Infection prevention and control program
 102. (1) Every licensee of a long-term care home shall ensure that the infection prevention and control program required under subsection 23 (1) of the Act complies with the requirements of this section. O. Reg. 246/22, s. 102 (1). (2) The licensee shall implement, (a)  any surveillance protocols issued by the Director for a particular communicable disease or disease of public health significance; and (b)  any standard or protocol issued by the Director with respect to infection prevention and control. O. Reg. 246/22, s. 102 (2). (3) The Director shall update the standards and protocols mentioned in subsection (2) regularly to reflect relevant evidence and best practice. O. Reg. 246/22, s. 102 (3). (4) The licensee shall ensure, (a)  that there is an interdisciplinary team approach in the co-ordination and implementation of the program; (b)  that an interdisciplinary infection prevention and control team that includes the infection prevention and control lead, the Medical Director, the Director of Nursing and Personal Care and the Administrator co-ordinates and implements the program; (c)  that the interdisciplinary infection prevention and control team meets at least quarterly and on a more frequent basis during an infectious disease outbreak in the home; (d)  that the local medical officer of health appointed under the Health Protection and Promotion Act or their designate is invited to the meetings; (e)  that the program is evaluated and updated at least annually in accordance with the standards and protocols issued by the Director under subsection (2); (f)  that a written record is kept relating to each evaluation under clause (e) that includes the date of the evaluation, the names of the persons who participated in the evaluation, a summary of the changes made and the date that those changes were implemented; and (g)  that the program is implemented in a manner consistent with the precautionary principle as set out in the standards and protocols issued by the Director under subsection (2) and the most current medical evidence. O. Reg. 246/22, s. 102 (4). (5) The licensee shall designate a staff member as the infection prevention and control lead who has education and experience in infection prevention and control practices, including, (a)  infectious diseases; (b)  cleaning and disinfection; (c)  data collection and trend analysis; (d)  reporting protocols; (e)  outbreak management; (f)  asepsis; (g)  microbiology; (h)  adult education; (i)  epidemiology; (j)  program management; and (k)  current certification in infection control from the Certification Board of Infection Control and Epidemiology. O. Reg. 246/22, s. 102 (5). (6) A licensee is not required to comply with the qualification requirements for the infection prevention and control lead under clause (5) (k) until three years after this section comes into force. O. Reg. 246/22, s. 102 (6). (7) The licensee shall ensure that the infection prevention and control lead designated under subsection (5) carries out the following responsibilities in the home: 1.  Working with the interdisciplinary team to implement the infection prevention and control program. 2.  Managing and overseeing the infection prevention and control program. 3.  Overseeing the delivery of infection prevention and control education to all staff, caregivers, volunteers, visitors and residents. 4.  Auditing of infection prevention and control practices in the home. 5.  Conducting regular infectious disease surveillance. 6.  Convening the Outbreak Management Team at the outset of an outbreak and regularly throughout an outbreak. 7.  Convening the interdisciplinary infection prevention and control team referred to in subsection (4) at least quarterly, and at a more frequent interval during an infectious disease outbreak in the home. 8.  Reviewing the information gathered pursuant to subsection (9). 9.  Reviewing any daily and monthly screening results collected by the licensee to determine whether any action is required. 10.  Implementing required improvements to the infection prevention and control program as required by audits under paragraph 4 or by the licensee. 11.  