Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...

Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
Ministry of Long-Term Care

Long-Term Care Home Licensing
Capital Planning Branch
Foundational Briefing
September 2020
Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
Highlights of the Licensing Program
The foundation of the Licensing Framework is a legislated risk based assessment that
underlays any licence or approval issued by the Ministry.
•   The Long-Term Care Homes Act, 2007 (LTCHA) and Ontario Regulation 79/10 requires that
    all long-term care (LTC) beds be licensed or approved by the Ministry and also establishes
    the framework for this process.
•   As of May 2020, there are 627 long-term care (LTC) homes in Ontario with approximately
    78,890 beds.
•   The Licensing Program is currently focused on:
          • Licensing activity relating to 210 LTC homes of which:
               • 60% is attributed to creating new licensed capacity through re/development
               • 40% relates to licence transfers, changes in controlling interest, temporary
                  licences and licence amendments, management contracts, beds in abeyance,
                  and specialized units
          • Identifying measures that would reduce processing times to further support the
             Premier’s commitment to end hallway medicine and expand LTC by 15,000 in the
             next five years.
          • Transformation of the licensing program to improve stakeholder confidence, align
             with Ontario’s Digitization Strategy and burden reduction efforts;
          • Strategizing approaches to sustain bed capacity as the expiration of over 26,000
             beds approaches in 2025.

Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
LTC Licences and Approvals
The Ministry is able to address immediate and longer-term capacity needs through
distinct licensing approaches.

              Approval                           Licence
              - Issued by the Minister           - Issued by the Director
              -Authorizes premises to be used    - Applies to for-profit and
              for a Municipal or First Nations   non-profit homes
              Homes only for a specified # of    - Transferrable (subject to
              beds                                    Ministry approval)
              -No fixed term                     - Term of up to 30 years
              -Cannot be transferred

                   Temporary Licence             Temporary Emergency
              -Issued by the Director to a LTC   Licence
              home or stand alone home           -Issued by the Director to
              -Used to authorize:                any LTC home or stand alone
              1. Premises to be used as a        - Used to authorize:
                   LTC home on a temporary       1. Premises to be used as
                   basis                              a LTC home on a
              2. Temporary additional beds            temporary basis
                   at a LTC home                 2. Temporary additional
              - Term of up to 5 years and             beds at a LTC home
3             cannot be transferred.             - Term of up to 1 year
Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
Principles of the LTC Licensing Framework
The LTCHA, Regulation and related policies provide for a robust LTC licensing
•   A LTC Home Licence provides the Licensee with:
      1.   The rights to operate the home; and,
      2.   A committed funding stream (under current Ministry funding policies); and,
      3.   The ability to monetize the licence by (transferring/selling the licence, subject to Ministry

      all for up to 30 years (in accordance with the LTCHA and Regulation 79/10 and subject to Ministry
      approval where required.)

•   The licensing framework enables a due diligence process to determine the competency of the Licensee
    to operate a LTC home without compromising the delivery of care and services to residents.
•   At the core of the licensing framework are three key decision variables:
      1.   An assessment of the competency of the Applicant/Licensee
      2.   Public interest tests
      3.   A decision by the Director to issue a licence
•   These elements also ensure that the safety and security of residents, remains critical when deciding on
    the issuance of a licence.

Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
Licensing Framework – At A Glance
With the exception of temporary emergency licences, the LTCHA stipulates the same
approval requirements regardless of the scale or magnitude of activity.

                                                    The Minister agrees that there is a need for beds in the
    A licence or approval
    can only be issued by
    the Ministry once these
    requirements are met.                           The Minister establishes that the impacts of
                                                    concentration of ownership and sector balance are in
                                                    the public interest.

    Changes to the
                                                    The Director reviews the past conduct, operational and
    ownership or                                    financial competency of the proposed licensee, including
    controlling interest of a                       any individual with controlling interest in the licensee.
    licence, location of
    beds, or management
    of a home, will trigger
    a licence review.                               The Director has considered any feedback from a public
                                                    consultation relating to the licensing proposal.

