Accreditation Report. Quality Improvement Plan & Benchmarking Data. Prepared for Schlegel Villages

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2 Report Quality Improvement Plan & Benchmarking Data Prepared for

3 Decision Three-Year Expiration: November 2014 Organization 325 Max Becker Drive, Suite 201 Kitchener, ON N2E 4H5 Canada Organizational Leadership Bob Kallonen, Chief Operating Officer James Schlegel, President/CEO Survey Dates November 7-9, 2011 Survey Team Avanthi Goddard, B.B.A. Hon., Dip. Adult Ed., Administrative Surveyor Brent Selman, Program Surveyor Alexander M. Candalla, Program Surveyor Patsy H. Long, B.S., ADM, RN, Program Surveyor Programs/Services Surveyed Person-Centred Long-Term Care Community 1 Report

4 Programs/Services by Location 325 Max Becker Drive, Suite 201 Kitchener, ON N2E 4H5 Canada Administrative Location Only The Village of Erin Meadows 2930 Erin Centre Boulevard Mississauga, ON L5M 7M4 Canada Person-Centred Long-Term Care Community The Village of Riverside Glen 60 Woodlawn Road East Guelph, ON N1H 8M8 Canada Person-Centred Long-Term Care Community The Village of Wentworth Heights 1620 Upper Wentworth Street Hamilton, ON L9B 2W3 Canada Person-Centred Long-Term Care Community The Village of Tansley Woods 4100 Upper Middle Road Burlington, ON L7M 4W8 Canada Person-Centred Long-Term Care Community Report 2

5 The Village of Sandalwood Park 425 Great Lakes Drive Brampton, ON L6R 2W8 Canada Person-Centred Long-Term Care Community The Village of Taunton Mills 3800 Brock Street North Whitby, ON L1R 3A5 Canada Person-Centred Long-Term Care Community The Village of Humber Heights 2245 Lawrence Avenue West Etobicoke, ON M9P 3W3 Canada Person-Centred Long-Term Care Community The Village of Winston Park 695 Block Line Road Kitchener, ON N2E 3K1 Canada Person-Centred Long-Term Care Community The Village of Glendale Crossing 3030 Singleton Avenue London, ON N6L 0B6 Canada Person-Centred Long-Term Care Community The Village of Aspen Lake 9855 McHugh Street Windsor, ON N8P 0A6 Canada Person-Centred Long-Term Care Community 3 Report

6 Survey Summary Areas of Strength has strengths in many areas. A unique leadership style is driven by the family values of the owners and is the basis for the criteria used in hiring at all levels of the organization. A strong team approach to resident care includes input from residents and family members as the approach to the Appreciative Inquiry system is developed. The organization is supported by its vision and resident-focused philosophy of care by the University of Waterloo Research Institute for Aging, which is a unique partnership in the province and has been recognized by its peers. A unique hiring process that includes a group approach to hiring focuses on behaviours and attitudes. A physical environment is supported by research that guides the implementation of the village concept at all sites. A unique research relationship exists with the University of Waterloo in developing a long-term care centre to support research in the aging process. A philosophy of aging, not of long-term care, encourages innovative approaches to improved physical health and supports the dignity of residents as they progress through their aging years. The implementation of a measuring tool to assess the journey from institutional care to the social model is noted and encouraged. The organization is commended on its leadership of introducing a practical research focus to ensure that residents benefit from good practices to support the social model as soon as benefits are realized. The careful approach to improvement is noted as the organization embraces change and implements a pilot type of improvement process to ensure that the implementation of the solution is having the expected outcome that it was designed to have. This is evident in the approach to centralization of the financial management system, the approach to the use of technology, and the approach to create a culture change. Staff members are proud to be working in an organization that is truly resident focused and feel empowered to make changes that benefit the quality of life of residents. The medical director, along with the Research Institute for Aging, has recently introduced a model of accountability for the medical staff. The focus on an inter-professional team care approach is being led by the medical director; the Research Institute for Aging continues to focus its work on pain management and falls. Compassion and integrity are clearly evident throughout the villages. Personnel at all levels of the villages consistently employ the philosophy of resident-centred care. A comfortable, inviting neighbourhood atmosphere is evident in each of the villages. The villages offer a diverse recreational therapy program that includes the services of physical therapy and kinesiology. Report 4

