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COUNTY OF SIMCOE Powered By Docstoc
					                                  COUNTY OF SIMCOE
 ITEM FOR:                Human Services Committee
 SECTION:                 Homes for the Aged
 ITEM NO:                 HS 03-036
 MEETING DATE:            March 11, 2003
 SUBJECT:                 Homes Annual Report


 THAT Item HS 03-036, being the Homes’ Annual Report be received for information.

As part of our Continuous Quality Improvement program, statistics are collated to provide a basis
 for program evaluation and development.

 A summary of the financial performance for the period January 1 – December 31, 2002 is
 presented in Schedule 1, page 4.

 SCHEDULES:           Schedule 1 Statistical Highlights/Analysis
                      Schedule 2 Georgian Manor – Detailed Annual Report
                      Schedule 3 Simcoe Manor and Simcoe Village – Detailed Annual Report
                      Schedule 4 Sunset Manor – Detailed Annual Report
                      Schedule 5 Trillium Manor – Detailed Annual Report

 PREPARED BY:         Jane Sinclair, Senior Homes Administrator

 APPROVALS:                                               Date
 Peter Finlay, General Manager of Finance                 March 4, 2003
 Helen MacRae, Chief Administrative Officer               March 4, 2003
Schedule 1                   Homes’ Resident Statistical Highlights

NOTE: Please refer to detailed analysis in later section for statistics that are highlighted.

        INDICATOR                GEORGIAN          SIMCOE         SUNSET         TRILLIUM

 Long Stay Beds                       105             124              148           120

 Admissions                            19             36               65             46

 Admissions from                       14             33               50             43
 Waiting List
 Deaths - In Hospital                   4              9                7              4
        - In Home                      15             28               52             41

 Discharges                            2               2               18             4

 Resident Turnover %                 20%            31.45%            52.0%          40.8

 % Occupancy                         99.6%          99.08%            98.7%          98.8

 Average Age of Admissions             81            81.58             83            83.7

 Barrie Residents at                   3               6                9             1
 period end
 Orillia Residents at                  1               2                0             63
 period end
 % Preferred at period end           44.8%          54.8%             62.1%          61.5

 YTD Preferred Occupancy             46.9%          57.33%            62.1%          61.9

 % Basic – Full                      5.7%           9.67%             6.1%           7.7

 % Basic – Part                      47.6%          33.06%            30.5%          30.8

 Waiting List                         161             187              59            190

 Short Stay Beds                       2               2                2             2

 Days of Service                      386             369              325           332

 Clients Served                        33             25               28             32

 % Occupancy                         52.9%          50.54%            44.5%          45.5

 Adult Day
 Clients Served                        75             18               63            n/a

 Client Days                         2817             33              2172           n/a

 Volunteer Hours                     3110             --               --             --
Schedule 1
                            Homes’ Staff Statistical Highlights
          INDICATOR              GEORGIAN       SIMCOE       SUNSET       TRILLIUM

 Discharges                            2            2              4          3

 Resignations/Retirements              6           23              17        12

 % Turnover                           7.6          17.5           13.6       11.0

 New Staff                            12           34              26        22

 # Active Full Time                   63           59              75        62

 # Active Part Time                   32           72              71        61

 Scheduled FTE                       76.43         93.4       109.95       88.388

 Staff on Leave                        9           12              9         13

 Total Staff                          105          143            155        136

 Casual Pool                          31           16              21        28

 Total Worked Hours               161,483.92    177,000.45   209,932.59   174,875.81

 Worked FTE                          82.81        90.77       107.65        89.68

 NPC Hours/Resident Day
      - Scheduled                    2.42         2.49            2.43       2.52
      - Worked                       2.46         2.46            2.40       2.50

 C.M.I.                              88.84        94.74           99.03     93.66

 Volunteer Hours                    8380.65       7503            6685      9360

 Ontario Works Hours                1887.5         191            155        0.0

 Other Unpaid Hours                 3050.5        1699            2593     2382.5

 Sick and Absent Days/FTE            12.17        19.78           15.26     14.36

 Incidents of                        5.93          8.59           5.51       6.21
 W.S.I.B. Lost Days/FTE              0.072         .045            .81       3.8

 Modified Work Days/FTE             0.1457         .257           1.72       .42
 New W.S.I.B. Claims/FTE             0.08          .053            .05       .07
Schedule 1
                          Homes’ Per Diem Costs

     COST CENTRE         GEORGIAN        SIMCOE          SUNSET            TRILLIUM
                            5.45           5.17            8.92               5.33
                           21.92          20.12            23.30               20.70
                           75.19          73.30            72.08               74.65
                            8.54          8.80              9.18               7.46
                            4.85          4.21              3.42               4.46
                           11.60          13.47            11.65               12.79
                            4.65          3.97              5.44               7.36
                            .28           0.046             .28                 .19
                            .012           --                0                  .42
                            2.65          1.18              .73                 .18
                           135.14        130.26            135.05             132.70
                           134.92        136.50            135.09             133.30

                           Fire Drills Conducted

    HOME          DAYS        EVENINGS            NIGHTS              COMMENTS
                   10            8                   8             Staff participation is
GEORGIAN                                                                   good
SIMCOE             16               13              19             Powerteam and D&L
                                                                      Fire Protection
                                                                    inspections done in
                   11               13              9                        --
                   11               10              8                  16 Audible
TRILLIUM                                                                13 Silent
Schedule 1
                                 Homes’ Medications

                                 GEORGIAN      SIMCOE    SUNSET   TRILLIUM
# Medications per resident per      10.76        13.13    7.86       8.8
month (includes prns and
Medication Errors – Pharmacy          7           2        14        20
- No impact on resident               1           1         6         0
- Resident affected
Medication Errors – Staff             2           17        0        1
- No impact on resident              30           40       53        9
- Resident affected
                                     40           60       73        30
Total Medication Errors
                                    0.37         0.47     0.49      0.25

                                 Homes’ Resident Falls

                                    158          340       293       282
Level 1 - No Injury
                                     25           42       80         72
Level 2 - First Aid
                                      3           5        14         5
Level 3 - Medical Aid
                                      5           5        10         7
Level 4 – Hospital
                                     191         392       397       376
Total Falls
                                      4           3         8         5
                                    15.9          20       20         18
Average # Residents
Falling Per Month
                                     1.8          3.1      2.6       3.08
Resident Falls Bed
Schedule 1
                         Homes’ Aggressive Behaviour Summary

                                         122       147      372       237
# of incidents
                                        1.14      1.16     2.48       1.9
# of incidents/resident in facility
                                         41       18.9     11.25     12.75
# of residents exhibiting
aggressive behaviour/month
                                         53       155      155        92
# of incidents/shift     Days
                                         57        56                132
                         Evenings                          210
                                         12        85       7         13
                                         67         6      158        84
# of incidents           Staff
                                         38        55      214       151
directed toward
                         Residents       15        92       0          2
                                        111        0       159       229
# of incidents of        Physical
each type monitored
                         Verbal          4        130      213        7
                                         7         17       0         1
                                        110       141      372       219
# of incidents where the resident
had a known cognitive illness
Schedule 1
                                 STATISTICAL ANALYSIS

1.    Resident Turnover: The Resident turnover rate increased significantly in 2002. The
      range for the Homes in 2001 was between 10 to 35 percent. In 2002 the range was
      between 20 to 52 percent. An increase in the acuity level of Residents admitted to the
      Long Term Care facilities was the largest contributing factor in this increase. For
      example, at Sunset Manor in 2001, the mortality rate of Residents with a length of stay
      less then one year was 32 percent. In 2002, the mortality rate of Resident with a length of
      stay less then one year increased to 43 percent.

2.    Occupancy Rates: The overall Resident occupancy rate for the four Homes decreased
      slightly in 2002, dropping from a average rate of 99.45 in 2001to 99.04 in 2002.
      Contributing factors impacting this trend included unoccupied bed days related to a
      higher turnover rates, delays in admissions as a result of facility outbreaks, increased
      waiting times in receiving applications as a result of changes in the CCAC process, and
      additional Long Term Care beds within the County of Simcoe.

3.    Preferred Accommodation Fees: The preferred accommodation rate changed
      across all four sites in 2002. Trillium and Sunset Manor experienced a decrease,
      maintaining a preferred rate slightly above 60 percent. Georgian and Simcoe Manor
      experienced a more significant drop, decreasing more then five percent from the year
      prior at rates below the 60 percent. An increase in the basic accommodation
      fee of $3.02 per day played a significant factor in this change. Shortly after the increases
      were announced by the Ministry of Health, waiting lists developed in response to a large
      volume of requests from Residents and families to change to a lower accommodation

4.    Basic Accommodation Fees: Of those Residents paying the basic amount of
      accommodation, an increased proportion was subsidized by the MOHLTC division in
      2002. The percentage increased from 31 percent in 2001 to 35 percent in 2002. Similar
      to the trend noted above regarding preferred accommodation fees, following the increase
      in basic accommodation fees, an increase in requests for subsidy was observed.

5.    Respite Utilization: The short stay utilization rate decreased significantly from
      56 percent in 2001 to 48 percent in 2002. Trends impacting this reduction in utilization
      include delays in admissions as a result of facility outbreaks and an infusion of new
      “respite” beds in the area with the opening of several new Long Term Care facilities.

6.    Staff Turnover: A marked reduction in staff turnover has been observed in 2002. The
      turnover rate ranged from 15.3 percent to 27.1 percent for the Homes in 2001. In 2002,
      the turnover rate ranged from 7.6 percent to 17.5 percent. With the implementation of
      the pay equity plan and ratification of several collective agreements, wages and salaries
      increased in 2002. Other factors commonly effecting retention and recruitment will be
      investigated in 2003 with the implementation of staff satisfaction survey.

7.    Volunteer Hours: The reported number of volunteer hours across all four Homes
      decreased by 5,776 hours in 2002. A total of 37,705 hours reported in 2001 was
      reduced to 31,928 in 2002. The disbandment of the Ladies Auxiliary and the new
      requirement for flu immunization of volunteers played a significant impact on the
      reduction in hours in 2002.

8.    Per Diem Costs: The per Diem rate for Program and Support Services was
      significantly higher at Sunset Manor during 2002 related to a variance in the level of
      Chaplaincy services. With the new model of Chaplaincy services in 2003,
      equitable service delivery and a more consistent per Diem will apply across all Homes.

