board of directors meeting open session a g e n d a

BOARD OF DIRECTORS MEETING

OPEN SESSION

Thursday, September 26, 2019

5:30 pm – Hot Buffet Dinner Provided – La Verendrye General Hospital –Board Room

6:00 pm – La Verendrye General Hospital – Board Room

A G E N D A

Item Description Page

1. Call to Order – 6:00 pm – Reading of the Mission Statement *

1.1 Quorum

1.2 Conflict of Interest and Duty

2. Presentation – Finance 101 – C. Larson *3. Patient / Resident Safety Moment – Accreditation Tracer Video4. Consent Agenda

4.1 Board Minutes – June 25, 2019 *4.2 Chair’s Report – J. Ogden4.3 President & Chief Executive Officer Report – T. Scholten *4.4 Clinical Services Report – J. Loveday *4.5 Corporate Report – H. Gauthier *4.6 Long Term Care Report – B. Harten *4.7 Chief of Staff Report – Dr. M. Kowal *4.8 Governance Committee Report – J. Begg *4.9 Audit & Resources Committee Report – J. Beazley *4.10 Quality Safety Risk Committee Report – S. Weir4.11 Community Advisory Council Report – T. Scholten *4.12 Riverside Foundation for Health Care Report *4.13 Auxiliary Reports *

5. Motion to Approve the Agenda

6. Business Arising

7. Quality, Safety, & Risk Strategic Discussion – Covered with Item 3.0 Accreditation Tracer Video

8. New Business8.1 Board Member Consolidated Confidentiality, Accountability & Roles & Responsibility

Statement – Annual Signing *8.2 Board Chair Report – Verbal Update8.3 Rainycrest Update8.4 OHA – Governance – Advanced Board Portion of the Northern & Rural Health Leadership

Conference Board Member Overview – J. Begg9. Opportunity for Public Participation

10. Move to In-Camera

11. Other Motions/Business

12. Date and Location of Next Meeting: October 24, 2019 – Emo Health Centre

13. Adjournment

* denotes attached in board package / **denotes circulated under separate cover / *** denotes previously distributed

Board of Directors - Open Session September 26, 2019 1 of 63

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BOARD OF DIRECTORS MEETINGANTICIPATED MOTIONS – OPEN SESSION

Thursday September 26, 2019

5. Motion to Approve the Agenda THAT the RHC Board of Directors approve the Agendaas circulated/amended

10. Move to In-Camera THAT the RHC Board of Directors move to in camerasession at (time)

11. Other Motions/Business

13. Adjournment THAT the RHC Board of Directors meeting beadjourned at (time)


Our MissionImproving the health of every person we serve, responding to the needs of our communities.

MISSION

Innovative, high quality health care - inspired and delivered by our team and partners.

VISION

STRATEGIC PILLARSQuality • Organizational Health • Partnerships • Advocacy

R I V E R S I D E H E A L T H C A R E

Our ValuesVALUESIntegrity • Respect • Excellence • Growth

Our Vision


•Healthcare Finance 101: Agenda

. The Basics

ci Service Accountability Agreements

s Funding

Rh ancial Compliance Requirements

Item 2.0


Heafthcare Finance 101:The Basics

Reports øperabng Revenue & ExpenseSummary, Balance Sheet

?evenues & Expenses

s Surplus vs Deficit vs Balanced Budget

Fiscal vs Calendar period

s Budgets

RiversideH


Riverside

*1

Operating Revenue & Expense Summary

April 1,2019 to August31, 2019

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Fund Type 2- LHIN Funded -Counselling S Non Profit Housing ProgramsMental Health - Case Management - Housing - Addictions - Problem Gambiln

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Fund Type 3- Oth.r MInistry/Agency Funded - Non Hospital ServicesPartner Assault Response - Family Violence

Fund Type 2 - LHIN Funded - RainyCrest Community Support Services(Home Support. Assisted Uving. Adult Day. Meals on Wheel,)

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Healthcare Finance 101:Budgets

.

s HAPS (tpitai Accountability PlannmgSubmission)

s CAPS (Community Accountability PlarmingSubmission)

LAPS (Long Term Care Home AccountabilityPlanning Submission)

Healthcare Finance 101:Service Accountability

Agreementss HSAA: Hospital Service Accountability

Agreement

c MSAA: Multi-Sector Service AccountabilityAgreement

ri LSAA Long Term Care Home ServiceK:countability Agreement

s Other Funding Agreements


Healthcare Finance 101:Funding

+ Global Funding • Level of Care Envelope Funding

+ HBAM: Health Nursing & Personal Care

Based Allocation r Program & Support ServicesMethod or Raw FoodActivity Funding Other Accommodations