7 An excellent and well-deserved reputation for the provision of quality and compassionate care is enjoyed by the villages. This is reflected in the many tributes paid by residents, family members, and the community. The villages benefit from strong partnerships with schools, colleges, and universities in the greater Toronto area. The following are strengths identified at the program sites. One of Taunton Mills greatest assets is its team members, who are compassionate, have a passion for those they serve, and create a positive environment for services and programs to occur. Although some members of the management team at Taunton Mills are relatively new in their positions, they are a passionate and committed leadership team. The team demonstrates its management philosophy of resident-centred care through its various practices of being accessible, supportive, and committed to the care team as well as those persons served. Taunton Mills has recently celebrated one year with no time lost because of team member injury. Taunton Mills currently has a wait list of over 700. This is testimony to the excellent reputation it has established in the community. Team members are proud to discuss the Sip and Go program, which monitors the residents fluid intake, thereby decreasing the incidents of dehydration. One of Sandalwood Park s greatest assets is its team members who are compassionate, have a passion for those they serve, and create a positive environment for services and programs to occur. Eighty-eight percent of the personal support workers (PSWs) at Sandalwood Park have been trained in the resident-centred care process. The Sandalwood Park team offers a dynamic recreational therapy program that meets the needs and interests of a culturally diverse population. Team members embrace the resident-centred care approach in recreational activities that promote freedom for each resident to choose his or her desired activities. The chaplain at Sandalwood Park has compiled a Spiritual Rites reference guide. With such a culturally diverse population, this reference guide enables the Sandalwood Park team members to provide end-of-life care that is culturally acceptable. One of Humber Heights greatest assets is its team members who are compassionate, have a passion for those they serve, and create a positive environment for services and programs to occur. Over 100 of the Humber Heights team members have been part of the Humber Heights family for over five years. The Humber Heights team members have raised over $10,000 for the Alzheimer s Association. The team is proud to talk about its recent accomplishments. It has seen a decrease in team member turnover, the use of restraints, and injuries due to falls. Team members communicate regularly to ensure that the residents preferences, choices, and personal goals are met. This resident-centred care approach maximizes the effectiveness of the various programs and services offered, including inter-generational activities. 5 Report

8 The Humber Heights team members have developed a very meaningful way to honor those residents who have passed away. While being removed from the village, the deceased resident is covered with a quilt. An honor guard composed of team members, residents, and family members lines the corridors to show respect as the deceased is accompanied through the front door. The recreational therapy team, including rehabilitation kinesiology and physiology, includes excellent programming and passionate staff. Employee turnover is low. Nearly one-third of the employee pool has been in the Erin Meadows community for longer than eight years; more than half has been employed for at least five years. This provides consistency and stability for the community but, most importantly, provides comfort and familiarity for residents served. There is an open-door policy for communicating with the leadership. All employees and residents interviewed in focus groups agreed that all concerns, if any, can be readily addressed to their satisfaction. The WHAM meetings give opportunities for employees and the leadership team to communicate and address day-to-day issues affecting all stakeholders. The street landscape design of the hallways at Erin Meadows takes away the institutional feel within the building. It is unique and cleverly named. The performance improvement process involves a routine medication compression review that is participated in by the multi-disciplinary team. The presence of inter-generational programs by partnering with organizations for first-time parents enriches residents and staff members lives. The organization s new employee orientation model, including the mentorship program, provides all new team members with an immediate sense of belonging on top of getting a good picture of the organization s culture. The organization is committed to staff members career development. The staff members are experienced and have a certain zest in their work. It is apparent that the employees are dedicated to the organization and the persons served. The campuses are in beautiful locations and are tastefully decorated. The laundry services receive rave reviews from residents. Areas for Improvement should seek improvement in the following areas. The organization should develop written procedures to guide personnel in responding to subpoenas, search warrants, and investigations. Evacuation routes should be clearly defined. An accessibility status report should be prepared annually. Care plan documentation should include resident-centred goals. At this time, the stated goals are very clinical in nature. Report 6

