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Residents at the peopleCare Oakcrossing long term care home in London, Ont., take part in the weekly Laughter Yoga class on Mar 24, 2022.Fred Lum/the Globe and Mail

The inspection system overseeing Ontario’s long-term care homes collapsed during the first wave of the COVID-19 pandemic, and homes were not held accountable for failing to keep residents safe, says a new report from the province’s Ombudsman.

Ontario Ombudsman Paul Dubé called for a “complete overhaul” of the long-term care inspection system, after his report released Thursday revealed that inspections stopped for at least seven weeks – and in some areas, even longer – and no reports were issued for two months during the first wave of COVID-19 in spring 2020.

“Few knew that this oversight mechanism had fallen apart,” Mr. Dubé said in his report, Lessons for the Long Term.

“Tragically, the Ministry of Long-Term Care was unprepared and unable to ensure the safety of long-term care residents and staff during the pandemic’s first wave.”

In the early days of the pandemic, inspections stopped because staff didn’t have access to personal protective equipment or training in infection prevention and control, with some refusing to enter homes.

Instead, they called into homes to check in on them, and even when on-site inspections resumed, only those who volunteered were sent inside facilities with COVID-19 outbreaks. Homes were also given reduced penalties for non-compliance – such as a written notice, instead of an order – and were allowed months to deal with issues “that were causing serious harm to residents,” Mr. Dubé said.

The report describes stories from families of residents who “tried in vain” to get the ministry to respond to their concerns about the conditions of the homes, with several of the residents dying before anything was done.

In one example, a resident’s son complained three times about the lack of COVID-19 infection control and his mother’s worsening conditions at the home. After she died, an inspection was not performed for six months.

The report said the office heard about many homes in which more than 80 per cent of staff tested positive for the coronavirus, leaving most unable to work. In April, 2020, a staff person at the Orchard Villa home in Pickering, Ont., called the ministry to report that “ … there is no staff to feed and care for residents, and that living conditions are like hell.”

The Ombudsman also pointed to “disturbing cases” where homes were not penalized to the extent that they could have been, despite repeated findings of non-compliance.

“Even when the inspections resumed, and violations of the law were found, the inspections branch often took the least severe enforcement action available, even in serious situations. Homes were given many months to fix significant issues that posed a serious risk of harm to residents, and the action taken was often documented in confusing or poorly written reports,” Mr. Dubé told reporters at Queen’s Park.

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

Legislation in place since 2017 would have allowed the government to fine homes up to $100,000 in response to findings of non-compliance, but it was only proclaimed into law in 2021 under the Fixing Long-Term Care Act.

Newly-named Long-Term Care Minister Stan Cho said the government has spent $72.3-million to double the number of inspection staff, and has launched a new investigations regime to address complaints and critical incidents.

“COVID-19 was an unprecedented global event with devastating impacts on long-term care homes around the world. The lessons learned from this have ensured we take action by creating a new investigations unit that can refer charges when necessary and introducing new monetary penalties for bad actors,” Mr. Cho said in a statement.

Shortly after the Progressive Conservatives entered office in 2018, the ministry all but eliminated wide-ranging inspections, focusing instead on responding to critical incidents and complaints.

Prior to then, the ministry conducted comprehensive inspections of most homes in 2015, 2016 and 2017. In 2019, just nine of the province’s 627 nursing homes received such inspections.

Opposition MPPs said the Ford government’s changes to the inspection regime contributed to the problems portrayed in Mr. Dube’s report.

“It was a wrong approach to reduce comprehensive inspections, essentially almost eliminate them,” said interim Liberal Leader John Fraser.

New Democrat Wayne Gates, the party’s long-term care critic, accused the government of failing seniors during the pandemic. “Under this government’s watch, inspectors did little or nothing to hold these homes accountable,” he said.

The Ombudsman found that the ministry of long-term care’s lack of planning and unpreparedness was “unreasonable, unjust and wrong,” and made 76 recommendations to the ministry and government. The recommendations include regular training for inspectors, adequate stockpiles of personal protective equipment, and establishing clear rules on when on-site inspections are required.

The government accepted all of the recommendations, and the ministry agreed to report back to the Ombudsman every six months on progress, the report said.

Between the start of the pandemic and April, 2022, 4,335 long-term care residents and 13 staff members died from COVID-19, and more than 41,000 were infected. Close to 2,000 COVID-related deaths in long-term care occurred during the first wave of the pandemic, from Jan. 15, 2020, until Aug. 2 of that year, the report said.

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