance from other residents and staff.

Staffing

To support long-term care homes that are experiencing staffing challenges, 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, it should work with the public health unit when implementing these measures.

Return-to-work following a COVID‑19 infection

Please refer to the Ministry of Health’s Infectious Disease Protocol Appendix 1: Case Definitions and Disease Specific Information Disease: Diseases caused by a novel coronavirus (PDF), which includes guidance on staff returning to work following infection.

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

Admissions and transfers

Per section 5.1 of the Minister’s Directive, for matters related to admissions and transfers as well as applicable isolation and testing requirements for long-term care homes, homes are to abide by requirements set out in the Ministry of Health COVID‑19 Guidance: Long-Term Care Homes, Retirement Homes, and other Congregate Living Settings for Public Health Units (PDF) (refer to Appendix E: Algorithm for Admissions and Transfers for Long-Term Care Homes and Retirement Homes).

Absences

Per section 6 of the Minister’s Directive, licensees are required to ensure that the resident absence requirements as set out in this guidance document are followed. 

Currently, there are no COVID-specific requirements or restrictions related to absences.

Homes cannot restrict or deny absences for medical, palliative or compassionate reasons at any time. This includes when a resident is in isolation or when a home is in an outbreak.

When a resident who is self-isolating on Additional Precautions is required to leave the home for a medical absence, homes should notify the health care facility so that care can be provided to the resident with the appropriate Additional Precautions in place.

Residents returning from absences

Homes are not required to actively screen, test or isolate residents upon return from an absence unless the resident is symptomatic. Any resident who is symptomatic must be permitted entry but isolated on Additional Precautions and tested for COVID‑19 as per the Infectious Disease Protocol Appendix 1: Case Definitions and Disease Specific Information Disease: Diseases caused by a novel coronavirus (PDF) and the COVID‑19 Guidance: Long-Term Care Homes, Retirement Homes, and other Congregate Living Settings for Public Health Units (PDF). 

Visitors

Per section 7 of the Minister’s Directive, licensees are required to ensure that the visitor requirements as set out in this guidance document are followed.

It is strongly recommended that visitors wear a mask in all resident areas indoors except when with a resident in the resident’s room or when eating and drinking with a resident in communal spaces.

Homes are reminded that residents have a right under the Fixing Long-Term Care Act, 2021, to receive visitors and homes should not develop policies that unreasonably restrict this right. Homes are to set their own visitor policy, in accordance with applicable guidance and laws, including requirements under the Fixing Long-Term Care Act, 2021 and Regulation.

As a reminder, section 267(1) of O. Reg. 246/22 requires licensees to ensure that essential visitors, which includes caregivers, support workers, persons visiting for compassionate reasons, including for end-of-life care, and inspectors, continue to have access to long-term care homes during an outbreak. 

Homes must follow the direction from their local public health unit during an outbreak, which may include advising general visitors to postpone all non-essential visits, per the COVID‑19 Guidance: Long-Term Care Homes, Retirement Homes, and other Congregate Living Settings for Public Health Units (PDF).

COVID‑19 asymptomatic screen testing

Per section 8 of the Minister’s Directive, licensees are required to ensure that the asymptomatic testing requirements as set out in this guidance document are followed.

Currently, there are no asymptomatic screen testing requirements.

While homes still have the option to implement their own asymptomatic screen testing policies, it is not recommended at this time. If homes do implement asymptomatic testing policies, they must not apply to outdoor visitors, those visiting residents who are receiving end-of-life care or to inspectors with a statutory right of entry.

The routine testing of asymptomatic staff, students, volunteers, support workers, caregivers and visitors who have not been exposed to COVID‑19 is different from COVID‑19 testing of individuals who are symptomatic, have had high risk exposure or are in an outbreak setting as directed by the local public health unit. Testing of symptomatic residents will continue, and staff, students, volunteers, general visitors, caregivers and support workers are encouraged to get tested if symptomatic.

Prohibition on reselling or distributing to any other person

Antigen tests that have been provided by the Province of Ontario, either directly or indirectly (for example, through an agency of the government), must only be used for intended purposes and not be resold or distributed to any other person.

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 71 under the Act
  • licensees are to co-operate with the residents’ council, appoint an assistant, and respond to council concerns and recommendations

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 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 resident council meetings; please visit OARC’s Tools webpage to access these important resources.

Case and outbreak management

Per section 4 of the Minister’s Directive, licensees are required to ensure that the requirements for case and outbreak management as set out in this document are followed.

Outbreak definition

For matters related to the definition of an outbreak in long-term care homes, please refer directly to the Ministry of Health COVID‑19 Guidance: Long-Term Care Homes, Retirement Homes, and other Congregate Living Settings 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 an epidemiological link as part of their investigation, which will inform their decision as to whether or not they declare an outbreak.

Case and outbreak management

For COVID‑19 related case and outbreak management, homes are to abide by requirements under the Fixing Long-Term Care Act, 2021 and O. Reg. 246/22, and set out in:

Homes must follow direction from their local public health unit in the event of a suspect or confirmed outbreak. The local public health unit is responsible for managing the outbreak response. Local public health units have the authority and discretion as set out in the Health Protection and Promotion Act to coordinate outbreak investigation, declare an outbreak based on their investigation, and direct outbreak control measures.

For clarity, the local public health unit is responsible for defining the outbreak area (for example, a single affected unit vs. the whole home), directing outbreak testing, and leading all other aspects of outbreak management including isolation of residents and staff, as well as declaring the end of an outbreak.

Homes must follow any guidance provided by the local public health unit with respect to any additional measures that must be implemented to reduce the risk of COVID‑19 transmission in the setting.

Homes must ensure that any health system partners or external agencies that participate in any suspect or confirmed outbreak response inform the local public health unit and the Outbreak Management Team of their involvement. These external agencies must also follow any directions provided by the local public health unit to them pursuant to the Health Protection and Promotion Act.

Reporting outbreaks and cases

COVID‑19 is a designated disease of public health significance (O. Reg. 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 notify the local public health unit of all confirmed and probable resident cases of COVID‑19 as soon as possible, as well as outbreak-related staff and visitor cases, as per the outbreak definition found in the COVID‑19 Guidance: Long-Term Care Homes, Retirement Homes, and other Congregate Living Settings for Public Health Units (PDF).

The local public health unit is responsible for receiving and investigating all (reports of) cases and contacts of COVID‑19 in accordance with the COVID‑19 Guidance: Long-Term Care Homes, Retirement Homes, and other Congregate Living Settings for Public Health Units (PDF) and the Health Protection and Promotion Act.

Homes must follow the critical incident reporting requirements set out in section 115 of O. Reg. 246/22 made under the Act. Homes are required to immediately report any confirmed COVID‑19 outbreak to the Ministry of Long-Term Care using the Critical Incident System (CIS) report during business hours (Monday to Friday, 8:30 a.m. to 4:30 p.m.) or calling the Service Ontario After-Hours line at  1-888-999-6973 outside of business hours or during a statutory holiday and submitting a CIS report the next business day.

Contact information

Questions regarding COVID‑19 related policies and guidance can be emailed to the Ministry of Long-Term Care at MLTCpandemicresponse@ontario.ca.

Resources

General

Vaccination

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 resources related to the use of portable fans, air conditioning units, and portable air cleaners.