33. POCPCC

Before LTCHA Section 24 – Reporting Certain Matters to the Director

Any person who has reasonable grounds to suspect that any of the incidents in the table below has occurred or may occur must immediately report the incident, as well as the information on which the suspicion is based, to the Director.

The table sets out the different types of incidents that all persons must report and how quickly these incidents must be reported. It also sets out the acceptable method of reporting by the Home and the timing of follow-up reporting on the results of investigations and actions.

Key Considerations

The requirement to report to the Director set out in section 24 of the LTCHA applies to every person.

The MOHLTC has an online reporting system for both mandatory reports and critical incidents (section 107 of the Regulation) that is used by the Home. Mandatory Critical Incident System (MCIS) forms should be used by the Home to file both the initial and follow-up reports for the types of incidents identified in the table above.

Any person who is aware of an incident listed in the table above and who does not have access to the Home’s Mandatory Critical Incident Reporting System should report using the toll-free Long-Term Care ACTION Line at 1-866-434-0144.

The MOHLTC’s normal business hours are Monday to Friday from 8:30 a.m. to 5:00 p.m. ALL other times and statutory holidays are considered “after hours”.

The MOHLTC’s current method for after-hours emergency contact by the Home is an after-hours pager. Section 24 of the LTCHA does not require persons to report an assault on a staff member by a resident. However, if a staff member or any other person is taken to hospital for an injury arising from such an assault, the matter must be reported as a critical incident under paragraph 45 of section 107 (3) of the Regulation.  There may also be requirements to report staff injury to the Ministry of Labour.

Key Linkages

Section 108 of the Regulation defines the term “misuse” of funding provided to a licensee for the purposes of mandatory reporting requirements in the LTCHA (paragraph 5 of section 24 (1) and paragraph 6 of section 25 (1)) as the use of funds provided by the MOHLTC or a LHIN for a purpose other than a purpose specified as a condition of funding or in a manner that is not permitted under a restriction that was specified as a condition of the funding. Staff, volunteers, residents, residents’ family members or any other persons who have reasonable grounds to suspect a misuse or misappropriation of funding that has already occurred or may occur must report the suspected misuse to the Director (section 24 of the LTCHA). The reporting may be made by directly calling the toll-free Long-Term Care ACTION Line at 1-866-434-0144. Upon receipt of that information, the Director must have an inspector make inquiries or conduct an inspection (section 25 of the LTCHA). Section 21 of the LTCHA and section 101 of the Regulation require the Home to have a documented complaints procedure.

A resident is not required to report under section 24 of the LTCHA, but he or she may do so.

It is an offence for anyone, other than a resident who is incapable, to include false information in a report to the Director.

Practitioners, including physicians (or any other person who is a member of a College under the Regulated Health Professions Act, 1991), drugless practitioners and members of the Ontario College of Social Workers and Social Service Workers, have a duty to report under section 24 (1) of the LTCHA, even when the report is based on confidential or privileged information. No action for making the report can be taken against a practitioner unless he or she acted maliciously or without reasonable grounds for the suspicion.

The following persons are guilty of an offence if they fail to make a report under section 24 (1) of the LTCHA (section 24 (5) of the LTCHA)

  • The licensee or person who manages the Home under a management contract.
  • An officer or director of the corporation, if the licensee or person who manages the Home is a corporation.
  • A member of the committee of management of a Home or board of management of a Home approved under Part VIII of the LTCHA.
  • A staff member other than those exempted under section 105 of the Regulation.
  • Any person who provides professional services to a resident in the areas of health, social work or social services work.
  • Any person who provides professional services to a Home in the areas of health, social work or social services work.

The following persons are guilty of an offence if they coerce, intimidate or discourage anyone from reporting, or authorize, permit or concur in a contravention of the duty to make a report under this section (section 24 (6) of the LTCHA):  

  • The licensee or person who manages the Home under a management contract.
  • An officer or director of the corporation, if the licensee or person who manages the Home is a corporation.
  • A member of the committee of management of a Home or board of management of a Home approved under Part VIII of the LTCHA.
  • A staff member other than those exempted under section 105 of the Regulation. Nothing in section 24 of the LTCHA abrogates any privilege that may exist between a solicitor and the solicitor’s client.