5        *See Appendix D for further information.
Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
Licence Review Process
Licence activity and requirements of the LTCHA vary by the type of LTC home provider:
some or all of the activities below will be included in the ministry’s licence review

                Public Consultation
                s.106                                                             For non-municipal
                (if required)                                                      homes, Director
                                                                               Decision on Issuance of
                                                                               a Licence/ Undertaking
    Minister’s Determination
    s.96 and s.97                        Review                Decision
    - On the need for beds,              process               process
    sector balance and
    concentration of ownership

                                                                          For municipal homes, the
                     Director’s Determination s.98                         Minister’s decision on
                     - Licensee Attestations                                 undertaking or any
                     -Financial Review                                      municipal approvals.
                     -Review from: Legal Services Branch, LTC
                     Inspections Branch, Financial Management Branch,
                     Ontario Health Oversight Branch

Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
Applying the Licensing Principles during Pandemic
The Ministry is able to leverage provisions relating to temporary emergency licences
and management contracts to support LTC Homes during the pandemic.
•   Temporary emergency licences enable the Director to respond to needs for immediate LTC bed
    capacity for up to one year.
        •   As hospitals were preparing for an influx of COVID-19 related intakes, temporary
            emergency licences quickly enabled the creation of additional bed capacity and the
            subsequent transfer of ALC patients from hospitals to LTC homes.
        •   A total of 97 spaces were created in 69 LTC homes.
        •   LTC homes identified unlicensed rooms or family rooms/palliative care rooms that could
            be repurposed for resident accommodation.

•   Management contracts
       •  To date, 10 LTC homes engaged with hospitals for management of the home while in a
          COVID related outbreak and for infection control support.
       •  This represented the first time for hospitals to provide management services to LTC
       •  Provisions in the emergency order enabled the Director to approve the management
          agreement within days of Homes/Hospitals identifying a proposed management

Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
LTC Licensing – Chronology of Pandemic Response
Working with LTC homes, LHINs and hospitals to enable capacity and professional expertise to LTC
 homes facing extreme Covid-19 challenges.
                    Mar 16, 2020
               Commence outreach to                   Mar 22, 2020 - Apr 23, 2020
                  LHINs to identify                 97 temporary emergency licences
              unused LTC bed capacity                    issued to 69 LTC homes                                                            May 29, 2020 - Jun 17, 2020
                   in LTC homes                                                                                                  Execution of agreements to approve management
                                                                                                                                           of 10 LTC homes by hospitals

          Mar 1, 2020
                                                       Apr 2, 2020
                                                                                                                                                                                 Jun 30, 2020
                                             LTC Capacity Form released to
                                                 sector (alongside Memo
                                                 from Minister Fullerton)
                                            for homes to pro-actively identify
              Mar 22, 2020                   any unused capacity available
Commence outreach to LTC Licensees
directly on potential additional capacity
          identified by LHINs –                                                                                                                                      Jun 15, 2020
     Commence issuing temporary                                                                                                                                     Hawthorne and
          emergency licences.                                                                                                                                 North York General Hospital

                                                                 Jun 1, 2020                                                                           Jun 13, 2020
                                                                                       Jun 4, 2020                                                                                Jun 17, 2020
                                                               Downsview and                                                                         Orchard Villa and
                                                                                    Camilla Care and                                                                         Woodbridge Vista Care and
                                                             Humber River Hospital                                                                   Lakeridge Health
                                                                                Trillium Health Partners May 29, 2020 - Jun 17, 2020                                              William Osler
                                                                                                Execution of agreements to approve management
                                                                                                          of 10 LTC homes by hospitals

                                                                                               Jun 5, 2020                                     Jun 12, 2020
                                                                                           Forest Heights and                           Extendicare Guildwood and
                                                                                                                                                                            Jun 16, 2020
                                         May 29, 2020                                      St. Mary's Hospital                          Scarborough Health Network
                                                                                                                                                                           Eatonville and
                                     River Glen Haven and                                                                                                                Unity Health Centre
                                Southlake Regional Health Centre
                                                                                                                    Jun 8, 2020
8                                                                                                                  Altamont and
                                                                                                            Scarborough Health Network
Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
LTC Home Temporary Emergency Capacity Form

Long-Term Care Home Licensing Framework - Capital Planning Branch Foundational Briefing September 2020 - Ontario's Long-Term Care COVID-19 ...
LTC Licensing

Context for Transformation
The current LTC sector landscape presents opportunities for the Ministry to move
forward with changing how licensing reviews are conducted.

•    Since 2010, Licensing, Policy and Development Branch (LPDB) has processed an
     estimated 2,940 licence related transactions.
•    Stakeholders have expressed concern with the current process citing it is time
     intensive, not transparent, timelines are non-committal, and that application
     requirements are not consistent with the scope of the transaction (i.e. transferring 5
     beds vs. building a new home).
•    Stakeholder confidence during the development process may be low as the timing of
     Ministry approvals can adversely impact construction/building timelines.
•    Through process improvement, LPDB has identified and implemented strategies that
     will better align the program with provincial priorities that focus on generating LTC
     capacity, eliminating hallway healthcare, improving stakeholder experience and
     reducing red tape.