4 One Time • Per Diem FundingFunding (LHIN •: Resident, Patient & Client Fees &and MOHLTC) Revenues

• Quality Based Other: Small HospitalFunding Transformation Funding, HIRF

(Health Infrastructure Renewal• Bundled Care Fund), and other program specificFunding funding


.3


Minutes of the Open Board Meeting – June 25, 2019 Page 1

RIVERSIDE HEALTH CARE FACILITIES INC.MINUTES

OPEN SESSION

Date of Meeting: June 25, 2019 Time of Meeting: 6:00 pm

Location of Meeting: La Verendrye General Hospital – Board Room

PRESENT: D. Robinson T. Scholten Dr. M. Kowal P. HowieC. Steiner S. Weir * C. McKinnon J. OgdenJ. Forbes J. Beazley J. Begg Dr. L. Jenks*via OTN/teleconference

STAFF: L. Maki, H. Gauthier

REGRETS: B.Booth

GUEST: J. Savage (Item 2.0), T. Morelli (Item 7.0)

1. CALL TO ORDER:

J. Beazley called the meeting to order at 5:59 pm. J. Ogden recorded the minutes of this meeting. J.Forbes read the Mission Statement.

1.1 Quorum

Jan shared there were no regrets. Quorum was present.

1.2 Conflict of Interest

No conflict of interest or duty was declared.

2. Presentation – Draft Financial Statements – BDO Auditor – Jeff Savage

Jan welcomed Jeff Savage, BDO Auditor, to the meeting. Jeff provided a summary of the financialstatements noting this was requested by the Audit & Resources Committee. The following washighlighted:

• Rainycrest LTC - $4.2 million deficit - $2.9 million to be recovered.• Overall Deficit for 2018-19 - $3.2 million.• “Going Concern” was discussed. Management agreed to the “going concern” note; RHC is at

risk to meet liabilities. Additional MOH funding is required. The “going concern” notation maybenefit in regards to requesting additional funding.

• The audit is in alignment with Ministry needs and meets standards.• Jeff read the auditor’s opinion noting a clean report in all respects. He reiterated this is still an

unqualified clean report even though there is a going concern. Jeff confirmed the going concernis as per auditing standards.

Jan thanked Jeff for attending and providing an overview.

It was,

MOVED BY: J. Begg SECONDED BY: D. Robinson

THAT the Board of Directors approves the 2018-19 audited financial statements, as reviewed andrecommended by the Audit & Resources Committee.

CARRIED.

Item 4.1



3. Patient / Resident Safety Moment

Ted and Lori shared a safety moment regarding alcohol hand sanitizers in high traffic areas disappearing.They shared lock boxes have been placed on the sanitizers to prevent this from happening.

4. CONSENT AGENDA

The Chair asked if there were any items to be removed from the consent agenda to be discussedindividually. Ted shared his President & CEO report referenced the Kenora Rainy River RegionalLaboratory Program’s 2018 Annual Report however it wasn’t attached. Ted offered a hard copy to themembers. The following was removed:

• 4.5 Corporate Report

5. MOTION TO APPROVE THE AGENDA:

ADD: 8.3 Corporate Report

6. BUSINESS ARISING:

There was no business arising.

7. Quality, Safety, & Risk Strategic Discussion – Patient Ombudsman – LTC Placement – T. Morelli

Jan welcomed Tara Morelli to the meeting who initiated a strategic discussion around the PatientOmbudsman – LTC Placement. Conversation highlights included:

• Fairness and equity in transition; transition into placement from another LTC home.• 4 hour drive for family while Rainycrest was closed.• Process into LTC through the LHIN is a big stress and there is confusion around process.• Relationship building between hospitals and LHIN’s.• Better the process for families; LHIN eligibility, rate the client to determine needs.• Category I – crisis (hospital holds), home client with needs not being met.• Category II – Reunited with spouse or partner.• Category III – Religion or ethnic.• Category IV – High care needs but most being met at home with services.• Veterans – Priority access – There are 3 beds at Rainycrest.• Improve communication to families.• Meet with the LHIN Home and Community Care weekly and prioritize.• Respite care needs as well and trying to balance this.• Resident and Family Handbook has been redone and provided to the LHIN Home and

Community Care and hospital.• Time in the home ahead of admission (ie. set up room prior to admission and finances).• Pharmacy orders 24 hours prior to avoid delays.• Welcome packages.• The survey post-admission shows very good results.• Management team personally greets new admissions at the door.

Jan thanked Tara for attending and speaking to this topic.

8. NEW BUSINESS:

It was,

MOVED BY: C. McKinnon SECONDED BY: J. Begg

THAT the Board approves the Agenda as amended.CARRIED.