      The per Diem for Administration was higher at Trillium Manor in 2002 as a result of a
      Human Resource issue. A more consistent administration per Diem is projected for

      The actualized costs per Diem across the four Homes in 2002 were more consistent and
      reduced overall. The costs ranged from 126.89 to 156.03 in 2001 and 130.26 to 135.14 in
      2002. The heightened per Diem costs in 2001 included a pay equity agreement that
      resulted in retro active payment extending back to 1990.

9.    Medication Incidents: There has been a significant reduction in the number of
      medication incidents, falling from 268 in 2001 to 203 in 2002. The initial inflation of
      incidents occurred in 2001 at Sunset Manor following the implementation of a new
      medication delivery system. With continued monitoring and education, the rate of
      incidents decreased considerably.

10.   Resident Falls: A reduction in the number of falls occurring in the Homes decreased by
      171 incidents in the year 2002. In addition to some initial strategies implemented in
      2002 around fall prevention and increased therapy programs, this area has been targeted
      as one of the Homes’ Best Practice pilots. Ongoing development in this area by the Best
      Practice Team for the County of Simcoe Homes will continue throughout 2003 to work
      toward further reductions in Resident falls.

11.   Resident Aggressive Incidents: An increase of 174 incidents occurred in 2002. Of
      particular note, was the implementation of “verbal aggression” reporting at Sunset
      Manor. With the onset of their new tracking system, increased sensitivity in reporting
      was observed. However, due to the large variance in reported verbal incidents
      across the four Homes, further investigation into the definition and reporting systems for
      this particular indicator will take place in 2003.
Schedule 2
                   GEORGIAN MANOR – 2002 ACCOMPLISHMENTS

Resident Care
    Conversion of 10 DLX Carroll Beds to electrically operated models
    All Liko lifts were serviced and a new Arjo lift was ordered, to be delivered in the early
    A new 5 week cycle menu was introduced to enhance meal selection
    Family BBQ held with good attendance. Change of location to parking area outside 2nd
      floor made inside food set up possible in the air conditioned ADC Area, and easy
      movement in & out of building for food pick up. It also provided easy access to
      wheelchair accessible washroom & allowed event to continue without interruption due to
      rain (tent covered seating area)
    The Medical Protocol was revised
    Laundry and nursing routines were reviewed and revised for improved service delivery
    On site kinesiology provided services 5 days per week until the October. Will be
      recruiting new kinesiologist in 2003 related resignation of previous provider
    Resident Audit noted that 98 percent of residents are involved in some activities and/or
      Therapy Programs
    Respite Care/Admission/Annual Surveys responses indicate a high level of satisfaction,
      with some helpful comments that have resulted in minor changes which hopefully
      increase customer satisfaction
    Incontinence Product utilization audit was developed to ensure proper sizing & use of
    Wound Care Team continues to be proactive in prevention & management of wounds
    Adult Day Care (ADC) staff have arranged outings - several combining both sites which
      have been enjoyed by both clients and care givers
    ADC Penetang Program has a waiting list of ten. Program goal of maintaining
      participants in the community is well met at both sites
    ADC Penetang Program booked for 12-13 clients/day on frail elderly days. This is done
      to hopefully meet attendance expectations (10/day)
    With the referral process from CCAC, an increase in referrals noted resulting in an
      increase in admissions to both programs this year
    ADC Client Visits-Penetang Jan-Dec 2161 - increase of 62 units from 2001
    ADC Client Visits-Elmvale Jan-Dec 656 - increase of 295 units from 2001
    Family Caregivers are appreciative of the support the staff gives, especially through the
      admission process to LTC if it becomes necessary.
    ADC Client/Caregiver surveys responses indicated a high level of satisfaction with the
    An Information Day with speakers from the local Fire Dept. and Police, held at the
      Elmvale Site achieved positive results
    Resident pictures are now being taken with digital camera upon admission process
    A family information session on Alzheimer’s was provided
    Family Christmas Dinners held Dec 10th & 11th were well attended
    Implementation of bed alarm system to improve resident safety.
    Received Reader’s Choice Award as favorite Retirement Home in our Area.
Schedule 2
Information Management
    Adult Day Care was added to Manor server and E-mail. Four new computers installed
    Revision of Resident /Family Handbook
    Most registered staff are now inputting resident care plans and updates (information) on
      computers. An on-site staff Resource person trained for Compu Care Program
    Therapy Program developed for Computerized Care Plan
    Audit of the ”Quarterly” Documentation in Resident Charts & Care Plans to identify any
      inconsistencies & make recommendations to ensure documentation standards are being
      met for Classification
    Utilization of New Computerized Infection Control & Resident Incident Record System
      making Statistical Data Collection & Reports more efficient
    A computer for the Elmvale ADC Program was purchased in Sept. from funds donated
      by Elmvale Lion’s Club, Legion and Maple Syrup Festival
    ADC Staff continue to provide progress summaries every six months and on discharge
      These are forwarded to CCACSC and LTC facilities (to assist with admission process)
    One ADC staff member continues to upgrade computer skills and is sharing this
      information with other staff
    Initiating relocation of frequently used forms to Dept/Program specific Forms folders.
    Resident Wandering lists revised to include residents’ pictures for easier identification
    Health & Safety & Professional Advisory Minutes have been moved to the U: drive to a
      Minutes Folder to allow access to additional designated staff required to enter data.
    For effective tracking, the Narcotic Control Summary Sheet was revised and a new
      Emergency Narcotic Control Sheet developed
    Revised Quarterly Assessment Sheet introduced to make information easier to read and
      can be completed in sections as time permits
    Dietary Policy & Procedure Manuals updated prior to retirement of Dietary Supervisor.
    All Department & Program Manuals converted to Word
    Resident/Family Annual Survey revised to include better mechanism for follow-up
      regarding comments
    New Catering Form implemented (to be used when planning a function or needing
      supplies from Dietary Department)
    Education manuals for Georgian Manor Wound Program are complete and will be
      circulated to the Units, as well as to new staff during their Orientation
    Digital photograph tracking is being used to track wounds by offering a pictorial view of
      the status and progress of the wound

Human Resources
   A new Cook and Food Service Supervisor were hired in the Dietary department
   An Orientation Package was put together for Dept. Heads who have Co-op/Ontario
     Works or Volunteers working in their Dept. Orientation Evaluation Form was revised
   Maintenance hired a casual temporary Electrician to complete some major electrical
     projects - then hired full time in Dec. 2002
   Multiple casual positions were recruited in the nursing department
   Two Summer Students hired through HRC program, which maintained and enhanced
  Schedule 2

      the Activation programs for the summer
      Staff Dress Code revised for compliance across the four Homes
      Post Placement Evaluation Form developed
      Staff Satisfaction Survey completed, Facility Wide results posted & Dept specific results
       given to Dept Heads for Follow-up as indicated
      Implementation of re-imbursement for required in-services with record of attendance to
       Dept. Heads
      Volunteer efforts supported programming e.g. meal assistance, outings, Palliative Care,
       Residents Council, Spiritual services , visiting, special events, and fundraising.
      Volunteer Recognition luncheon held
      Utilization of Ontario Works & Community Service Workers provided additional support
       in several departments to enhance care and service delivery.
      Resident Care Manager assisted one day a week as extra resident Care Manager
       Coverage at Sunset for two months until the SA/DRC in place
      New County Psychogeriatric Resource Consultant has held one in-service and had two
       meetings with Psychogeriatric Resource Staff
      Continue to have a good relationship with Georgian College providing training for PSW
       students. The students develop excellent work habits when they peer with staff and the
       residents benefit from the additional attention and care
      ADC Volunteers 2580 hours in Penetang & 530 hours in Elmvale. They support
       programming and special events. Two students from local high school have done
       community placements with positive results.
      Change in role for Activation Director to PSSM for two County Homes (Georgian &
       Sunset) initiated Dec 2002
      Supervisor for Maintenance & Services took on responsibility for housekeeping/ Laundry

    Health & Safety – Six months in the year incident free with close monitoring of near miss
      incidents & lost time, with emphasis on utilization of Modified work program where
    Installation of carpet for 1st Floor Lounge & draperies installed on 1st floor North side
    Purchase of steam cleaner which can be used for a variety of items by housekeeping and
    Water Coolers installed on 4 East, 1North and Special Care connected to the Home’s
      water supply. Easy access to cold water is enjoyed by the residents and staff.
    Environmental services initiated use of Resident Room Audit and Schedule to audit all
      rooms yearly.
    Installation of Fencing around 4 East & 3rd floor patios to increase building security by
      limiting the doorways that can be used to enter & exit the building. Keys for the gates
      have been given to Nursing staff for emergency exit use
    Fan Out Calling System retested in January with good results – format being adapted
      across all Homes to ensure most effective and consistent process is in place
    Water testing of 4 Whirlpool tubs & Main dining room water cooler – all were good &
   Schedule 2

      met Bacteriological & Provincial Standards
      Arranged for an extra pick up for garbage to alleviate build up of refuse
      Window air conditioners installed in staff lounge, Main Dining Room and front office
      Emergency Plan reviewed by Penetang Emergency Planning Coordinator , no revisions
      Emergency Planning contract and Hot Weather procedure updated
      Roof project completed
      Emergency Planning Audit completed for – door name plates, emergency boxes, bomb
       threat folders and emergency supplies
      Penetang Fire Dept toured the facility to familiarize themselves, and ask questions
      Introduced procedure for Personal Clothing Precautions which doesn’t use bleach in the
       sanitizing process
      Central air conditioning purchase from Springwater Hydro Funds agreed to by Elmvale
       Advisory Group for Elmvale ADP Site. To be installed Spring 2003
      In-house phone installed in main dining room and 5th floor staff lounge to provide
       emergency support if needed
      Renovation of storage room to Resident Care Manager’s office. Storage room created in
       back half of residents’ laundry room
      Successful Influenza Immunization Program - 91.5% Resident and 89% staff
      Trees removed from area between two parking lots
      Provisions for replacement of Domestic hot water boiler, with installation date early in

