31 Hamilton facilities didn't have a detailed outbreak plan weeks into pandemic

Roughly one month after Ontario declared a state of emergency in response to the COVID-19 pandemic, 31 retirement homes and residential care facilities in Hamilton still did not have adequate plans for how to respond to an outbreak of the virus.

In the weeks that followed, some of those homes, including the Roslynn Retirement Residence where 85 people tested positive and six residents have died, have seen both staff and residents test positive and outbreaks be declared.

Public health ordered a total of 43 facilities, in mid-April, to improve infection controls or face consequences. 

A CBC analysis of each of the orders reveals 31 facilities (72 per cent of the total number of homes that were written up) were cited for the following issues:

• Lack of an adequate supply of personal protective equipment, or training on use of personal protective equipment (PPE), which would prevent staff from safely providing appropriate care to ill residents.
• Lack of a sufficiently detailed outbreak response plan.
• Lack of a written policy and processes for in-home isolation of ill residents and/or physical distancing.

Five homes were cited for a not actively screening residents, staff or visitors, 11 for lacking of supplies or capacity for appropriate environmental cleaning and disinfection and 24 for not having a staffing contingency plan to permit the facility to operate safely in the event of staff absences.

The orders were issued to a mix of retirement homes and residential care facilities following a round of inspections of congregate living areas in the city.

By that time the province had been under a state of emergency for weeks. It was first declared on March 17, prohibiting organized public events of more than 50 people and closing bars, restaurants and libraries, then extended another two weeks, this time adding warnings for anyone over the age of 70, or with an underlying health condition, to stay home and self isolate.

A city media release dated April 15 announced the first 31 orders, describing them as a "proactive action" to reduce the spread in congregate living settings.

Residential care facilities — sometimes referred to lodging homes — feature shared dining and common areas and on-site support for residents, including those with cognitive or mental health struggles.

Retirement homes, on the other hand, are generally privately-owned residences where seniors can rent a room and live with some services and support, often with more flexibility and without 24-hour care and supervision found in long-term care homes.

The push to bring the facilities up to standard continues, with a new round of inspections last week that focused on a number of homes owned by the same ownership group that owns  the Rosslyn and new orders issued to several of them.

Retirement homes must have infection plan

No long-term care homes in the city received orders, but Dr. Ninh Tran, associate medical officer of health for the city, said that didn't come as a shock.

"There is a difference in term of past experience, past practice, past expectations of long-term care homes versus retirement homes," he explained in a recent interview.

"We knew that they probably had less experience with this. So we weren't surprised that significantly more issues came out in retirement homes."

He added that when the state of emergency was first declared most of the provincial messaging and guidelines were aimed at long-term care homes.

"It was more of a strong ... recommendation that retirement homes start looking into doing the same type of things."

However, a spokesperson for the Retirement Homes Regulatory Authority (RHRA), which oversees homes in Ontario, said that in order to be licensed a retirement home must have an infection prevention and control program in place.

The RHRA began reminding operators of their obligations around infection and emergency plans back in January, as well as the need to report any staff or residents with symptoms of COVID-19 to public health, wrote Farrah Bourre in an email to CBC.

In March 2020, long before the inspections of facilities in Hamilton began, the province also amended the Retirement Homes Act to require home owners to "follow any recommendations by the Chief Medical Officer directed at long-term care homes as they relate to COVID-19," she added.

Orders came after education failed

Public health regulates residential care facilities and started by inspecting, quickly realized they should do the same for retirement and long-term care homes too, Dr. Elizabeth Richardson, Hamilton's medical officer of health, previously told CBC.

The aim was "supporting them around making sure they're taking all the actions that need to be taken around infection control knowing they house some of our most-vulnerable people," she said at the time.

The orders were issued under the Health Promotion and Protection Act (HPPA), which empowers a medical officer of health to take further steps to ensure compliance if education alone isn't working.

They were only written out after the health unit had carried inspections and made an effort to encourage and educate the facilities to make changes. Some homes didn't seem to get the message.

"We said at that point: 'We've tested, we've assessed, we've educated, we've looked for ways to help you, but at this point you have to get on with it or you'll be ordered' and that's the stage we're at," Richardson explained on April 15.

Richardson has since said each of the facilities has made changes brining them into compliance.

However the Rosslyn, which has been emptied of residents and is currently the site of the most severe outbreak in the city, was issued a second order.

On Friday Paul Johnson, director of Hamilton's emergency operations centre, said the home did not have a "true understanding" of infection control and that it provided officials with "conflicting information" about access to PPE, noting even when protective equipment was provided those working in the home were not using it in the "most appropriate way."

The Rosslyn has not responded to repeated calls and emails requesting comment on the outbreak and situation that led to it.

Johnson, who previously said congregate settings in the city are doing "amazing work" by and large stated, during an update on May 19 that the evacuation of the Rosslyn raised concerns for him.

"It really highlights for me … the re-look we need to have in congregate settings," he explained. "Some of it's design work, some of it is training and education, some of it is the funding that's required in these organizations, but many are struggling under the weight of this pandemic."

The original order at the home pointed to a lack of a sufficiently detailed outbreak response plan and a lack of a written process for in-home isolation of ill residents and/or physical distancing, warning the home was "inadequately prepared to respond to a case or outbreak of COVID-19."

It also called for the home to take eight actions including making sure staff were trained on how to use personal protective equipment, developing a plan to isolate ill residents and creating a contingency plan in case of staff shortages.

After the outbreak was declared at the Rosslyn, health officials carried out a second inspection on May 14 and wrote a new order that pointed to several issues home was supposed to have addressed under the first one.

Tranh explained this by saying the initial order was meant to be pro-active and identify potential problems, adding the expectations for home in an active outbreak are different.

More orders issued to homes

When asked about the fact some of the issues identified in the second order mirror actions the home was directed to take after the original order, he conceded the question was "fair."

"I think that's something we have to look at ... in terms of how does a home temporarily or at one point get into compliance and then not get into compliance and what changed," the doctor explained. "I don't have a specific answer to that, but I think that's a point well-noted."

Public health spent last week urgently inspecting seven other homes associated with the owners of the Rosslyn following the outbreak and evacuation.

On Friday Richardson revealed new orders had been issued to four of them, again citing basic areas of concern including infection protocols, along with screening of visitors despite being months into the pandemic.