Highlight of changes

As of December 30, 2021 the following changes have been made to this document.

  • Entry into the long-term care homes by general visitors has been paused, including outdoor visits. General visitors will continue to be permitted to enter the home to visit residents receiving end-of-life care.
  • Day absences for all residents for social purposes are paused. All essential, medical or compassionate absences will continue to be permitted.
  • Updated testing requirements for residents who go on essential, medical or compassionate day absences.

As of December 31, 2021 (unless otherwise specified) the following changes have been made to this document.

  • Mandatory third (booster) dose for all staff, students, volunteers and caregivers are requirements.
  • Residents of long-term care homes are eligible for a fourth dose of an mRNA vaccine if at least three months have passed since their third dose.
  • The inclusion of a section on staffing that includes updated testing and isolation requirements for staff, students, volunteers and caregivers including updates to test to work.
  • Updates to testing during an outbreak due to longer than expected processing time for PCR tests.

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, 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

Currently, Ontario is experiencing a rising number of covid 19 cases and the proportion of cases that are due to the Omicron variant is rapidly increasing.

Public Health Ontario has noted that the risk of severe disease, reinfection, and breakthrough infection related to Omicron in Ontario is moderate with a high degree of uncertainty. The overall risk assessment may change as new evidence emerges.

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

Homes should review their fall preparedness plans in the context of Omicron and rising covid 19 cases overall.

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 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, effective immediately, residents of long-term care homes will be 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 more 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

The Minister’s Directive: Long-term care home covid 19 immunization policy has been updated. All staff, student placements, volunteers, support workers and visitors are required to be fully vaccinated against covid 19 or have a valid medical contraindication to covid 19 vaccination to gain entry to the home. The following are the requirement for caregivers:

Caregivers

While proof of vaccination will also be required of caregivers, recognizing their essential role, caregivers will be given a transition period as follows:

  • No caregiver can enter a home if they have not provided proof of having received at least a first dose of covid 19 vaccine, and as of February 21, 2022, they must have received all required doses to be able to continue accessing the home.
  • Any caregiver who is designated after December 15, 2021 is required to be fully vaccinated to enter the home.

Caregivers who have not met the vaccination requirements above are only permitted to enter the home if they have shown proof of a valid medical exemption or for visiting a resident receiving end of life care. In these instances, the caregiver or resident will be restricted to only visiting in the residents’ room.

Mandatory third (booster) dose

All staff, students, volunteers, support workers, and caregivers who are eligible (that is, three months after receiving the second dose) will be required to show proof of their third dose to come into or work within the home, unless they have a valid medical exemption. Effective dates are as follows:

  • Staff, students, volunteers, support workers and caregivers who were eligible on or before December 31, 2022 must provide proof of having received a third dose by January 28, 2022. The majority (over 90%) will fall into this category.
  • The remainder of staff, students, volunteers, and support workers will have until March 14, 2022 to show proof of their third dose, recognizing the deadline to be fully vaccinated was December 13, 2021.
  • The remainder of caregivers will have until May 23, 2022 to show proof of their third dose, recognizing caregivers were recently provided until February 21, 2022 to become fully vaccinated if they were not already.

General visitors are currently prohibited and the Ministry will be working with the Office of the Chief Medical Officer of Health to determine ongoing requirements, including for children, prior to the pause concluding.

Caregivers and general visitors will continue to be permitted entry into the home to visit residents receiving end of life care, regardless of vaccination status.

All individuals are highly encouraged to get their third doses as soon as they are eligible (in advance of the mandatory deadlines).

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

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 should 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 PHU, Ministry of Labour, Skills, Training and Development, and MLTC for LTCHs upon request.

General IPAC requirements

As a reminder, licensees are subject to Section 86 of Ontario Regulation 79/10 under 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 Long-Term Care Homes Act, 2007 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 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 homes’ 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
  • 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 Ontario Regulation 79/10 under 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.

Please note that in homes where the personal care service provider is a general visitor and not a staff member the provider will not be able to gain entry to the home at this time.

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:

  • O. Reg. 95/20: Streamlining Requirements for Long-Term Care homes, under the Reopening Ontario (A Flexible Response to covid 19) Act, 2020:
    • Licensees 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.
    • Licensees are not required to ensure minimum number of staffing hours are met, provided all care requirements are met.
  • O. Reg. 79/10: General, under the Long-Term Care Homes Act, 2007, provides homes with operational flexibility during a pandemic:
    • Where homes are not able to meet the requirement for 24-hour RN coverage under Long-Term Care Homes Act, 2007, other regulated health professionals (for example Registered Practical Nurses (RPNs)) may fill the role with appropriate supervision.

Homes should read the applicable regulations for a full understanding of all requirements.

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 Limiting Work to a Single Long-Term Care Order that restricts fully vaccinated staff from only working in one location when a home is in outbreak. In these circumstances if a staff 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.