    SCREAM Team and Maintenance involved in the review of purchasing process for all
    Site Administrator/Director of Resident Care along with other SA/DRC’s is working with
      Senior Homes Administrator to provide consistent service to the residents in all four
    Maintenance & Services now report to County of Simcoe Property, Fleet & Purchasing
      Manager in Administration Centre
    Accreditation Teams have created opportunities for improvement – Document updated
    ADC Program Manager is doing at least one presentation a month to promote programs.
      These have been successful, resulting in donations to augment renovations, supplies, and
      equipment for the Elmvale Site
    Winterama Community Pancake Breakfast hosted by Manor Volunteers.
    ADC Fundraising efforts have been successful with garage sales, 50/50 draws,
      MacDonald’s Restaurant, quilt raffle, and craft sales to augment supplies and equipment
      and subsidize outing. These enhance quality of programming at both sites
    Money has been set aside for renovations (materials & equipment) at Elmvale Site
    Adult Day Program daily attendance fee increased to $12.00 from $10.00/day to increase
      recovery line on budget
    Hosted Health Unit Flu Clinic for the general public
   Schedule 2

      Quality Display Week in November with seven Quality Projects and new AIM
       Accreditation information displayed
      Staff Appreciation Breakfast held Dec 18th from 0630 – 1000.
      Compliance Standards met, action taken to address the Recommendations and
       observations made during the Nov.-Dec. Compliance Review.
                       GEORGIAN MANOR – UNMET OBJECTIVES

     Adult Day Care
      To support and inform those clients with CVA issues
      Information Day at Penetang Site not done due to lack of interest. 2 meetings arranged
       but had to be cancelled.
      Volunteer Manual Policies and Procedures not revised.
      Advisory Council not developed for Penetang site. Objectives will be brought forward to

      Accreditation Teams were not reactivated to work on new Accreditation Standards &
       Document due to proposed structure changes in Accreditation Teams for the Homes
       awaiting further direction.

     Maintenance & Services
      Purchase of 2 new washers for Laundry has been brought forward to 2003 budget

      Palliative Care brochure not revised, carried forward to 2003 objectives
      Relocation of RCM Offices on or near units will be completed in 2003.


A.      Simcoe County Health Unit Inspection
        Food premises and Hazard Analysis Critical Control Point Audit - March 26,2002,
        good report.
        Food premises and Hazard Analysis Critical Control Point Audit –October 29, 2002. No
        Recommendations were made and Dietary department was found “Very clean and well
        maintained throughout”.

B       Penetanguishene Fire Department
        January 25, 2002 - Minor issue re replacement of batteries & one heat detector needing
        replacement. Items corrected.
        Aug 2002 - As a result of fencing the 3rd floor patio, the Fire Dept can’t access the
        standpipe hose connections. After discussing the standpipe connection problem it was
        agreed that we would supply an additional gate in direct line with the connections and

Schedule 2

        put the lock on the exterior for their access. This has been completed.

C.      Otis Elevator Inspection
        Monthly Inspections Completed.       A minor problem was identified, which Otis has
D.    Dietary Fire Hood Inspection
      January 2002.
E.    Roof Inspection
      Aug. 2002 Audit by Tremco Canada Roofing Division.

F.    Economy Chemical
      Laundry Service Monthly Reports -Test on chemicals and equipment

G.    ECO Lab Monthly Dishwasher Inspection
      Efficiency of Operation & Cleaning & Sanitizing.

H.    City Chemical
      Audit of Water Treatment for heating/cooling systems.

I.    PCO
      Monthly Inspections.

                        GEORGIAN MANOR – INSERVICE LIST
                                   TOPIC                                 Attendance
 Care Related                 Alzheimer’s & Its Progression                  5
                             Bed Alarms                                      8
                             Chronic Non Malignant Pain Management           5
                             Compression Bandages/Support Stockings         14
                             CPR                                            21
                             Glucometer Pen                                  4
                             Hearing Aide Workshop                           6
                             KCI Therakair Pressure Relief Mattress          9
                             New Medi SENSE                                  8
                             Novolin Pen – Insulin Injection                10
                             Psychogeriatric Consultation Role/ LTC         32
                             Sabina Sit to Stand Lift Video                 11
                             Sling Removal Made Easy                        15
                             Uno Lift Video                                  4
                             Vital Air Information on Oxygen                 7
                             Concentrators & Services Provided
 Care Standards                CMI Training                                 12
 Information Management          Compu Care Training                        11
                             Payroll Training Vadim                         12
                             Photocopier                                    12
 Personal Development           True Colours                                40
                             Whats New About Menopause, What Are            11
                         The Options
Required                  Back Care / Emergency Transfers               76
                         Fire Equipment Demonstration                   56
                         Health & Safety Review                         41
                         Prevention of Abuse / Harassment               45
Safety Program             Prevention & Management of Aggressive        22
                         General Orientation                             9

               CONFERENCE/WORKSHOP/MEETING                           Attendance
Care Related             Advanced Directives                             2
                       Caregiver Conference                              3
                       Caregiving in a Healthy Way                       6
                       Classification Training                           2
                       Connections that Heal                             1
                       CPR                                               1
                       Developing a Dementia Network                     1
                       Pain Management in the Cognitive Imp.             5
                       Doing Our Best For Your Mother                   12
                       Management of Psychosis & Aggression              3
                       Associated with Dementia
                       Preventing Alzheimer’s Aggression                 7
                       Roho seating & Support Services                   1
                       The Kaleidoscope World of Dementia                4
                       Wound Care & Seating                              1
                       Ontario LTC Conference Trade Show                 1
Care Standards           College of Nurses - Documentation               2
                       National Sanitation Training Program              4
Conference              OANHSS Region 4 Meeting/Workshop                 7
Information Management     Compucare Training Program                    2
                       Electronic Records Management                     1
                       Lotus Training                                    2
                       Microsoft Word Training 1& 2                      1
                       Excel Training                                    1
Palliative Care          Aboriginal Palliative Care (six sessions)       3
                       Annual Palliative Care Workshop                   6
                       CA of the Brain                                   3
                             8th Annual Palliative Care Workshop                   6
                             Hospice Presentation                                  1
                             Nausea & Vomiting                                     3
                             Terminal Delirium                                     5
                             Spiritual Care in Palliative Care                     4
 Personal Development            Performance Review & Development                 11
                CONFERENCE/WORKSHOP/MEETING                                  Attendance
 Safety Program               Every Second Counts                                  1
                             Train the Trainer Fire Safety For Care                1
 Meetings                     OANHSS Convention                                    1
                             DOC Meeting                                           1
                             Administrators Forum Monthly Meetings                 1
                             PMHC                                                  1
                             SCREAM Team Monthly Meetings                          2
                             Environmental Managers Conference                     1
                             County Manor Environmental Managers                   1
                             CCAC                                                  1
                             County Administrators                                 1
                             Region 4 Maintenance & Housekeepers                   1
                             OANHSS Region 4 Meeting                               1
                             PIECES Meeting                                        2
                             Maintenance & Services Dept.                          1
                             LTC Purchase Group Presentation                       2
                             Best Practice Guidelines                              1
                             RNAO Orientation Program                              1

Schedule 2
                       GEORGIAN MANOR – CURRENT ISSUES

    Continue to support each other through restructuring process.
    Some challenges experienced with budget decisions during transition with new system.
      Regular budget printouts not always available.

    New Dietary Food Supervisor started in December.

    Redefining roles for Resident Care Managers.
Adult Day Care
   Senior Homes Administrator and Program Manager continue to review budget to address
      salary increase

    Lead Hand position pending in 2002.

Maintenance & Services
   New Maintenance & Services Supervisor started in December.
   Lead Hand position pending in 2002.

Program and Support Services (P.S.S.)
    PSS decrease in Kinesiologist hours in October 2002 from five days per week, seven
      hours per day, to one day per week. Noted decrease in Kinesiology treatments from 757
      in the 3rd quarter to56 treatments in the 4th quarter

                        GEORGIAN MANOR - 2003 ACTION PLAN

                                       RESIDENT CARE
             Goal                           Objectives                         Indicator
To continue to enhance the        Complete an updated                New brochure completed by
Palliative Care Program.          Palliative Care brochure to        June 2003.
                                  inform residents/families of
                                  the services.
Increase resident participation   Work with the Therapy              Increase therapy services by
in Rehabilitation Programs.       provider to reinstitute the        Mar. 2003.
                                  Kinesiology programf to five
                                  days per week, (lost this
                                  service the last quarter in
                                  2002, stats reflect).
Develop Pain Management           Select pain management             Implement program by June
Best Practice Model.              committee to develop terms of      30, 2003 that ongoing
                                  reference.                         evaluation of pain
                                  Utilize Best Practice              management supports the
                                  Guidelines to enhance pain         resident’s pain management
                                  management.                        plan.
                                  Ensure policy & guidelines in      Present Best Practice model to
                                  place by June 30, 2003 to          Professional Advisory
                                  support model.                     Committee by July 31, 2003.

Development of Diabetic           Select one Registered staff        Consistent approach to
Resource Staff Person.            interested in leadership role to   diabetic management by Sept.
                                  liaison with PGH Diabetic          30, 2003
                                  Clinic Staff & Dietician
                                 consultant by April 30, 2003.
                                 Establish Diabetic protocol &
                                 guidelines by June 30, 2003.
                                 Provide education to Diabetic
                                 Resource Person by June 30,
Address Dietary issues & be      Provide alternate choice for all   MOH Dietary Consultant
prepared for MOH Dietary         meals including pureed diets       Review with no unmet
Consultant Review related to     by January 2003.                   standards.
hire of Dietary Food             By March 17, 2003 to serve
Supervisor.                      all evening meals no earlier
                                 than 5pm.
                                 Utilize nourishment carts
                                 when purchased by April
Institute multi-dose drug        Provision of education to all      Multi dose drug system in
administration system to all 4   Registered Staff to ensure         place and all staff proficient
Units.                           competence in the new              with the process by April 30,
                                 system.                            2003.
                                 Introduce multi-dose drug          Staff evaluated for time
                                 system, one Unit at a time, in     utilization, competence, &
                                 consultation with Pharmacist.      reduction in medication errors
                                                                    by June 30, 2003.
             Goal                          Objectives                         Indicator
To maintain the assistive        Repair and replace Infra Red       Canadian Hearing society to
hearing system at optimum        System by May 2003.                inspect and recommend
level.                                                              changes and repairs.
                                                                    Contact local service club that
                                                                    provided equipment to cover
                                                                    System upgraded.
To improve Resident patios       Volunteer committee to             Project of patio repairs and
and maintain a safe pleasing     explore cost of renovation on      enhancements of patio
environment.                     4E patio and enhancement of        completed by July 2003.
                                 1st and 3rd patios.