Licensing Transformation Roadmap
Transformation of the licensing program relies on a critical analysis of each program,
policy and process element to identify how it can be made more effective and efficient.

Continuous Improvement
    The Ministry continually reviews and refines the LTC Licensing Framework to meet the
    needs of internal and external stakeholders.
    •     Stakeholder feedback has centered on the length of approval processes, which is perceived as a barrier to moving
          capital projects from the planning to the building phase.
    •     Additional changes are being considered to further streamline the licensing review process including regulatory
          changes related to the requirement to consider LHIN input on licensing requests and minimizing administrative
          burden for the ministry and stakeholders (e.g. bed in abeyance, financial reviews - see Appendix D).

    Improvements to Date

          Multi-Stream Licensing                     Improving Transparency                       Public Consultation
                  Review                             and Licensee Experience                        Modernization

•        Evolving from a “one size fits all     •   Kick-off meeting with Licensee        •    Legislative amendment as of July 1,
         review model” to a “risk-based             outlining the licence review               2019 modernize the way the
         multi-stream licensing model” for          process.                                   ministry seeks public feedback on
         LTC development projects, resulting    •   Acknowledgement Letters sent to            licensing activities by allowing
         in rapid progress for eligible low-        Licensee to clearly outline project        additional/alternative formats; and
         risk LTC Projects from the LTC             details, required documents and            provide discretion to the Director
         planning to building phase                 next steps.                                to determine the best format for
•        (See Appendix E).                                                                     each individual circumstance.

2025 Licence Expirations
The program area is identifying strategic options to mitigate risks of disruption to LTC
care and capacity.
                                    Critical Dates

                                                                  Licences for approximately 26,531 beds in 257
            Planning, data gathering and options                              LTC Homes will expire.

                       2020 - 2021                                                June 30, 2025

                                                   June 30, 2022

                                   LTCHA Requirement: Three years before a licence
                                    expiration, the Ministry must provide notice of
                                     it’s intention to provide a new licence or not.

•    Building on the ministry’s successful approach for licenses expiring in 2020, the Licensing, Policy &
     Development branch has initiated strategic planning for licenses expiring in 2025 with the aim of:
           •     Creating opportunity in the sector and strengthening sector partnerships;
           •     Reallocating any LTC beds before they are expected to come out of operation in 2025; and
           •     Ensuring the Ministry and sector’s legislative compliance while maintaining continuity and
                 quality care for all LTC residents in Ontario.


Appendix A: Licensing Sector Profile
Sector Breakdown
                                                                                     Market Concentration
           For-profit beds: 41,856
                                                                       57 %
                                                                                  Provincial Index                  375
           Non-profit beds: 37,028
                                                                       43 %        Indexes
Appendix B - LTC Licence Term issued in 2010
     •   In accordance with the LTCHA, all LTC homes must be licensed or approved.
     •   A Licence can have a fixed term of up to 30 years.
     •   The terms of licences issued in July 2010 varied by the structural classification of the LTC home.
                                   Structural Classification*                                          Term of Licence
     New Beds** - Built since 1998 to current design standards                                            30 years**

     A Beds** – Built prior to 1998, but almost meets current standards                                   25 years**

     B Beds – Substantially exceed 1972 standards but do not meet A-bed criteria.                           15 years
     C Beds – Meets 1972 design standards                                                                   15 years
     Upgraded D – Upgraded through the 2002 D Bed program but do not meet the                               10 years
     1972 design standards
     D Beds – Do not meet 1972 design standards, and were not upgraded. Upon                                4 years
     expiration, these beds did not receive a new licence unless they redeveloped to
     meet current design standards.

 * For the purpose of issuing licence terms in 2010, the LTCHA also outlined the term of a licence for homes with more than
 one structural classification, these are not reflected in the above table.
 ** In January 2015, the LTCHA was amended and licence terms were extended by an additional five years for “New” and
 “A” subject to the requirements of the LTCHA (s.193.1)

