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===Role, mandate===
The purpose of a PCQO is to receive and address complaints from “patients” about the quality of health care they have received ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|581]])(or in some cases, the health care which the person should have received but did not). Residential care facilities licensed or funded by health authorities are covered by the Patient Care Quality Review Board Act.([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|592]]) The Office can receive a wide variety of care quality concerns. Most by definition relate to care – for example, deficiencies in care, misdiagnosis, or medication-related concerns. The second most common type of matters dealt with by the PCQO relate to the health care provider’s attitude and conduct, followed by accessibility (which includes issues such as eligibility to be admitted to a care facility, wait-times for treatment, test results and the availability of services), lack of communication (such as explanation about medical conditions or procedures), and “environmental issues” (which includes matters such as food services, and housekeeping).
===Scope===
The Office is expected to deal with the complaint promptly and fairly and has specific timeframes in which to work. The PCQO must acknowledge receipt of complaints in two (2) business days and complete the investigation within 30 business days.
The complaint process is not supposed compromise access or service. Once the complaint is formally registered, the Office works with the complainant to resolve the issue. The Office is required to respond within 40 business days (8 weeks) to explain any actions taken and decisions made. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|603]]) If the Office cannot help with the complaint, they may refer to an agency or body who can (“external complaints”).
The PCQOs in each health authority must report the outcomes of their investigations to the person who made the complaint, and let them know they have a right to a further review by the local patient care quality review board if they remain dissatisfied.
====Available remedies from PCQO?====
The way that the problem may be resolved by the PCQO will depend on the specific issue at hand, and the willingness of the parties. It is difficult to determine what remedies are available to the PCQO and what authority it actually has. In most cases, people bringing concerns to the PCQO are interested in resolving the matter for their situation, plus preventing its occurrence for others. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|614]])
===Review of Complaint or Concern===
===Use===
Only about seven percent of all the 4558 complaints made to the Patient Care Quality Offices throughout the province in 2012 related to residential care.([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|625]]) A 2012 review of the PCQO and PCRB systems noted there are systemic challenges in being able to effectively serve people in residential care or residents of small communities. Personal relationships and fear of retribution were seen as significant barriers to any complaint process. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|636]])
Also the legislation generally requires PCQO complaints to be handled on a first-come, first-served basis; this does not facilitate triaging according to case severity. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|647]]) The program predominantly serves English-speaking Caucasians. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|658]]) It has been pointed out that the intended focus of the program is unclear– is it on providing a process for managing complaints, resolving complaints or identifying opportunities for improvement? ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|669]])
==Patient Care Quality Review Board==
These Review Boards are governed by the Patient Care Quality Review Board Act and External Complaint Regulation in how they review complaints as well as what can and cannot be reviewed.
The boards may review any “care quality complaint” regarding services funded or provided by a health authority, either directly or through a contracted agency. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|6710]]) The boards may also review complaints regarding services expected, but not delivered, by a health authority (for example, a complaint regarding a cancelled surgery). The term “care quality complaints” also refers to the specifics of the health care services as well as the quality of the health care or “services related to health care”.
'''Important: The boards may only review complaints that have first been addressed by a health authority’s Patient Care Quality Office.'''
Under the Act, two types of people can lodge a complaint to the PCQO and PCRB:
*(a) the individual “to whom the health care or service was delivered or not delivered” (the “patient”) and ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|6811]])*(b) a person “authorized under the common law or an enactment to make health care decisions in respect of that individual, the person having that authority”. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|6912]])
'''Note: Third Party Consent Form'''
'''Are the rights listed in the Bill of Rights, “health care services” and therefore do they come under the scope of the Patient Care Quality Review Board?'''
Yes. The Patient Care Quality Review Board website specifically notes the existence of the Bill of Rights and points out that people can make formal complaints to the PCQO on these matters. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7013]])
===What can a Patient Care Quality Review Board review?===
([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7114]]) The boards can review:
* complaints about the quality of any health care service under the jurisdiction of the health authorities (these complaints must first have been addressed by a health authority’s local Patient Care Quality Office),
* involuntary admissions under the Mental Health Act (that would include involuntary transfers from the hospital to a residential care facility, or vice versa)
* a decision by a Medical Health Officer or Licensing officer under the Community Care and Assisted Living Act
* a decision of the Community Care and Assisted Living Act Appeal Board. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7215]])
The Review Board also cannot hear certain matters related to:
===Residential Care Issues===
Examples of residential care issues brought to the Review Board to date include: infection outbreaks; a resident’s loss of a subsidized residential care facility bed after being discharged from acute care facility; concerns about assisted bathing and toileting at a residential care facility. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7316]]) Although the PCQRB states that only three of two hundred requests for review received in 2012/13 dealt with residential care, it is clear that some concerns seen in acute care such as falls from beds would also come within scope in residential care.