To improve Resident access to    Work with Fleet manager to         Replacement of 1984 Bus by
transportation.                  investigate possibility of         September 2003.
                                 purchase or lease of new bus
                                 with greater WC capacity.

To eliminate the staff smoke     The Employee/Management            The staff smoking room will
room.                            Committee will implement a         be eliminated by May 1, 2003.
                                 no smoking policy for staff        A designated outside smoking
                                 inside the facility May 2003.      area will be chosen taking into
                                  With input from                   consideration safety issues and
                                  employee/management               staff input.
                                  committee to designate a
                                  winter & summer outside staff
                                  smoking area by May 1, 2003.

                                       Human Resources
             Goal                          Objectives                          Indicator
Provision in place for Staff      A budget is established           Budget Line Established and 1
Health & Safety Certification     specifically for Health &         staff trained by June 2003.
Training.                         Safety Certification Training
                                  by February 2003
To implement the Lead Hand        To keep the lines of              Service levels are maintained
system throughout various         communication open between        or improved.
levels of service delivery.       all disciplines involved.
                                  Target date February 2003
Provide volunteers for Adult      Investigate in-services, &        At orientation provide each
Day Program with education,       videos available.                 volunteer with education
especially in Alzheimer’s         Contact Education                 videos and articles. Provide
Dementia.                         coordinator at Alzheimer          this initiative on an ongoing
                                  Society re giving an in-          basis by April 2003.
                                  service for volunteers.
                                  Survey volunteers to find out
                                  what it is that they need to
Increased days at Elmvale         Senior Homes Administrator        Funding received & staffing
Site                              to dialogue with Ministry of      increased by May 2003.
                                  Health to provide increased
                                  funds for staffing for one
                                  additional day by March

                                   Information Management
             Goal                          Objectives                          Indicator
Computerized Care Plans will      Compu Care program installed      Computerized Care plans for
reflect resident Activation and   on Activation Computer for        Activation and Restorative by
Restorative Care.                 easy access.                      Mar. 2003.
                                  Staff training for
                                  computerized care plans.
To enhance customer               Development of on-line            Implementation of system
satisfaction by improving on      request for Maintenance           through the satisfaction
delivery of service.              system to be utilized through-    surveys:
                                  out all areas of responsibility      - # of follow-up calls
                                  by March 2003.                       - Budgets controlled
                                  To enable Management and          Target date June 20, 2003.
                                 customer tracking of requests.
                                 To assist with tracking of
                                 costs associated with the

             Goal                          Objectives                        Indicator
To evaluate building status of   Evaluate status of Georgian       Recommendations submitted
Georgian Manor                   Manor and provide                 to Human Services Committee
                                 recommendations around            in 2003.
                                 future utilization or

Increase in fundraising for      Call churches, service clubs      Increase in donations realized
both Adult Day Program sites.    and businesses, set dates for     to enhance activities provided
                                 presentations.                    by Adult Day Program.
                                 Program Manager to write
                                 letters and do presentations to
                                 service clubs and businesses
                                 educating community re
                                 function of program by April
                                 Review and monitor menu           Dietary department spending
Obtain and comply with a set
                                 costs to comply with set          costs will be within the set
Dietary Budget for raw food
                                 budget.                           budget for 2003 and meet
costs, dietary supplies and
                                 Know what limitations there       Ministry of Health Standards.
small wares.
                                 are for dietary supplies i.e.
                                 paper products and small
To have all recommendations      Documentation has been            Responses to Accreditation
& suggestions addressed from     completed from 2000               recommendation have been
2000 Accreditation.              Accreditation by target date:     addressed and recorded in
                                 June 2003.                        readiness for Accreditation.
                                                                   Teams have addressed the
                                                                   AOpportunities for
                                                                   Improvement which they
                                                                   identified and responses
                                                                   recorded in readiness for
                                                                   Final report forward to Senior
                                                                   Administrator by target date.

 Prepare for Accreditation       Georgian Manor will               Accreditation document
review in 2003.                  participate in the New Simcoe     completed.
                                 County Accreditation Teams        Successful Accreditation.
                                to facilitate the completion of
                                the self assessment document
                                and identify opportunities for
                                improvement which will lead
                                to the development of
                                common policies and
                                procedures where possible.
                                To participate in the
                                development of the schedule
                                for teams to review standards
                                to ensure all documents for
                                Accreditation completed by
                                target date.

Schedule 3
                    SIMCOE MANOR - 2002 ACCOMPLISHMENTS

Resident Care
    Water jug implementation to increase residents’ water intake.
    Purchase of insulated dishes for tray meals.
    Developed and implemented monitoring and documentation system for nutritional
    Re-developed and re-introduced a system to monitor utilization of general purpose
      resident equipment
    Audited all facility owned resident mobility equipment to ensure safety and
    Requested ergonomic review of inside wheelchair ramp. Report received along with
      recommendations regarding purchasing of future wheelchairs
    Successful management of significant enteric illness outbreak. Developed new
      “Outbreak Manager Kits”
    Continue to develop wound care skills of Clinical Resource Nurse
    Supported introduction of the role of County Psychogeriatric Resource Consultant at this
    Trained an RN in the MOHLTC PIECES Psychogeriatric assessment program
      Successful increase to Nursing and Personal Care Funding via increase in Case Mix
       Index. Strategies learned from consultant appear to have been key success factors
      Activation Department successfully implemented CompuCARE care planning for all

Information Management
    Increased numbers of staff using email and other programs for communication
    Clerical support added to weekly Senior Management Meetings
    Revised payroll input responsibilities on site to match Finance Department goals.

Human Resources
   Identified and developed skills of one Administration Secretary to become Site
     Purchasing Coordinator
   Successfully filled all vacant RPN and RN positions after lengthy shortages
   Provided placement opportunity for ten (10) first year Nursing Students from Georgian
   Supported change in PFP department at this site

    Adjala ice machine replaced
    Pronto steamer (1) replaced in main kitchen.
    Monitored successful renovation of community outreach space to host VON Adult Day
    Continued to implement Electronic Card Access System
    Renovation to staff dining room doors to allow visibility related to OHSC
    Successfully moved all residents (6) that smoke to unit where designated smoking area
   Schedule 3

      Roof restoration of the area set out by Tremco was completed by LaFleche; decking was
       removed on the two large decks on the Innisfil unit, membrane was replaced by
       LaFleche, then new decking was installed by maintenance(old decking lumber went to
       the museum)
      one domestic water tank was replaced in Inn/Nott mechanical room
      uneven uni-lock areas were leveled
      added a cut into the curb where residents walk in order to reduce risks of falls
      bed inventory of the complete facility completed and kept up at all times
      A/C was installed for the Inn/Nott units, north and south by Lobby Mechanical, with very
       good results
      Simcoe Village suite doors, we added five more suite closures to aide in ease of door
       opening (automatically close upon activation of the fire alarm)
      Simcoe Village decks on the 2nd and 3rd floors had automatic door openers installed
      26 resident rooms were painted, meeting our goal of five year paint program

    Assisted PFP Department with physical asset inventory
    Developed further understanding of MOHLTC funding formulas
        Developed understanding of Supportive Housing Funding formulas
        Developed and implemented action plan to address unmet compliance standard. No
         concerns have been noted on routine tours
        Reorganized roles of Nursing Resident Care Managers to enrich leadership role
        Lead staff through reorganization of Maintenance Department

                         SIMCOE MANOR – UNMET OBJECTIVES

 A. Compliance review resulted in one unmet standard related to control of hazardous
substances. Action plan developed and successfully implemented to correct issues.

                        SIMCOE MANOR – EXTERNAL REVIEWS

A.       Simcoe County Health Unit Inspection – Planned inspections in January, May &
         September - no outstanding issues. Outbreak inspections in January & December.

B        New Tecumseth Fire Department – no visit in 2002. Review January 2003, and full
         tour scheduled for February 2003.

C.       Otis Elevator Inspection - monthly inspections, no outstanding issues. Door timing
         adjusted at Simcoe Village

D.       Dietary Fire Hood Inspection – two inspections, no outstanding issues.

J.       Roof Inspection LaFleche Roofing - infra red scan done Spring 2002.

K.    Eco-Lab Chemical – monthly reviews, no outstanding issues
Schedule 3

L.       PCO – monthly inspections, no outstanding issues

M        Boiler Room Inspection - monthly, no outstanding issues.

                           SIMCOE MANOR – INSERVICE LIST
                                    TOPIC                                         Attendance
 Cooling Temperature Rates/ Clostridium Perfringens                                   7
 Importance of Increasing Resident Fluid Intakes (Unit Team Meetings)                30
 Dysphagia Inservice (Dec. 6/02)                                                     20
 Tube Feeding (Dec. 13/02)                                                           14
 Proton Sanitation Course (July/Aug./02)                                              6
 Swish Dispenser Use (Dietary)                                                        9
 Automatic Floor Scrubber Review                                                     15
 Bed Alarms                                                                          11
Pharmacology – Zyprexia                                       8
Cauterization Training                                        1
Chest Assessment review                                       1
Oxygen Therapy                                                6
Pharmacology – Resperdal and Reminyl                          8
Chest Auscultation                                           19
Floor Scrubber                                               15
H/S WHMIS review                                             94
Swish Dispenser                                               9
Swish Products                                               24
WHMIS full training                                          14
Performance Evaluations                                       6
               CONFERENCE/WORKSHOP/MEETING               Attendance
Palliative Care Workshop                                     2
Spring Serca Food Show                                       3
Fall Serca Healthcare Show                                   4
Complete Purchasing Show                                     1
OANHSS Dietary Managers (Feb/May/Sept)                       1
Advanced Care Planning                                       7
Aggressive Behaviour Management                              1
Basic Rescuer                                                7
Care Giving in a Healthy Way                                 1
Dementia Care Conference                                     3
Functional Fitness – Restorative Care Workshop               1
Nurses Make a Difference                                     1
OANHSS Annual Convention                                     4
OANHSS Region 4 Annual Conference                            6
Pain Management                                              1
PIECES Training                                              1
Corporate Health and Safety Training                         3
Food Safety Training                                         8
Health and Safety Basic Certification                        1
Health and Safety Workplace Specific Training                1
OANHSS Administrator Certification – Recertification         1
CompuCARE Software Training                                  3
Memorabilia Scapbooking                                      3
Palliative Care Training                                     2
 Palliative Care Workshop                                                              2
 Foot Reflexology                                                                      1
 OANHSS Region 4 Environmental Services Managers Meetings                              1
 OANHSS Region 4 Administrators/Directors of Care Meetings                             1

                          SIMCOE MANOR – CURRENT ISSUES

    New corporate philosophy requires moving of resident designated smoking area and
      elimination of inside staff smoking area.