8.1 Rainycrest Update

Ted provided an update highlighting the following:

• Gastro outbreak since June 20, 2019. 9 cases and 4-5 staff members affected.• Admissions are on hold until the outbreak clears.• The search for an Administrator continues. In the interim, Senior Staff are filling in.• Discussion took place regarding language and the term “outbreak” when communicating.

8.2 OHA – Northern & Rural Health Leadership Conference Board Member Overview – J. Begg

Jon provided a summary of the OHA – Northern & Rural Leadership Conference he attended. Highlightsincluded:

• Systems thinking; “complex not complicated”.• Client centered/direct care is the focus.• Impact of government decisions on municipalities (new and unknown pressures).• Physician recruitment / social isolation.• Rural Health Hubs.• Flexible medical delivery model for attracting and retaining new physicians.

ACTION: Jon will request the power point presentations and send to Brooke for uploading to the Boardportal.

ACTION: Jon will provide a summary on the Governance – Advanced Board portion of the Conferenceat the September Board meeting.

Jan thanked Jon for taking the time to attend these sessions.

8.3 Corporate Report

Discussion took place regarding the 8 critical incidents. Henry noted there was a peak in May. He notedthere is an increase in the culture of reporting now. Henry and Tara discussed reasons around theincidents noting new environments, new staff, outbreaks all contribute to the increased risk of the fallsreported. Conversation ensued around alleged abuse whether substantiated or not. Tara providedclarification.

9. OPPORTUNITY FOR PUBLIC PARTICIPATION

There was no public participation.

10. MOVE TO IN-CAMERA:

11. OTHER MOTIONS/BUSINESS:

There was no other motions/business.

It was,

MOVED BY: S. Weir SECONDED BY: C. Steiner

THAT the Board go in-camera at 7:08 pm.CARRIED.



12. DATE AND LOCATION OF NEXT MEETING:

September 26, 2019 – La Verendrye General Hospital

13. ADJOURNMENT:

It was,

MOVED BY: D. Robinson

THAT the meeting be adjourned at 8:16 pm.CARRIED.

________________________________ ___________________________________Chair Secretary/Treasurer


President & Chief Executive Officer Report - September 2019

Page 1

Strategic Pillars & Directions:

Quality

• Patient Census at LVGH has continued to remain relatively stable in the mid to high 30s. Thanks to all those that havehelped to coordinate scheduling of coverage in all departments and those taking extra shifts to assist us to this point.

• Ontario Health Teams (OHT) - little to no update from previous report. Group has not met as we await a data packagefrom the Ministry. In the meantime we remain designated as “In Development”. Again, according to the informationprovided from the Ministry contact, the proposal submitted by the North West (NW) was strong and met most of therequirements; however, we are required to provide additional information regarding performance measurement in orderto strengthen our proposal before we can be considered for submission of a full application. Our assigned MinistryContact person, Mr. Osagie Omere has advised us that we will receive "Patient Attribution Data" from the Ministry sometime toward the end of September, which will guide future discussions and directions in the development of our OHT. Asthe Ministry cannot guarantee time lines for the release of this data, we have been asked to wait until the information isavailable prior to scheduling our next NWOHT Working Group meeting. We have also been advised that a Ministry ofHealth representative will be in attendance at this meeting to facilitate a review of the data. In speaking with peer NWCEOs, it appears all are “staying the course” given the many unknowns that currently exist. Plan is for the NW WorkingGroup to reconvene with guidance from our Ministry contact as soon as the Data package is received.With the announcement of the results of the OHT Readiness Assessment submissions, it has become evident that someof the initial parameters changed significantly. We were initially told that OHTs would provide a full and coordinatedcontinuum of care for a defined population of approximately 250,000 to 300,000 people within a geographic region.Some of the teams, who have been invited to submit a full application, reflect a significantly smaller population base.Initial communications also suggested that the Ministry of Health would start with a small number of teams (5 to 7) whowould be selected as "Early Adopters" in the first wave of the proposed health care transformation. A total of 31 OHTswere invited to submit a full application by October 9th, 2019. We are all anticipating the announcement of the firstOntario Health Teams to be established in the Province, which we expect to receive sometime this Fall.The changing communications and parameter shifts have certainly created some confusion and unfortunately, raisedsome doubts in the process. There have been concerns raised across the Province regarding the changing parameters,evidence of political influence, the lack of clarity regarding expectations and the lack of transparency in the process. Wehave also heard that the NW OHT submission was impressive in terms of the content and the number of stakeholderswho were engaged in the process and we would like to maintain the positive momentum that we had achieved.

Organizational Health

• Visited Rainy River Health Centre September 13, 2019 and had opportunity to connect with patients, staff and thephysician on site. Although the facility has certainly stabilized from the flood, the recent loss of a long time staff memberand injury to another has been difficult.