===Recourse===
The review board can make a broad range of recommendations. For example, they may recommend that the health authority’s Patient Care Quality Office reconsider the complaint, or may recommend specific changes in policies, procedures and practices to improve patient care quality. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7417]])The review board may ask the Minister of Health to consider directing the Health Authorities as a whole to take certain steps. The Boards may comment on the appropriateness of fees charged by a health authority, but will not make recommendations regarding reimbursement.
A health authority might be asked to review a current protocol (such as a delirium protocol or a falls prevention protocol), with specific suggestions on how to implement it better. Administration of the facility might be asked to meet with the resident’s family to review a care plan. Nonetheless, the people expressing the concern about the quality of care may not feel the actual situation in the facility has been resolved. For example, in one Patient Care Quality Office case about perceived negligent care, the recommended “care plan review” led to the resident being discharged from the care facility to the family. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7518]]) That approach does not address the underlying issue of the quality of care in the facility.
The review boards are required to submit an annual report to the minister. In addition each PCQRB can also submit recommendations for improving patient care to the minister or to the health authority.
Community care licensing offices are staffed by licensing officers and overseen by medical health officers. Licensing officers are responsible for ensuring that residential care facilities licensed under the CCALA meet the requirements of that Act and its regulations. Licensing officers carry out the routine inspections for care facilities.
Anyone who is concerned that a facility is not meeting the CCALA requirements can complain to the licensing office for that area. By law medical health officers must investigate every complaint that alleges that a residential care facility licensed under the Act is not fully meeting the legislated requirements. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7619]])In practice, however, the responsibility for conducting these investigations is delegated to licensing officers who are employees of the health authorities. The duty of the licensing office for the inspections is owed to the public, as opposed to individuals. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7720]])
====Advocacy Points====
* Identifying specific areas where the requirements are not being met by reference to the CCALA or the Regulations.
The Act gives medical health officers and their delegates (the licensing officers) the authority to examine any part of a facility and to inquire into and inspect all matters concerning its operations, employees or residents. Medical health officers can also require operators to produce records. Currently health authorities receive very few formal (licensing) complaints relative to the number of licensed facilities and beds.([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7821]])
The Ombudsperson has criticized the fact that private hospitals are not required to be regularly inspected like residential care facilities, and has made recommendations to the health authorities on this matter. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|7922]]) Fraser Health now states it is conducting these regular inspections for private hospitals. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8023]])
====Complaints against Private Hospitals====
The CCALA does not apply to facilities governed by the Hospital Act. Licensing officers are not authorized to investigate complaints about those facilities. As a result, older adults residing in facilities governed by the Hospital Act have fewer options for pursuing complaints than older adults who live in CCALA facilities, even though they have the same care needs delivered by similar persons in similar circumstances. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8124]])
===How Licensing Complaints Are Investigated===
This may involve conducting a “non-routine” inspection of the facility in question and interviewing those involved in the allegation. Licensing officers are expected to document all of these steps.
Violations are categorized under one of ten categories: Care and/or supervision; Hygiene and communicable disease control; Licensing; Medication; Nutrition and food services; Physical facility, equipment and furnishings; Policies and procedures; Program; Records and reporting; and Staffing. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8225]])
If a licensing officer concludes that a contravention has occurred, the officer must then decide whether to recommend that the regional medical health officer take any steps to adjust the facility’s licence (conditions, suspend or cancel). Medical health officers have the authority to attach terms and conditions to a licence, suspend or cancel a licence. Terms and conditions are requirements above and beyond those of the Act or Regulations.
:“Terms and conditions may be used when a licensee needs more direction than the statutory requirements to ensure that the health or safety of persons in care is properly maintained.” ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8326]])
Some examples of licensing conditions include
* requiring a facility to improve its documentation,
* temporarily suspending a facility’s ability to admit new residents,
* requiring a facility to increase the hours of its on-site manager, ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8427]]) and * requiring the facility to have a new manager. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8528]])
Compliance with terms and conditions is required to continue to operate the facility. Terms and conditions are written on the facility licence and posted at the facility. The operator can request reconsideration (or seek an appeal) when terms and conditions are attached to the license.
===The Approach: Education and Progressive Compliance===
According to the Ministry of Health, the purpose of community care licensing is to prevent risk of harm. This is accomplished through working proactively with applicants for a community care facility licence, assessment of applicants, ongoing monitoring of the facilities, risk assessment, and inspection of licensed community care facilities. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8629]])New facilities are automatically considered high risk because they do not have a track record.
By law, the most recent routine inspection record is required to be accessible to residents and families. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8730]]) However, the publicly available records are written and coded in a way that is not useful to the public to determine either the nature of the violations or how serious they are.