    Currently do not meet MOHLTC standard for leadership (dietitian plus food service
       supervisor hours). To be addressed during reorganization.

    Current Resident Care Managers are not in role full time. Hours allocated are 15
      hours/week. A review of the nursing and personal care services is currently in progress
      to review potential enhancements to leadership roles to ensure effective service delivery
      and equity across all Homes.

Adult Day Care
   No outstanding issues.

    Recent retirement of Housekeeping/Laundry Supervisor resulted in responsibility for
   Schedule 3

      department moving to PFP Department. Site representatives will be working closely
       together to review and improve overall housekeeping procedures.

   Implementation of new supervisor role completed.
   Lead hand positions in maintenance and housekeeping/laundry pending.

Program and Support Services (P.S.S.)
    Program continues to operate under traditional style. Full implementation of new
      Program and Support Services Manager role expected Spring 2003.
    Activation Director temporarily provided management support to Trillium Manor
      January – February 2003.

                               2003 Facility Wide Action Plan
                                          Resident Care
           Goal                         Objectives                        Indicator
 To move resident smoking      a) Meet with residents to explain Guardian Satisfaction Survey
lounges away from a              need for move
resident care area(s).        b) Develop plan of action to
                                 minimize impact
To ensure safe, secure        c) Develop polices and              Monitoring of incident reports
resident smoking area.           procedures for safe resident
                                 smoking in this site             Renovate with budget
                              d) Renovate lounge for general      approval
                                 purpose use

To enhance independence       a) Develop guidelines for           # of residents using individual
and health status by             assessing resident seating       seating (%)
developing guidelines for        needs.
seating and surface           b) Outline staff responsibilities   guardian satisfaction survey
assessment.                      and accountabilities for
                                 assessment, access for
                                 funding and evaluation of
                                 seating and surface needs.
                              c) Audit internal equipment and     review of data base for
                                 develop a data base to           accuracy
                                 maintain accurate records of
                                 facility resources.

To Evaluate work              a) assess impact of 2002 report     # of staff complaints re: work
conditions via Ergonomist     b) develop plan of action to        place conditions
Assessment                       promote healthy work             # of workplace injuries
Increase Resident Access to   a) develop spaces that will         # of residents using
Refreshments Current             promote this independence        refreshment areas
systems do not allow those       opportunity                      guardian satisfaction survey
residents who are capable     b) coordinate with all
access to refreshments           departments to ensure safety
without supervision

            Goal                         Objectives                          Indicator
Renovation of Smoking         a) renovation of resident           As above
Areas                            smoking lounge
                              b) move residents to current
                                 staff smoking lounge
                              c) eliminate staff smoking inside
                                 the building
                              d) designate outside smoking
Dining Room Space             a) review spaces to maximize        All residents will be seated
                                 utilization without              within designated dining
                                 renovation.                      room.
                                                                   Guardian satisfaction survey
To enhance facility security   a) Complete installation.           Continuation of 2002 project.
by completing installation     b) Provide all staff with access
of electronic access.             cards.
                               c) Determine hours of operation
                                  for outside doors.
                               d) Develop policies for
                               e) Revise existing security
                                    HUMAN RESOURCES
           Goal                           Objectives                         Indicator
To ensure that all             a) Develop standards of safety      Ergonomist will audit
equipment purchases meet          for facility owned and           equipment in fall 2002.
the health and safety needs       resident owned equipment.
of staff.                      b) Review standards with all
                                  staff via education series.
                               c) Review standards with
                                  residents and families via
                                  Family Information Meeting.
To enhance staff education     a) Develop staff education skills   Staff needs assessment
by developing a staff             in lead staff members.           Participation and interest in
education team.                b) Ensure core group of staff       education team
                                  with knowledge base and
                                  education skills at all times.   # of on site education sessions
                               c) Provide onsite, timely           held
                                  educational activities for       # of staff participating in
                                  staff.                           sessions
To enhance the facility’s      a) Survey other facilities and      Defer to HR
attendance management             types of organization
program to ensure                 attendance rates.
scheduled staffing levels at   b) Recruit an attendance
all times.                        management team.
                               c) Determine a program suited
                                  to facility.
                               d) Implement and evaluate
Smoking Cessation              a) Offer cessation programs in      # of staff participating in
                                  conjunction with health unit.    programs
                                                                   # of staff reporting smoking
                                                                   cessation after 6 months
Corporate Relationship            Develop front line staff
                                  member’s awareness of, and
                                  feelings of connectedness
                                  with corporation as a whole.
                                      INFORMATION MANAGEMENT
                 Goal                               Objectives                         Indicator
     Review compliance with           a)    Audit and determine level of
     corporate records                      compliance.
     management policy.               b)    Remove and destroy records
                                            as needed.
                                      c)    Educate departments on
                                            corporate and facility policies
                                            for records management.
     Develop facility wide            a)    Review current practices for      Continuation from 2002
     comfort levels with                    communication under four
     electronic communication.              broad categories: resident
                                            information; facility wide
                                            communication; staff

                 Goal                                Objectives                          Indicator
     Review funding and               a)    Educate and review funding        Ongoing as part of
     revenue plans to develop               and revenue mechanisms.           Performance Management
     performance indicators.          b)    Determine areas where             Activities.
     Review 2002 planned                    expenditures exceed funding.
     expenditures to determine        c)    Determine indicators of
     compliance with above.                 performance related to above.
     Enhance staff knowledge of       a)    Share quarterly management        Continued from 2002
     facility operation.                    activities and reports
                                            quarterly. Share action
                                            plan(s) and progress within


    Period: Jan. 1 – Dec. 31, 2002
     INDICATOR             1996            1997    1998    1999       2000    2001    2002       COMMENTS


Admissions                        6          12       11          5     11        9          5

Discharges                        4          10        7          3      9        8          4
Deaths                          2      2       4      2       2      1

Avg. Length of Stay (Yrs)                   3.45     5.0    3.6    2.7      4

% Occupancy                                 99.2    99.4   99.3   98.9   99.25

# Clients at Period End        36     37      36     36      36     36     34

# Clients Served in Period     40     46      47     41      47     45     38

# Females at Period End                       28     30      30     30     28

# Males at Period End                          8      6       6      6      6

# Couples at Period End                        4      4       4      4      2

Average Age of Clients                      82.0    82.9   82.8   82.9     83

Waiting List                         169     202    241     183    195    192

New Applications/Period                       47     51      48     40     24

% Full Pay Clients           53.0   49.0    49.0   49.25   54.5   50.7   49.25

#Client Complaints                             0      0       0      0      0


Dietary Homemaking Hrs                       910    912     913    910    912

Hskpg Homemaking Hrs          588    588     588    592     592    592    592

Red Cross Home. Hours        2978   4489    5917   5568    4675   4639   4638

Total Homemaking Hours                      7415   7072    6698   6141   6142

                                    SIMCOE VILLAGE REPORT

         INDICATOR           1996   1997    1998   1999    2000   2001   2002    COMMENTS


Service Package Meals                       5718   5568    5673   5562    5595

Extra Client Meals                          1541    1522   1450   1400    1835

Visitor Meals                                 73      65     61     80      87

Total Meals                  6962    6880   7332    7155   7184   7042    7517

#One Way Trips                              1358     1538     1432    1448     1627

#Manor Nursing Visits          72     108      94       94     206      85      N/A

Housekeeping Hours          941.5   941.5   941.5     972      972     972      968


Budgeted Per Diem                            38.79   40.59 36.01      43.52   43.40

Per Diem at Period End      32.86   34.32    36.85            42.43   40.26     N/A

# Overdue Accounts              0       0        0        0      0        0        0

    Schedule 4
                         SUNSET MANOR - 2002 ACCOMPLISHMENTS

    Resident Care
        Progress in maintaining consistency of staffing achieved following increased challenges
          in recruitment during the summer months of 2002
        Palliative Care Lounge Chair donated by local Canadian Legion for Resident comfort and
        Flu vaccine policy revised, and Resident, Staff and Public Influenza Clinics held at
          Sunset Manor. Sunset Manor staff assisted in corporate flu clinic held at the
          Administration Centre
        Policy and procedure developed for CPR protocol upon ambulance transfer
        Resident Falls Assessment protocol developed and implemented. Ongoing development
          continues on program to establish a Best Practice for all County Homes
        Head Injury Routine (HIR) protocol developed and implemented
        A multi-disciplinary task force lead by the Manager of Food Services, successfully
          developed enhancements of the meal and nourishment services to Residents. The
          effectiveness of food service delivery was noted in the 2002 Annual MOH Compliance
        Continued monitoring of Multi-dose medication system occurred. Analysis indicated a
          reduction in medication incidents during the year and staff time efficiencies
        Sunset Manor was voted the “Readers Choice Award” for the best LTC facility in the
          Georgian Triangle area
        Wound Care Program continued to develop throughout the year within additional
          assessment and preventative measures established
        PIECES Psychogeriatric program enhanced with the addition of a new resource Team
          operating in the County of Simcoe. Regular meetings and consultations held with staff
          and resource person to assist in care planning and service delivery
        Policy & procedure development completed regarding assessment and application of
       compression stockings.