9 Decision has earned a Three-Year. On balance, the organization has a few areas for improvement, but also demonstrates many strengths and areas of exemplary practice. The organization is encouraged to continue to produce evidence of positive outcomes for the residents and their quality of life. 7 Report

10 Exemplary Conformance Section 1. ASPIRE to Excellence A. Leadership The philosophy for a person-centred approach is being supported by the Appreciative Inquiry program, which is a culture change movement that examines policies, practices, and behaviours through the administration of focus groups of families, residents, and staff. The policies, practices, and behaviours will transition the organization from an institutional model to a social model of service delivery. This is evident at all sites through examples provided by staff, families, and residents, where all stakeholders feel they are a part of the care team and care process. The resident is the team leader of his or her life. In addition, the excellence in person-centred philosophy is supported by the University of Waterloo Research Institute for Aging, which focuses on practice-relevant research that drives quality and innovation in long-term care and retirement communities. It is the first partnership with a university, a college, and long-term care and retirement communities of Schlegel Villages that have a view of translating practical research into training to create a social environment in the aging process that is similar at all stages of life. Section 2. Care Process for the Persons Served A. Program/Service Structure The innovative program for active living is unique in that the discipline of kinesiology works together with the physiotherapists to produce effective results for residents to enhance functional ability and improves activities of daily living and self-dignity. Consultation Section 1. ASPIRE to Excellence H. Health and Safety It is suggested that the organization streamline/revisit the coding verbiage. Many staff members were unable to quickly determine what each colour represented in the event of an emergency. Some sites also have different colours for each emergency situation. The organization is encouraged to ensure that up-to-date material safety data sheets (MSDS) are available electronically at all sites. Documentation on self-inspections is not being consistently implemented in a comprehensive manner; i.e., completing the forms fully. It is suggested that documentation on the inspections be done as per the organization s requirements and be consistently implemented. Report 8

11 Staff members indicated that, in an evacuation, they will tell residents to stay in their rooms. However, most residents are not in the rooms all of the time as per the philosophy of care. Clarification could be given on where the evacuation routes are. I. Human Resources Adding a suggestion box in staffing areas could be a good way to offer employees an opportunity to voice concerns or offer compliments. It could be helpful if the sign-in procedures for visitors and pets were more visible. L. Accessibility Any posting on the board for residents to access is not always readable print; e.g., residents rights and menus. It is suggested that the posted materials be visible for residents with visual impairments. Barriers are identified at in a decentralized process. It is suggested that these reports be coordinated and linked to a strategic barrier report that also links to a barrier report that may be developed by the board/leadership team to identify barriers to the unique vision of the organization. Section 2. Care Process for the Persons Served A. Program/Service Structure The philosophy of care is written and communicated in various places and formats (such as DVDs), in practice and verbally. In keeping with the future direction of the organization, where growth is a strategy, it is suggested that the health and wellness philosophy that the organization has developed and is starting to be implemented across be communicated in a coordinated manner through a written format. It is suggested that the residents be given more time to preview the menu to be able to provide input into the choices given should the resident prefer something else. At this time, the residents see the choices on the day it is delivered, and this does not allow staff to respond to preferences in a timely manner. The policy is unclear as to whether residents are allowed to bring in pets. It is suggested that the policy be clarified and aligned to the person-centred philosophy of care. The organization is encouraged to ensure that regulatory and legislative changes are implemented in a way in which the choices and daily routines of the persons served can continue to be decided on by them. This could allow the person-centred philosophy to be embraced by staff and persons served. Consultation does not indicate non-conformance to standards, but is offered as a suggestion for further quality improvement. 9 Report