Appendix C: Minister & Director Requirements for
Licensing Activities
                             Minister’s Public
                                                 Public Meeting(s)/   Director’s Determination of Eligibility of
   Licensing Activity            Interest
                                                   Consultation                the Licensee/Applicant
          Regular Licence           Yes                 Yes                              Yes
  Municipal/First Nation                                                                 No
               Approval                                               Note: Director provides the Minister with
                                                                        input received from the LHIN and the
                              Yes (s. 96 only)          Yes
                                                                      Service Area Offices (for compliance and
                                                                       inspection information) to support the
                                                                      Minister decision on issuing an Approval.
       Temporary Licence            Yes                 No                               Yes
       Temporary Emerg.                                                                  Yes
                                    No                  No
Acquisition of Controlling
                              Yes (s. 97 only)          No                               Yes
Agreement to Approve a        Yes (s. 97 only)
                                                        No                               Yes
 Management Contract

Appendix D: Licensing Activities Requiring Ministry
The LTCHA requires the same approval processes regardless of the scale or magnitude of

               New licence,
                                 Transfer a     Relocation of      Transfer         Hiring/

                change in
                               LTC home or      LTC home for     shares of a      Retaining a   Closing a LTC
               bed capacity
                               beds under a     redevelopme       LTC home       management        Home
                or licence
                                LTC licence          nt            licensee        company

                                                                                                   A Closure
                                                                                                Agreement is
               Requires the                                                                         with the
                                Results in a     Results in a
                issuance or                                      May results
                                 change in        change in                                        ministry.
               amendment                                         in a change

                                the licensee     location of                     Management       Approval is

               of a licence/                                    in controlling
                               or location of   the beds and                      contracts     also required
                 temporary                                         interest,
                                 beds and          requires                        require      if the closure
                  licence/                                          which
                               reissuance or    reissuance of                     approval      notice is less
                 temporary                                         requires
                                amendment          licence/                                        than five
                emergency                                          approval
                                of licence(s)     approval                                         years and
                   licence                                                                        before the

Appendix E: LTC Long-Stay and Short-Stay Program
     •   Long-Term Care homes can offer Long-Stay and Short-Stay Programs.
     •   Long-Stay and Short-Stay programs can be offered under all Approval and Licence Types
         (i.e. Approval, Licence, Temporary Licence, Temporary Emergency Licence, Short-Stay
     •   The Act and Regulation outline specific requirements for each of the programs (e.g.
         admission criteria, wait list rules etc.)

Program         Usages            Descriptions
Long-Stay       Long-Stay Beds    Created to enable occupancy by residents who need long-term care on a
                                  continuous basis.

Short-Stay      Interim Beds      Created to provide increased LTC capacity for Alternate Level of Care (ALC)
                                  patients (i.e., no longer require acute hospital care), and who are eligible
                                  for long-stay admission but are on a waiting list for a LTC home.

                Convalescent      Created for persons who need time to recover strength, endurance or
                Care Beds         functioning and who are expected to return to the community within 90
                Respite Beds      Created for persons who have caregivers who require temporary relief
                                  from their caregiving obligations or persons who require temporary care in
                                  order to continue to reside in the community. Residents in respite beds are
                                  expected to return to their residences within 60 days after admission.
Appendix F: Financial Review Policy Refinements
         Evaluation of the financial framework is critical to ensure that it functions as efficiently as possible without
         compromising the level of risk assessment. This allows us to keep pace with internal and external trends.

     Refinements                                                                                                          Current Status
                                                                                                                              First Pilot: Early 2018
     1. Process: Modified financial reviews for public companies.
                                                                                                                            Implemented: April 2018

     2. Process: Utilize previously submitted financial information in place of requesting all documents for subsequent
                                                                                                                            Implemented early 2018
     financial reviews. Transition to requesting financial information in soft copy only.

     3. Policy: Updated financial requirements for redevelopment projects
     •    Removed provisions relating to disclosure of 3 highest salaries and insurance requirements
                                                                                                                            Implemented May 2019
     •    Removed requirement for accountant review of financial Projections to align with Canadian accounting

     4. Process: Lender Support- consultations with lenders to explore potential overlap of analysis processes.              Completed (May 2019)

     5. Policy and Process: Consultations with Deloitte to identify areas of continuous improvement in the financial

     6. Policy: Further refinements to financial requirements
     •    Remove requirements to disclose material credit agreements and to identify any risk of loss of charitable
          status as these would be disclosed in audited financial statements.
     •    Remove requirements to submit year to date financial statement.                                                   Completed January 2020
     •    Remove requirements to disclose occurrences of bankruptcy/insolvency and shift requirement to Deloitte to
          perform bankruptcy search.
     •    Remove calculation of ratios

     Refresh the Financial Guidelines For Licensing Reviews to incorporate any changes from #3 and #5 above. (The         Target completion (June 2020
     Financial Guidelines are the detailed policy guidelines for licence transfers)
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