Information Management
    Staff training of CompuCare computerized care plan model implemented and care plans
      revised facility wide
    Completion of computer upgrades to Microsoft Word and Lotus Notes
    Decrease in use of paging system for incoming calls by direct forwarding
    Companion Phone system upgraded to eliminate “dead zones” within facility
    Enhanced utilization of 24 hour Resident Care report implemented
    Payroll input commenced with Vadim Program
    Introduced Performance Management to Supervisors
    Introduced voice mail for Administrative Staff to enhance communication
Human Resources
    Site Administrator/Director Resident Care hired in October 2002
    Program & Support Services Director hired in November 2002
    Team Leader position for Program & Support Services hired December 2002
    Part-time Program & Support Services staff hired December 2002
    Opportunity for job shadowing increased through “Bring Your Child To Work” Program
Schedule 4

      Development of Best Practice Model for delivery of care in process and new Team
       members being recruited.
      Non Violent Crisis Intervention Training (NVCIT) recertification program for currently
       trained staff completed.
      Restructuring of the Environmental Department accomplished through the twining of
       Sunset Manor and Simcoe Manor
      Back Care program & return to work orientation implemented across the organization

    Utilization of County of Simcoe purchasing support systems to ensure quality and cost-
      effective purchases of equipment/repairs to building
    Expansion to Resident Dining area in South Simcoe Unit completed
    Internal building décor improved and maintained as appropriate
    A Smoking By-law implemented in the Town of Collingwood. Resident smoking
      lounges reduced from two to one and staff prohibited from smoking in the facility.
      Specialty protective equipment provided for staff who are required to clean or enter the
      Resident smoking lounge.
    Purchase of ergonomically designed wheels for utility carts within the department
    Participation in the S.C.R.E.A.M. Team for the procurement of goods and services
    Old, broken or unusable wheel chairs and other assistive devices removed from service
    Second phase of lawn sprinkler system installed
    Uneven areas of Unilock stone have been leveled in front entrance
    Three pull stations replaced in West Simcoe Unit due to Resident’s ability to pull the fire
    Maintenance Shop and Day Away fire zones have been split into two separate zones.
    Hot water boiler for the laundry was replaced.
    Emergency planning – Fan Out procedure established for Sunset Manor. Fan out system
         run through planned for 2003

    Georgian Triangle Hospice suites development for respite care to clients in the
      Community supported with completion in February 2003
    Investigation/Research into establishing a Foundation for the Residents of Sunset Manor
    Leadership roles for the Senior Homes Administrator and Site Administrator/Director
      Resident Care were successfully implemented
    Implementation of monthly meetings of the four Site Administrator/Director Resident
      Care and the Senior Homes Administrator to promote continuity and consistency in
      communication and program development
    Initiation of a Program & Support Services Director and Team Leader positions
      successfully implemented
    Successful Ministry of Health Compliance Review

Sunset Village
    Emergency response system established at front entrance to ensure prompt access of
       emergency services such as ambulance and police. Intercom system has been integrated
Schedule 4

        into the nurse call system at Sunset Manor for emergency purposes.
        Enhancements to landscaping implemented to increase privacy for ground floor
        Large maple trees replaced at the Village related to previous damage as a result of car
        Sunset Manor Catered meal service increased to twice per month at the request of
         occupants. Ongoing review of meal service in progress.

                         SUNSET MANOR – UNMET OBJECTIVES

        Initial training of staff in NVCIT presently at seventy-five percent not 100 percent as
        Exterior garden maintenance and enhancements not completed
        Development of a mortality audit not completed in 2002

                         SUNSET MANOR – EXTERNAL REVIEWS

A.       Simcoe County Health Unit Inspection
         Public Health Inspection for Dietary was conducted on December 12, 2002 and no
         concerns were identified at that time.

B        Collingwood Fire Department
         Annual Fire Audit and Annual Inspection and testing of alarm system completed.

C.       Hytrack Elevator Inspection
       Elevators inspected on a monthly basis by Hytrack. Elevator down time approximately
       one week as problem intermittent in nature. New circuit board in place as of February 3,

D.     Dietary Fire Hood Inspection
       Kitchen hood inspected on May 4, 2002. The six month inspection pending and will be
       completed early in the New Year.

E.     Roof Inspection LaFleche Roofing
       Infrared roof scan completed. Required repairs scheduled for 2003.

F.     EcoLab
       Inspections conducted on a regular basis re: utilization of chemicals. No concerns

H.     PCO
       Regularly monthly inspections and treatments completed. A few bedbugs identified but
       no source identified. Continued to monitor through the year.

Schedule 4
                      SUNSET MANOR – INSERVICE LIST
                                   TOPIC                                        Attendance
 General Staff Orientation                                                           11
 Wheelchair Seating                                                                  13
 Nonviolent Crisis Intervention Recertification                                      28
 Nonviolent Crisis Intervention Training                                             12
 Introduction to Tai Chi                                                              6
 Computerized Care Planning                                                           9
 Life Goes On Grief Discussion                                                        9
 Nutrition                                                                            9
 Wheelchair Steamcleaner                                                             13
 Ergonomics                                                                           8
 Compression Stockings                                                                7
 Hydration                                                                            7
 Caring for People with Dementia                                                     23
 Antipsychotics                                                                       9
 PIECES                                                                              12
 Wound Care                                                                          11
 Psychogeriatric Case Study                                                           7
 Fan-Out Procedure                                                                   31
 Compliance                                                                           28
 Documentation: Registered Staff                                                      22
 ADL Documentation for HCAs                                                           28
 BDL Documentation for HCAs                                                           26
 Purchasing                                                                            6
 Hepatitis                                                                             8
 Urinary Tract Infections                                                              8
 Fire Extinguishers                                                                   67
 The Health of the Health Professional                                                11
 Influenza                                                                            10
 Stress Management & Back Care                                                        14
 General Staff Orientation                                                             8
 Stress Management                                                                    15

                   CONFERENCE/WORKSHOP/MEETING                                    Attendance
 Advance Care Planning                                                                 2
 Palliative Care                                                                       8
 OAHNSS                                                                                6
 Managing Pain in the Cognitively Impaired Elderly                                     3
 Professional & Practical Ethics and Nutrition and Wound Care                          5
 Housekeeping Workshop                                                                 3
 PIECES Training                                                                       2

                            SUNSET MANOR – CURRENT ISSUES

    Bedbugs remain to be a problem within the Facility. Identification of entry point (s) has
      not yet been determined.

    Electronic menu boards have recently been installed and activated on all five units. Staff
       continue to learn how to input data for meal service.

    CMI results decreased 1.1 during 2002 MOH Classification
    The Union contract remains outstanding for the Registered Nurses.
    Recruitment of Registered staff inhibited by changes in Ontario College of Nurses
       protocol and increased requirements for entry to practice

    Usage of ergonomically designed casters for large carts has been positive for staff in
     easing their workload and may assist in decreasing physical stress and strain on staff.

   Snow removal has been more challenging this year as area traditionally used for dumping
      of snow is no longer available. Sourcing of new area for removal of snow is in process.

Program and Support Services (P.S.S.)
    Adjustment to the changes within the structure of the Department continues to evolve.

Schedule 4
                          SUNSET MANOR – 2003 ACTION PLAN
                                      RESIDENT CARE
             Goal                         Objectives                         Indicator
Enhance the Resident             1. Revise the Resident            1. Resident Handbook
Admission Process                   Handbook                          revised.
                                 2. Create a warm inviting         2. Separate quiet room with
                                    environment for Resident          quiet comfortable
                                    admission                         atmosphere to be utilized
                                                                      for Resident/Family
                                                                      admission process.

Enhance level of care funding    1. Documentation team to          1. Training by external
                                    receive further training          consultants.
                                    from external consultants.
                                 2. Schedule the
                                    documentation team             2. Each member scheduled 15
                                    adequate hours for                hours for 6 weeks
                                    preparation.                      commencing July 2003.
Implement Best Practice          1. Support the Best Practice      1. The Best Practice
Guidelines                          Team participants and             Guidelines and protocols be
                                    assist as appropriate.            initiated.
             Goal                         Objectives                         Indicator
Preventative Maintenance         1. Development of                 1. Compliance with the
Program to be implemented           Preventative maintenance          established schedule.
                               2. Development of a              2. Audit developed. Once
                                  preventative maintenance         developed compliance of
                                  audit                            90 percent or better.

Enhancement of external        1. Review maintenance           1. Establish availability of
gardens/grounds                     routines with Manager to       staff for grounds keeping.
                                    estimate availability of
                                    staff to do grounds work.
                               2. Initiate tendering process   2. Contact PFP at the
                                    for grounds management if      County of Simcoe for
                                    appropriate                    contracting out
                                                                   grounds keeping.
                                                               3. Grounds will be
                                                                   appropriately maintained
                                                                   and appealing to the eye.
Schedule for internal          1. Establish regular schedule   1. An appropriate number of
maintenance of Resident           for repairing /painting         rooms per month,
rooms to be initiated             Resident rooms                  determined in conjunction
                                                                  with manager to be
                               2. Establish inventory control     completed.
                                  list related to required     2. Adequate amount of
                                  supplies for refurbishing of    supplies present in house at
                                  Resident rooms.                 all times.
                                     Human Resources
             Goal                        Objectives                        Indicator
Introduce Orientation Program 1. Encourage new Registered      1. College of Nurses
to LTC as outlined in the        staff to be involved in the      Orientation Package
College of Nurses Orientation    Orientation program              incorporated into existing
Package.                                                          Orientation.
Increase retention and        1. Implementation of Exit        1. Increase in recruitment &
recruitment of all levels of     Interviews once finalized        retention as appropriate
staff.                           through human resources.         based on availability of new
Implementation of New          1. Enhance the quality of       1. Resident, family and staff
Chaplain contract                 Spiritual care for              satisfied with Chaplaincy
                                  Residents, families and         services.
Decrease staff absenteeism     1. Once need identified,     1. Monthly reporting of staff
                                   Resident Care               absenteeism at Nursing
                                   Coordinators to             Management meetings.
                                   speak/counsel staff to      Staff counseling conducted
                                   identify potential areas    by Resident Care
                                   that we can assist with.    Coordinators.
                               2. Encourage involvement of 2. Chaplain involved as
                                   Chaplain as appropriate.    appropriate.
Increase Volunteer base to     1. Work with Ontario Works 1. Human Resources to
enhance programming               Program to encourage       assist in recruitment of
                                  volunteers                 these students.
                               2. General meetings for
                                  volunteers quarterly.   2. Volunteer base will increase
                                                             by 50 percent over the next