12 Standards Conformance This section of the Report displays the specific reasons for any partial or non-conformance to standards identified as a result of the survey. The standards listed in this section are addressed in the organization s Quality Improvement Plan, which can be accessed at customerconnect.carf.org. Below are the possible reasons for partial or non-conformance to standards, along with an explanation of why each reason is cited. To receive the information contained in this section in an alternate format, please contact editing@carf.org. Reason for partial or non-conformance All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate Effort not comprehensive Financial ratio calculation below the median Forms inadequate Frequency inadequate Information not communicated understandably Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented Training inadequate Evidence of conformance inadequate Is cited: When a standard element requires more than one item, at least one item (but not all) is not in full conformance. When a standard element requires that an individual possess a specific credential or level of credential, the specific credential is not possessed, or the credential possessed is below the specified level. When the issue addressed by the standard element has not been considered and, consequently, the information necessary to address conformance has not been collected and/or evaluated in connection with the issue addressed. When a standard element requires documentation or that documentation contain specific information, the documentation either does not exist or does not contain the specific information. When a standard element requires an activity to occur, the performance of the activity is insufficient to address the full scope of the activity. When the standard element rating is based on the calculation of a specific financial ratio, such ratio is below the 50 th percentile. When a standard element requires use of a specific form or that the form contain specific information, the form is not used or does not contain the specific information. When a standard element requires that an activity occur with a specific frequency or some unspecified regularity, the performance of the activity does not occur, occurs less frequently than required, or occurs less frequently than appropriate if regularity unspecified. When a standard element requires that information be shared with certain persons, the information is either not shared or not shared in a manner that allows for comprehension by the recipient. When a standard element requires the involvement of certain persons, those persons are either not involved or not involved in a sufficient manner. When a standard element requires compliance with a legal requirement or a process for achieving legal compliance, sufficient evidence of compliance or the compliance process is not demonstrated. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance does not occur with sufficient regularity to be deemed standard operating procedure. When a standard element requires a policy/plan/procedure/practice, it is not in existence. When a standard element requires a policy/plan/procedure/practice, it exists but there is no actual performance. When a standard element requires a policy/plan/procedure/practice, it exists but the actual performance has not been in place for sufficient time to establish a track record. When a standard element requires that certain training occur, it either does not occur or does not occur with sufficient regularity to be deemed standard operating procedure. When the requirement of a standard element is not satisfied, or is inconsistently satisfied and no other reasons apply. Report 10

13 Standard Number Standard Text Reasons for Partial or Non-conformance 1.E.2.a. 1.E.2.b. 1.E.2.c. 1.H.15.b.(2) 1.H.15.b.(3) 1.L.3.a. 2.A.14.b.(6) The organization implements written procedures to guide personnel in responding to: Subpoenas. The organization implements written procedures to guide personnel in responding to: Search warrants. The organization implements written procedures to guide personnel in responding to: Investigations. Evacuation routes are: Understandable for: Persons served. Evacuation routes are: Understandable for: Visitors. An accessibility status report: Is prepared annually. Based on scope and identified needs, personcentered plans are implemented for the persons served: That address: The goals of the person served. All components not addressed Credentials inadequate Data or information necessary to address conformance not collected and/or evaluated Documentation inadequate X Effort not comprehensive Financial ratio calculation below median Forms inadequate Frequency inadequate Information not communicated understandably X X Involvement by appropriate person(s) inadequate Non-compliance with law, regulation, or other rule Policy/plan/procedure/practice not consistently implemented Policy/plan/procedure/practice not developed X X X Policy/plan/procedure/practice not implemented Policy/plan/procedure/practice recently implemented X Training inadequate Evidence of conformance inadequate 11 Report