All staff, student placements, volunteers and caregivers who are covid 19 positive, has covid 19 symptoms or is 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 ten days.

In circumstances of serious staffing shortages homes may have fully vaccinated staff return, prior to the ten days, under the following circumstances:

  • Close contacts: Test-to-work
    • a PCR test should continue to be taken as soon as possible and while awaiting the results, the staff member may return to work after two negative rapid antigen test (RAT) taken 24 hours apart
    • daily RAT
    • negative PCR on day six or negative RAT days six and seven allows for conclusion of testing
    • a positive result on any of the above requires following the positive protocol
  • In critical situations if some staff have tested positive, they may be cleared to return on day seven if
    • negative PCR test on day six or negative RAT days six and seven (both negative to attend work on day seven).

Homes should review the Updated Eligibility for PCR Testing and Case and Contact Management Guidance 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 LTC covid 19 Guidance Document 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, and exposed individuals should have daily negative RAT.
  • 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 the following testing and isolations are required:

  • Enhanced symptom screening for all admissions and transfers, and twice daily symptom screening for 10 days following the admission or transfer.
  • For admissions and transfers from another healthcare facility that is not in outbreak:
    • asymptomatic, fully vaccinated and no known exposure to a case, a polymerase chain reaction (PCR) test prior to admission or on arrival is required and the resident be isolated until a negative test result is received.
  • For all other admissions and transfers
    • PCR test prior to admission or on arrival and at day seven and isolate until negative test result from day seven is confirmed.

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)
  2. compassionate and palliative absences include, but are not limited to, absences for the purposes of visiting a dying loved one
  3. 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
  4. temporary absences include absences involving two or more days and one or more nights for non-medical reasons

Social day and temporary absences

As per Directive #3 (PDF), homes cannot restrict or deny absences for medical and/or palliative or compassionate reasons at any time. This includes when a resident is in isolation or when a home is in an outbreak. In these situations, homes must contact their local public health unit to obtain further direction.

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. In these situations, homes must contact their local public health unit to obtain further direction.

Isolation and testing requirements residents when returning from absences

The following are the testing and isolation requirements for residents who go on day and overnight absences (when not paused). Please note that residents are exempt from these requirements if they are within 14 days from their previous infection.

Day absences:

  • Rapid antigen test for seven continuous days or PCR test on days one and seven.
  • Residents that go on social 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 test on Tuesday; and PCR and rapid antigen test on Friday)

Overnight absences:

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 on return to the home and quarantined. A second negative covid 19 PCR test result collected on day seven is required to discontinue quarantine on additional precautions

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 suspended at this time.

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

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. 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 for support workers set out in the Minister’s Directive: Long-term care home covid 19 immunization policy and this guidance document, as applicable.
  2. 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

  3. Homes must ensure that all visitors have access to the home’s visitor policy.
  4. 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 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 1 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 operations of the home or residents that could not be adequately met if the person does not visit the home.

There are no limits on the 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. 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.
  • A maximum of two caregivers may be designated per resident at a time. (Note: caregivers who were designated prior to December 15, 2021, may continue to be designated as a caregiver even if this means the resident has more than two designated caregivers).
  • 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.
  • All caregivers newly designated 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.

A caregiver should not visit any other resident or home for 14 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

Caregivers – scheduling and 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.

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)

Where a caregiver is not fully vaccinated the visit should be restricted to the resident’s room. In these instances, the caregiver needs to ensure they are physically distancing from other residents or other individuals that are in the same room. This is a time limited provision until February 21, 2022, when all caregivers will be required to be fully vaccinated, unless a valid medical exemption has been provided.

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 younger than 14 years of age must be accompanied by an adult (someone who is 18 years of age or older). 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

  • Up to two caregivers per resident may visit at a time.
  • Caregivers must meet the vaccination requirements outlined in the Vaccination section in order to gain entry to the home
  • When a resident is symptomatic or isolating, only one caregiver may visit at a time.
  • No general visitors are permitted at this time unless visiting a resident receiving end of life care.

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

Resident Councils (RC) play an important role in every long-term care home. As a reminder:

All homes need to ensure that the RC is provided an opportunity to meet. When in-person meetings of the RC are possible, it is expected that the RCs 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 RC 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 RC meetings; please visit OARC's Tools webpage to access these important resources.

Outbreaks

Outbreak definition

a suspect outbreak in a home is defined as

  • one PCR or molecular confirmed covid 19 case in a resident

a confirmed outbreak in a home is defined as:

  • two or more PCR or rapid molecular confirmed covid 19 cases in residents or staff (or other visitors) in a home
  • two or more positive RAT results in residents or staff in a home with an epidemiological link, within a 14-day period, where at least one case could have reasonably acquired their infection in the home. Examples of reasonably having acquired infection in a home include:
    • no obvious source of infection outside of the LTCH or RH setting
    • known exposure in the LTCH or RH setting

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.