==Local Ethics Committees==
Frequently health care matters in care facilities, particularly related to consent and treatment can lead to disputes between the health care providers and residents or their families, between family members or between health care providers At least three health regions (Interior Health, Vancouver Coastal and Fraser Health) have a Clinical Ethics Committee or Clinical Ethics Services. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8831]])If the health care matter is unresolved by the facility staff or administration, the adult’s family or the health care provider can request a review by the Clinical Ethics Committee. In theory, the Committee can offer confidential case consultations for patients, residents, families and/or health care staff members or teams. The Committee can review policies and guidelines entailing sensitive or disputed ethical implications.
The committee may be able to help with several types of issues including informed consent; improving communication about ethical concerns among health care team members; end of life decision making; advance directives/advance care planning; and decisions about clients living at risk. Interior Health policy specifically notes that health care providers must not provide major health care until the dispute with a temporary decisionmaker is resolved. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|8932]]) Each committee sets its own process.
It is not clear whether residents or families are aware of these as a problem resolution resource. Recent Canadian research on informal consultations suggest that while the consultations may help health care providers think through ethical considerations, they tend to be of less help to patients or families. Indeed patients are rarely involved in the deliberations involving their lives and families only slightly more often.([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|9033]])
==The BC Care Aide and Community Health Worker Registry==
[[File:community health worker.jpg | right | frame | link=| <span style="font-size:60%;">Copyright www.shutterstock.com</span>]]
Under the Residential Care Regulations , operators have a responsibility to properly screen prospective employees (verifying their qualifications, character references, and conducting a criminal record check) before hiring, and to assure that people have the competence to carry out their defined duties.([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|9134]]) There is also an ongoing responsibility to monitor employees’ performance.([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|9235]])
In January of 2010, British Columbia became the first province in Canada to implement a registry for care aides and community health workers. The BC Care Aide & Community Health Worker Registry was established to help improve the educational standards of care aides (“health care assistants” or “HCA”s) in the province. Strictly speaking it is not a problem solving resource for residents, families, or advocates; but it can and is used by care facility operators to address problems that arise.
The Registry is a database of credentialed or “registered” care aides and community health workers working for, or wanting to work for, publicly funded employers in BC. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|9336]]) Access to the Registry is restricted to specific registered employers; all names and information contained in the Registry are confidential. Operators may use the Registry to assist them in screening candidates for positions.
Currently, any care aide who wants to seek employment with a publicly-funded health care employer must be registered with the Registry. So must the employers; some private employers have opted to participate voluntarily. To some extent, the Registry operates as a Regulatory College, although without the legal recognition accorded to other health professions. Instead it operates under a Letter of Understanding with bargaining associations. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|9437]])
The Registry’s role is three fold: to ensure that all HCA students in the province receive the same level of training, to register those that have this training, and to track and respond to cases of alleged “abuse” by health care aides. The Registry has the ability to “de-register” care aides, and these individuals are then permanently prevented from seeking further positions with publicly-funded employers.
Operators will have their own internal process for responding to suspected or actual abuse or neglect of a resident. They also have specific reporting responsibilities to the Ministry of Health.
Under the terms of its contract with the Ministry of Health or with a health authority, an employer who receives public funding is required to report to the Registry any employee who has been suspended or terminated for alleged abuse of a client, patient, or resident. This report must be made in writing within seven (7) calendar days of the employee being notified of the suspension. A copy of the report is sent to the union if the employee is represented by a union. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|9538]]) The circumstances are investigated by the Registrar’s office.
The actual investigations are undertaken by five investigators with experience in labour relations and mediations appointed by the Registry’s Advisory Committee. The cost of the investigation is borne jointly by the employer, and the union. If the staff person is not unionized, the costs are borne by the Registry.
Although the new registry (and “deregistering”) system exists, a recent review pointed out that it has several limitations. The mandatory registry requirement for employment only applies to care aide workers seeking employment in publicly funded facilities. Unlike a Regulatory College, the Registry can only investigate serious misconduct (“abuse”) and cannot address other workers’ “competence” matters. The Registry is unable to compel reporting of abuse or operators’ participation in the investigatory process.
Some operators feel the investigation process lacks transparency and the cost of investigation is burdensome. As a result, some employers may simply circumvent the investigation/ de-registry process by terminating the employee without necessarily reporting the incidents. This leaves these workers open to seeking employment elsewhere in health, possibly in private care. ([[Chapter Five Legal Issues in Residential Care {{PAGENAME}}#References|9639]])
Other issues that have been raised about the registry relate to: privacy considerations when it comes to sharing information for investigation, which affects investigators’ ability and authority to access health records, witnesses and licensing information; perceived partiality of investigator; multiple investigatory streams, and conflicting results; perceived loopholes in various processes; as well as questions about sustainable operating funding. There are also important philosophical differences around expectations between operators and the investigators whose background is in labour relations and mediation (“zero tolerance”, “just fire them” versus “graduated discipline”, without aides necessarily being dismissed and deregistered).