14 Benchmarking This section of the Report benchmarks your organization s conformance to standards. By comparing strengths and areas for improvement with various comparator groups, benchmarking encourages your organization to improve effectiveness, efficiency, satisfaction, and access. This information should also stimulate discussions among stakeholders focused on better meeting the needs and preferences of the persons served. In addition, benchmarking: Encourages a culture of continuous evaluation and improvement. Accelerates understanding of and agreement on areas for improvement. Helps prioritize improvement opportunities. Shifts internal thinking towards a focus on outcomes. Provides a reference to increase performance expectations. Motivates your team to work collaboratively to surpass benchmarks. This report provides benchmarks (mean % of conformance) for each section of the ASPIRE to Excellence quality framework. * When available, benchmark comparison groups include: All surveyed organizations. All surveyed organizations in the same primary CARF customer service unit. Surveyed organizations with the same ownership type. Surveyed organizations in the same geographic region. Surveyed organizations with similar number of persons served annually. Surveyed organizations with similar staff size. In addition, standards conformance for each organization undergoing resurvey is benchmarked against its previous survey in all standards areas. Benchmark Comparison Groups Primary area of accreditation: Aging Services (AS) Ownership type: Private, For Profit Geographic region: Canada - ON Staff size (FTEs): 500+ Persons served annually: 1,000 4,999 To receive the information contained in this section in an alternate format, please contact editing@carf.org. * Excluding Governance and Strategic Integrated Planning. Report 12

15 All surveyed organizations A: Assess the Environment Leadership CARF Three-Year CARF One-Year 90.6% 98.6% Nonaccreditation 75.7% P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders CARF Three-Year CARF One-Year Nonaccreditation 50.2% 83.6% 99.6% 13 Report

16 All surveyed organizations continued Legal Requirements CARF Three-Year CARF One-Year Nonaccreditation 81.3% 99.3% 92.3% 83.6% Financial Planning and Management CARF Three-Year CARF One-Year Nonaccreditation 72.3% 91.0% 99.1% Report 14

17 All surveyed organizations continued Risk Management CARF Three-Year CARF One-Year 79.5% 97.1% Nonaccreditation 59.4% Health and Safety CARF Three-Year CARF One-Year 85.0% 98.4% 96.5% Nonaccreditation 70.0% 15 Report

18 All surveyed organizations continued Human Resources CARF Three-Year CARF One-Year Nonaccreditation 97.4% 90.0% 78.9% Technology CARF Three-Year CARF One-Year 78.3% 98.4% Nonaccreditation 53.1% Report 16

19 All surveyed organizations continued Rights of Persons Served CARF Three-Year CARF One-Year Nonaccreditation 98.2% 93.0% 86.6% 95.8% Accessibility CARF Three-Year CARF One-Year 68.2% 95.3% Nonaccreditation 46.0% 17 Report

20 All surveyed organizations continued R: Review Results Information Management and Measurement CARF Three-Year CARF One-Year Nonaccreditation 35.5% 62.7% 96.9% E: Effect Change Performance Improvement CARF Three-Year CARF One-Year Nonaccreditation 18.0% 44.9% 94.2% Report 18

21 Other benchmarks A: Assess the Environment Leadership Aging Services Private, For Profit Ontario 500+ FTEs 97.7% 97.4% 98.1% 98.8% 1,000 to 4,999 Persons Served 98.8% P: Persons Served and Other Stakeholders - Obtain Input Input from Stakeholders Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 99.0% 96.8% 97.9% 99.6% 19 Report

22 Other benchmarks continued Legal Requirements Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 81.3% 97.7% 98.4% 98.6% 99.7% 99.6% Financial Planning and Management Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 98.1% 97.3% 97.9% 99.7% 99.6% Report 20

23 Other benchmarks continued Risk Management Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 95.7% 94.4% 96.2% 98.2% 97.3% Health and Safety Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 98.4% 97.0% 94.5% 90.1% 97.5% 96.2% 21 Report

24 Other benchmarks continued Human Resources Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 95.6% 96.1% 95.0% 98.5% 97.6% Technology Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 94.2% 96.2% 94.8% 99.8% 99.4% Report 22

25 Other benchmarks continued Rights of Persons Served Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 97.4% 97.6% 96.5% 98.0% 98.1% 95.8% Accessibility Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 91.6% 91.7% 91.2% 96.2% 94.3% 23 Report

26 Other benchmarks continued R: Review Results Information Measurement and Management Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 97.2% 90.8% 96.5% 98.4% 97.4% E: Effect Change Performance Improvement Aging Services Private, For Profit Ontario 500+ FTEs 1,000 to 4,999 Persons Served 83.2% 96.1% 94.0% 97.9% 95.3% Report 24

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