Ontario's Ombudsman is calling for an overhaul to how long-term care homes are inspected.
Paul Dube says the system was in collapse during the first wave of COVID-19 in 2020.
He says the Ministry of Long Term Care did not have a plan for inspections during a pandemic, leading to none taking place for seven weeks.
"Even as reports of outbreaks and health risks to residents and staff inside the homes poured in, inspectors did not have access to personal protective equipment or training in infection prevention and control. Many were directed to contact long-term care homes by phone and take on more of a supportive role than an investigative one," says Dube.
He says inspectors relied on the homes to self-report.
His investigation revealed serious COVID-related issues, such as infection prevention and control, or personal equipment and protective equipment usage not being inspected in a timely manner or at all.
"The inspections branch also did little or often nothing when homes did file reports about COVID-19 outbreaks. Even when the inspections resumed and violations of the law were found, the inspections branch often took the least severe enforcement action available. Even in serious situations."
The Ombudsman launched an investigation following reports from Canadian Armed Forces personnel about the conditions inside homes they were called to assist at in the early days of the pandemic.
Dubé’s office does not directly oversee long-term care homes but received 269 complaints and inquiries from family members of residents.
Dubé focused his attention on inspection and enforcement-related activities and made 76 recommendations.
“The people of Ontario should be able to count on their public services to learn lessons from our experience with COVID-19 and be adequately prepared for the next threat to our collective health,” says Dube.
The Ministry has accepted all of the recommendations and is committing to report on its progress to implement them every six months.