                                Information Management
            Goal                           Objectives                         Indicator
Integrate Computerized Care    1. PSSM to work with PSSM            1. Implementation of Care
Plans for Program & Support       of Simcoe Manor to                   Planning
Services                          implement Computerized
                                  Care Planning for
                                  Activation staff.
                               2. Staff training on                 2. All staff appropriately
                                  computerized care                    trained
                               3. CompuCare program                 3. Program installed on
                                  installed on Activation              Activation computer
                                  computer for ease of
Improve communication with     1. Create a Family Council           1. Family Council established
Family members                    within the Home.                     with meetings scheduled.
Improve communication          1. Establish a safe                  1. Staff feeling safe & secure
between staff on shift            communication system for             while working on any unit.
                                  staff working on all units
                                  but particularly in the
                                  Secure Units.
         Goal                               Objectives                        Indicator
MOH Compliance                 1.   Meet or exceed all MOH          1. No unmet standards at
                                    standards                          review.
Accreditation                  1.   Create teams to participate     1. Successful Accreditation
                                    in all areas of accreditation      Review November 2003.
                                    utilizing expertise within
                                    the County of Simcoe.
                               2.   Educate all Teams in the
                                    new AIMS standards
                                    related to accreditation
Continue to foster positive    1.    Establish positive rapport     1. Positive team and team
working relationship between         with Managers                     attitude developed
Managers & new S.A./D.R.C.     2.    Continue to encourage          2. Maintaining their
                                  their involvement in issues      enthusiasm and
                                  related to the Home.             involvement in Home
                               3. Participate in Team              activities.
                                  building exercises/events     3. Team building event in
                                  including the other County       conjuction with other
                                  Homes.                           Homes.

Schedule 5

Resident Care
    Heart and Stroke Strategy Program implemented.
    Infection Control Program has been reassessed to produce pertinent data.
    Palliative Care program upgraded to include a user friendly terminology for residents,
      families and staff.
    Initiated an Enteric Protocol for outbreaks.
    PIECES Program has two staff members to share the assessments.
    Increased the utilization of the facility’s flexible care and behaviour programs.
    College of Nurses standards emphasized to increase awareness regarding medication
    Revitalized the lifts, transfer and carry team.
    Reestablished the nursing routines committees on each unit.
    Completed a trial of fruit spread in the Severn Unit which resulted in a decrease in the
      number of residents requiring peristaltic stimulants.
    The Programs and Support staff initiated new programs including dances and a fashion
    Initiated Best Practice Teams in conjunction with the other three County Homes.

Information Management
    Nursing stations and offices computers upgraded and Lotus Notes installed for increased
    Purchased a portable telephone for the Trillium Manor bus.
    Initiated monthly meetings for all departments.
    Introduced performance management to supervisors.
    Streamlined purchasing protocols
    Payroll input commenced with the Vadim Program
Human Resources
   Increase in Staff development attained due to increase in inservice education which
     exceeded the Ministry of Health expectations. Focus was placed on team building,
     resident abuse, resident aggression and health and safety.
   Retention and recruitment – Colleges and student placement utilized to hire staff.
   Successfully recruited a new Medical Director.
   Successfully recruited for the vacant Resident Care Manger position.
   One staff member was certified in Health and Safety.
   Restructuring of the environmental department has been accomplished with the twinning
     of Trillium Manor and Georgian Manor.
   Purchasing contact established in the Manor.

    Restoration of part of the roof was completed by LaFleche Roofing.
    Participation in the S.C.R.E.A.M. Team for the procurement of goods and services.
    Deceased resident files past time lines shredded.
    Unusable, broken, outdated furniture and equipment removed from the Manor.
    New storage for deceased resident files created with the discarding of broken furniture
Schedule 5

      and equipment.
      Hot holding unit purchased to ensure compliance with food temperatures.
      Food blender purchased to ensure the pureed menu is consistent with the regular menu.
      Specialized utensils purchased to assist residents rehabilitation.
      Consumption of milk by residents increased according to Ministry of Health guidelines.
      Increased the meals on wheels program by one route due to the fact that Trillium Manor
       is able to provide specialized diets of varying consistencies.
      Purchased the Manual of Clinical Dietetics to assist with regular and specialized diets and
      Visual plate audit commenced as per Ministry expectations.
      Monthly Theme Days held for the residents with the lunch menu reflecting the theme.
      Increase in the number of food committee meetings from four to five at the residents
      Simcoe County Public Health Unit held a successful Influenza Clinic at Trillium Manor
       in November 2002.

    Successful Ministry of Health Compliance Review.
    Successful efficient transition of leadership by the Senior Administrator and the Site
    Staff survey completed and analyzed to determine appropriate food items for the vending
      machines to increase staff usage; therefore increasing dietary revenue.
    Best practice guidelines commenced as recommended by the accreditation process.
    Ministry of Health’s classification funding system increased by 4.17 points.

                       TRIILIUM MANOR – UNMET OBJECTIVES
     Resource Sharing. – Compiling common manuals between the four Homes will be
     commenced in 2003.
     Wall protectors on the doorways to resident units and rooms were not installed.

                       TRILLIUM MANOR – EXTERNAL REVIEWS

A.    Simcoe County Health Unit Inspection
      Public Health Inspections were conducted on January 2, 2003, June 4, 2003 and
      December 4, 2003. Hazardous Analysis Critical Point follow through were conducted on
      June 28, 2003 and October 21, 2003. Minor recommendations from these inspections
      received and instituted.
B     Orillia Fire Department
      Orillia Fire Department used Trillium Manor as a training walk through for the fire
      department on October 22, 2003. The fire inspection planned for December 17, 2003 was
      cancelled due the Norwalk like symptoms in the building and rescheduled for 2003.
C.    Hytrack Elevator Inspection
      The elevator was inspected monthly by Hytrack. Preventative maintenance was
Schedule 5

        preformed during the inspections.
D.      Dietary Fire Hood Inspection
        The kitchen hood was inspected by Huronia Fire Safety on October 9, 2002. The hood
        passed inspection and will require recertification before April 9, 2003
E.   Roof Inspection Tremco
        LaFleche Roofing completed restoration of the roof on the west side of the building.
        Water damage occurred to one bathroom due to rain during the maintenance. This was
        repaired by LaFleche roofing in a timely fashion..
F.   Diversy Chemical
        Quarterly chemical analyses and preventative maintenance were conducted by Diversy.
        Recommendations on chemical usage and loading the machines were received and
G.   Critter Ritter
        Monthly inspections were performed by Critter Ritter.

                         TRILLIUM MANOR – INSERVICE LIST
                                    TOPIC                                       Attendance
 Nestle – Med Pass (staff)                                                             13
 “Turkey” (residents, families)                                                        17
 The Anatomy of a Stroke (staff)                                                       16
 PSW Student Orientation (students)                                                     4
 A Fire Fighter’s Experience Residents)                                                29
 Chemspec – New Rug Cleaning Products (Housekeeping)                                    8
 The Psychosocial Effects of a Stroke (staff)                                          13
“Turkey” (residents)                                                29
Critiquing New Menu Items (Dietary, Nursing)                        19
DN Student Orientation (students)                                    2
“Stepping into Spring” Footwear (staff)                             14
“Stepping into Spring” Support Hose (staff)                         12
“Stepping into Spring” Staff foot Care (staff)                      12
Communications and Stroke (staff)                                   12
CPR Recertification (staff)                                         19
Leisure Activities for Stroke Victims (staff)                       11
Cooking Demo (residents, families)                                  27
Ongoing Changes of Orillia (Residents)                              25
HCA Behaviour Documentation (HCA’s)                                  8
Policies, Procedures and Forms (Reg’d staff)                        11
Mobility and Skin Care R/T Strokes (staff)                           4
Antipsychotic Drugs (Reg’d staff)                                    8
History of CFOR (Residents)                                         21
Stephen Leacock (Residents)                                          9
Dehydration (staff)                                                 25
New HCA Assignment and Behaviour Protocol (HCA’s)                    6
Tena Products and Incontinence (Nrsg. Staff)                         4
Mock Compliance Review (Management)                                  6
Classification Documentation Training (Documentation staff)          5
Strawberry Island (Residents)                                       11
Phila Shave Cleaning Demo (Ramara staff)                             5
Strokes – Routine Activities of Daily Living (staff)                 4
Strokes – Cognitive and Perceptual Problems (staff)                  4
No Bake Pie Making (Residents)                                      10
Purpose of the Tena Team/Increasing Membership (Tena Team)           5
The Origin of the Word “Trillium” and “Grace Avenue” (Residents)    15
Travel Log from Utah and Arizona (Residents, families)              21
Low Air Loss Mattresses (Nrsg. Staff)                                9
Origin of Orillia (Residents, families)                             13
Occupational Health & Safety Responsibilities of Supervisors         4
Strokes – Meal Assistance and Hydration (staff)                      6
Family History (Residents, families)                                19
Rug Hooking (Residents, families)                                   32
Fire Extinguisher Hands on Demo (staff)                            105
Fire Safety (staff)                                                101
Bed Alarms (staff)                                                 101
Evacu Sled (staff)                                                                         105
WHMIS Review (staff)                                                                       104
Back Safety (staff)                                                                        101
Worker Responsibilities (staff)                                                            102
Hand Washing (Glitter Glo) (staff)                                                         101
Russia (Residents, families)                                                                27
Cholesterol (staff)                                                                          8
Specific Behaviours with Stroke Patients (staff)                                             8
Use of Respirator for Resident Smoking Lounge (staff)                                   6 on going
Managing Incontinence after a Stroke (staff)                                                 2
Carpet Cleaning and Floor Care (new Hskg staff)                                              1
Abuse (staff)                                                                               78
Food cooking Demo (Residents, families)                                                     36
Fax Training (management, office staff)                                                      7
Test Taste – Egg Substitutions (staff)                                                       9
Cholesterol Meds and Physiology (staff)                                                     11
Student Orientation (student RPN’s)                                                          7
Risk Factors for Stroke (staff)                                                              2