Ensuring that there is in place a hand hygiene program in accordance with any standard or protocol issued by the Director under subsection (2) which includes, at a minimum, access to hand hygiene agents at point-of-care. O. Reg. 246/22, s. 102 (7). (8) The licensee shall ensure that all staff participate in the implementation of the program, including, for greater certainty, all members of the leadership team, including the Administrator, the Medical Director, the Director of Nursing and Personal Care and the infection prevention and control lead. O. Reg. 246/22, s. 102 (8). (9) The licensee shall ensure that on every shift, (a)  symptoms indicating the presence of infection in residents are monitored in accordance with any standard or protocol issued by the Director under subsection (2); and (b)  the symptoms are recorded and that immediate action is taken to reduce transmission and isolate residents and place them in cohorts as required. O. Reg. 246/22, s. 102 (9). (10) The licensee shall ensure that the information gathered under subsection (9) is analyzed daily to detect the presence of infection and reviewed at least once a month to detect trends, for the purpose of reducing the incidence of infection and outbreaks. O. Reg. 246/22, s. 102 (10). (11) The licensee shall ensure that there are in place, (a)  an outbreak management system for detecting, managing, and controlling infectious disease outbreaks, including defined staff responsibilities, reporting protocols based on requirements under the Health Protection and Promotion Act, communication plans, and protocols for receiving and responding to health alerts; and (b)  a written plan for responding to infectious disease outbreaks. O. Reg. 246/22, s. 102 (11). (12) The licensee shall ensure that the following immunization and screening measures are in place: 1.  Each resident admitted to the home must be screened for tuberculosis within 14 days of admission unless the resident has already been screened at some time in the 90 days prior to admission and the documented results of this screening are available to the licensee. 2.  Residents must be offered immunization against influenza and COVID-19 at the appropriate time each year. 3.  Residents must be offered immunizations against pneumococcus, tetanus and diphtheria in accordance with the publicly funded immunization schedules posted on the website of the Ministry of Health. 4.  Staff is screened for tuberculosis and other infectious diseases in accordance with any standard or protocol issued by the Director under subsection (2). 5.  There must be a staff immunization program in accordance with any standard or protocol issued by the Director under subsection (2). O. Reg. 246/22, s. 102 (12); O. Reg. 66/23, s. 23. (13) A licensee is exempt from paragraph 1 of subsection (12) with respect to a resident, (a)  who is being relocated to another long-term care home operated by the same licensee and section 240 applies; or (b)  who is transferring to a related temporary long-term care home, a re-opened long-term care home or a replacement long-term care home operated by the same licensee. O. Reg. 246/22, s. 102 (13). (14) The licensee shall ensure that any pets living in the home or visiting the home have up-to-date immunizations. O. Reg. 246/22, s. 102 (14). (15) Subject to subsection (16), every licensee of a long-term care home shall ensure that the infection prevention and control lead designated under this section works regularly in that position on site at the home for the following amount of time per week: 1.  In a home with a licensed bed capacity of 69 beds or fewer, at least 17.5 hours per week. 2.  In a home with a licensed bed capacity of more than 69 beds but less than 200 beds, at least 26.25 hours per week. 3.  In a home with a licensed bed capacity of 200 beds or more, at least 35 hours per week. O. Reg. 246/22, s. 102 (15). (16) Every licensee of a long-term care home shall consider the complexity and vulnerability of their resident population in the home and shall determine if the infection prevention and control lead is required to work more than the minimum number of hours required by subsection (15) or whether to designate additional infection prevention and control leads as required. O. Reg. 246/22, s. 102 (16). (17) The designation of an additional infection prevention and control lead under subsection (16) does not relieve the licensee with respect to its obligation to ensure the minimum hours worked in subsection (15) by the infection prevention and control lead. O. Reg. 246/22, s. 102 (17). (18) The licensee shall oversee the development and implementation of a quality management program to assess and improve infection prevention and control in the home, as set out in a standard or protocol issued by the Director under subsection (2). O. Reg. 246/22, s. 102 (18). (19) Every licensee of a long-term care home shall ensure that the direct contact information, including a telephone number and email address that are monitored regularly, of all infection prevention and control leads for the home are provided, (a)  to the local medical officer of health appointed under the Health Protection and Promotion Act or their designate; and (b)  where there exists a person or entity that is designated as the relevant IPAC hub for the home under a funding agreement with the Ministry of Health, to that IPAC hub. O. Reg. 246/22, s. 102 (19). Prevention of Abuse and Neglect