                 CONFERENCE/WORKSHOP/MEETING                                            Attendance
B.Sc.N completed at York University                                                            1 RN
B.Sc.N part time on going at St. FX University N.S.                                            1 RN
B.Sc.N. part time on going at Laurentian                                                       1 RN
B.A. part time on going at York University                                                     1 RN
Gerontology Certificate at Georgian College                                                  1 HCA
Intramuscular Injection Course at Georgian College                                            1 RPN
Advanced Care Planning at Woods Park Care Center                                             1 RCM
Annual Palliative Care Conference at Georgian College                                    8 PC Team
Pain Management in the Frail Elderly Workshop at Trillium                                  5 nursing
Managing Challenging Behaviours of the Alzheimer Victim in Mississauga                  5 Activation
American Sign Language 1 C with Huronia Hearing Impaired                                1 Activation
Professionalism, Legalities and Medical Ethics at Georgian College                             1 RN
American Sign Language 1 A with Huronia Hearing Impaired                                1 Activation
American Sign Language ABC/123 with Huronia Hearing Impaired                            1 Activation
Chartered Herbalist course completed through Dominion Herbalist College, Burnaby B.C.          1 RN
Treating the Behavioural and Psychological Symptoms of Dementia, Barrie                   10 nursing
LTC – Priority Project at CCAC Barrie                                                      2 RCM’s
 Adult Physical Assessment Course at Georgian College Barrie                          3 RPN’s
 Visiting Volunteer Training Program through Hospice                                   1 HCA
 Meeting the Challenge of Dementia at the Army, Navy and Air Force Club,                1 RPN
 SCPHU Educational Workshop at Public Health Unit Barrie                        Med. Dir., 1 RCM

 OANHSS Region 4 Annual Meeting at York Region NewMarket H.C. Center            5 Management
 Putting the Pieces Together: Multidisciplinary Approach in NewMarket                2 RCM’s
 OPP Abuse Workshop in Orillia                                                        2 RPN’s
 Advanced Care Planning at Simcoe Manor                                            1 Admin., 2
                                                                                 RCM’s, 1 RPN
 Managing Performance Outcomes at Nottawasaga Inn                                   SA/DOC
 The Art & Science of Chronic Wound Care at OSMH                                 4 Reg’d staff

Schedule 5
                                Infection Control Outbreaks

                                      Enteric Outbreak
                                       Norwalk Virus
                                        Final Report
                                        Dec. 27, 2002

Outbreak Number: 2260 – 63 - 02
Index Case: Nov. 26, 2002
Case Definition: Any resident or staff who after and including Dec. 3, 2002 exhibited 2 or more
episodes of vomiting/diarrhea, abdominal cramps or fever, or any lab confirmed case.
Length of Closure: December 3 to December 25 at 1200.
Deaths as a result of Outbreak: none
Residents Hospitalized: none
Total Residents Ill: 25
Total Staff Ill: 31

                           Enteric Outbreak: 2260 – 63 – 02 TOTALS
                  5                                                                 Residents
                  2                                                                 Total
                   Nov.   Dec. 4 Dec. 8    Dec.    Dec.    Dec.    Dec.
                    26                      12      16      20      24

Concerns during the outbreak:
Staffing was the biggest issue with respect to cost, staff illness and authenticity and not wanting
to work on the affected units. Supplies and costs such as incontinent products, gloves, sanitizers
and linens became an issue.

Visitors who were visiting non affected units and not following hand sanitizing protocol upon
entering the facility was another issue.
1.      Quick response to signs and symptoms by RPN on both Severn and Ramara.
2.      The virus was kept to one unit at a time and only two units were affected.
3.      No laundry staff came down ill. Isolation procedures were in place and worked well.
4       No deaths resulted from the virus.
5.      No resident hospitalizations resulted from the virus.
1.      Hand sanitizer dispensers will be installed at main entrance to facility and all entrances
Schedule 5

       to each unit. Hand sanitizing will be encouraged on a regular basis upon entering the
       facility and the units.
2.     Disinfectant spray changed from 256 to Virox, a more concentrated solution.
3.     Dietary staffs are to wear gloves when handling and preparing foods at all times.
       Copolymer gloves will be provided on an on going basis to the kitchen and each servery.
4.     Enteric Outbreak Protocol package devised.
5.     Electrolyte Replacement recipe given by Dr. Crawford was beneficial.

                          TRILLIUM MANOR – CURRENT ISSUES

    There is a decrease in the number of applicants for private accommodation for the secure

    There has been an increase in the Meals on Wheels program by one route. New
       containers are being discussed to maintain heat and for ease of the recipients.
    CMI increased to reflect the present care requirements of the residents. Staff have been
      redeployed to meet the needs of the residents. Casual staff often resign due to lack of
      hours requiring more casual staff to be hired to fill the vacancies.

    Approximately 25% of the linen in the building needs replacing. A colour coded system
     for linens will be put in place to ensure adequate linen for each unit.

   Ice build up on the roof allows water seepage onto the walk-in cooler creating ice
      conditions on the floor of the cooler. The lead hand position for maintenance remains
      vacant at this time.

Program and Support Services (P.S.S.)
      The Activation Director was off for several weeks. During this absence, the Program and
      Support Services Manager from Simcoe Manor visited site weekly to assist activation
      staff. All programming and activities for the residents have continued.

Schedule 5
                        TRILLIUM MANOR - 2003 ACTION PLAN
                                     RESIDENT CARE
           Goal                            Objectives                        Indicator
Improve continuity of care      1. Review unit routines on a       1. Routines committee audit
                                monthly basis to ensure an         for number of meetings and
                                even work load.                    outcomes.
                                2. Implement a basic check         2. Resident care audit.
                                sheet for care for each
                                3. Revise staffing levels on all   3. MOH Levels of Care
                                units to ensure all residents      Classification CMI for per unit
                                receive quality care.
                                4. Completed, current care         4. Care plan audit 100%
                                plans reflecting the residents’
                                needs, strengths and goals..
                                5. Medication documentation        5. PRN Medication audit
                                reflects pain management.          100%
                                Incontinence product use will
                                reflect the actual need of the
                                6. A process for                   6. Nourishment
                                documentation of resident          documentation audit 100%
                                nourishments will be initiated.
                                7. Restraint use will be           7. Restraint audit 100%
                                documented as per policy and
                                MOH standards.
Enhance the resident            1. Initiate a post admission       1. Survey implemented.
admission process               survey.
                                2. Revise the Resident             2. Resident handbook revised.
                                3. Revise the admission            3. Admission process revised.

Enhance level of care funding   1. Documentation team to           1. Training by external
                                receive further training from      consultants.
                                external consultants.
                                2. Schedule the documentation      2, Each member scheduled 15
                                team adequate hours for            hours for 6 weeks
                                preparation.                       commencing in July 2003.
                                3. Review documentation            3. MOH Levels of Care
                                prior to MOH Levels of Care        Classification audit 100
                                Classification.                    percent

Best Practice Guidelines        Participate in the Best Practice   The best practice protocols.
                                team                               initiated.

Enhance resident quality of     1. Present ten theme days a        1. Resident satisfaction
life                            year.                              survey. Theme day audit 100
                                2. Introduce new programs          2, Resident satisfaction
                                covering all four domains.         survey. New program audit
                                                                   increase percent.

            Goal                          Objectives                         Indicator
Environmental Manual review     Include procedures for all         Manual is complete and up to
                                maintenance equipment.             date.

Fire prevention                 On going Instruction for all       Annual fire extinguisher
                                staff on fire extinguishers and    inservice completed.
                                fire procedures.                   Fire drill audit 100 percent
Preventative maintenance roof   Prevent water from seeping         No further ice back up on the
                                onto the walk-in cooler in the     roof.
Preventative maintenance        That the preventative               Preventative maintenance
program                         maintenance program is              audit 100 percent compliance.
Enlarge resident dining rooms   Contact architect through PFP       Plans developed and
in 2004                         department for structural           approved.
                                design and plans.
Public Health Inspections       Meet all Public Health              Public Health Inspection audit
                                guidelines and standards.           100 percent
Food wastage                    Decrease food wastage.              Recipes devised for use of
                                                                    leftover food.
Storage space                   Redefine storage areas.             Designated storage areas.
Infection Control               Common manual for all the           Manual completed.
                                      Human Resources
             Goal                         Objectives                           Indicator
Improve staff participation     Change monthly meetings to          Audit for staff attendance
                                alternate months.                   shows increase.
                                Survey staff for educational        Develop a survey to be
                                and work needs.                     distributed to staff.
                                Implement fun days quarterly        Staff survey shows positive
                                for staff and residents             feed back.
Provide an enhanced             Offer new registered staff the      RNAO orientation program
orientation package for         RNAO orientation program.           implemented.
Registered Staff
Staff absenteeism               Decrease Staff absenteeism          Initiate staff absenteeism audit.
Staff education                 Increase staff attendance by        Audit for staff attendance
                                surveying staff for topics.         increased 25 percent
Recruitment and retention       Conduct exit interviews.            Increase in staff recruitment
                                Survey staff for work related       and retention.
                                 Information Management
           Goal                          Objectives                            Indicator
Improve communications          Upgrade the telephone system        IMS approval of new phone
                                All staff to be instructed in the   Staff use of e-mail for
                                use of e-mail                       communication.
                                Revitalize Family Council.          Increase in the number of
                                                                    meetings and attendance.
                                Family meetings quarterly           Number of meetings held.
                                Family newsletter semi              Number of newsletters
Improve computer usage          Train staff basic computer          Initiate a computerized report
                                skills.                             audit.
             Goal                   Objectives                         Indicator
Financial accountability   Each department to remain        Departments within budgetary
                           within budgetary allotment.      limits.
Bed utilization            Maintain the 60/40 ratio.        Bed utilization audit 100
MOH Compliance             Meet all MOH Standards           No unmet standards.
                                                            Compliance audits 100
Maintain dietary revenue   Increase meal costs for Meals    Revenue covers cost of
                           on Wheels and the VON Day        programs
                           Away Program to reflect
                           increasing costs.
Fund raising               Staff and family participation   Committee established
                           on a fund raising committee..
Accreditation              Create teams to participate in   Successful accreditation.
                           all areas of accreditation.
                           Educate teams in the new
                           AIMS standards for

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