• Initiating Senior Management Team Strategic Meetings 2 x Monthly in order to ensure we remain on task with Strategicpriorities. Reporting and Tracking tools are being introduced to ensure ongoing focus.

Partnerships

• Regional Orthopaedics Program- To date we have completed 33 of our 63 allotted Total Knee Joint Arthroscopies. Furtherorthopaedic services visits have been planned October 7-8. RHC has requested consideration of additional volumes,particularly Total Hip Arthroplasties as there have not been any completed here since 2018

• Kenova-Rainy River Regional Laboratory Program (KRRRLP):-o Fort Frances Hosted the KRR RLP Annual Symposium – this well attended 3 day event had more than 70

participants from across the NW with 20 + vendors. The Theme of the event was “Navigating the Technicaland Operational Future in the Laboratory. As Chair of the Board I was invited to attend official openingreception and provided opening remarks. CEO and Board members were encouraged to attend Thursdays’session focussed on challenges in recruitment and retention of Medical Laboratory Technologists. Advocacyefforts are needed to expand the availability of programs.

o Also Chaired first quarterly KRRRLP Board Meeting following conference.

• Attending Northwest Health Alliance Board Meeting October 24 and Regional NWLHIN CEO Working Group meeting.Verbal updates will be provided on the outcome of these 2 important meetings at the RHC Board meeting.

• Physician Recruitment and Retention:

Item 4.3


President & Chief Executive Officer Report - September 2019

Page 2

o FFLEG Logging ongoing. Next meeting Wednesday October 2, 2019 4:45 pm at Fort Frances Clinic.

Physician Recruiter attending NOAMA Annual LEG Meeting Toronto, November 8-9, 2019.

o GPA locums. Booked to February 2020.

o Dr. Carolyn Trottier approved revised Return of Service (ROS), committing to Fort Frances. Will know if

accepted into PGY3 Anaesthesia December 6, 2019. Timeline is likely Sept 2021 or earlier for GPA.

o Physician recruiter is maximizing locum housing with assistance from Human Resources at RHC. Definitely a

win–win.

o PR material released to New Gold, Anne Marie Rousseau. Short article for their newsletter very positive.

o Physician Recruiter is attending September 18-19 NOSM Recruit and Career Forum. Recruiter meetings in

morning, visit with NOSM residents and learners in the afternoon. He will discuss NW Ontario costs such as

overhead, incentives as well as recruitment challenges, GPA needs.

o Town CEO Doug Brown and Wendy Brunetta attended NOMA and lobbied the MOHLTC for

assistance/support with Physician Recruitment and Retention. No response.

o Society of Rural Physicians of Canada (SRPC) April 24-26; Northern Ontario Health Recruiter Association

(NOHRA) is offering NW Ontario communities to use their booth for a few hours; Ottawa April 24-26, 2020.

o Physician Recruiter is following up on a NOSM PGY3 Anesthesia resident from the area and provided our

info and contact.

Advocacy

• Attended OHA Small Rural Northern Council - the membership of this Council has changed with the retirement of a fewCEOs that formerly served on it. With Jan Beazley’s resignation I have officially assumed a position on the council as haveother replacement CEO’s. We met September 11 and discussed:

o Hospital Infrastructure Renewal Fund (HIRF)-no funds have been announced released to dateo LHINs- Variability across the province in terms of activity/leadership/scope of involvement with HSPs.o OHA Pre-Budget Advocacy priorities for OHA:

Relief Funding Training for LTC workers (PSW) Annual increase –beyond inflation Small Hospital Transformation Funding added to based funding but how do restrictions still apply?

o Stand Alone Nursing Degree Programs at Colleges - Ministry of Training, Colleges and Universities (MTCU) isconsulting with stakeholders on the current collaborative between universities and colleges and consideringwhether this affiliation needs to continue. Survey questionnaire feedback was provided.

• The KRRRLP will be drafting a letter of support to Minister Elliott due to the impending shortage of medical laboratoryprofessionals. We are anticipating that 44% of Medical Laboratory Technologists (MLTs) will be eligible to retire in thenext 4-8 years (potentially 3,000 people). The over 6,300 MLTs servicing Ontario laboratories process over 500,000 labtests each day. This shortage will impact each one of us using laboratory services in Ontario. Specifically we will berequesting:

o MTCU (Ministry of Colleges, Training and Universities) declare that seats in MLT programs across Ontario are apriority. (Cambrian College – Sudbury, St. Lawrence College - Kingston, St. Clair College – Windsor, OTU –Oshawa, Michener – Toronto). There is currently a wait list to each of these programs.

o Ministry of Health is looking at increasing funding for clinical placements in hospitals to support the increase inprogram seats.

o Ministry of Health is investigating the option to incentivize current MLTs that work in urban centers to relocateto rural and remote communities. These remote communities are experiencing this shortage now.

Respectfully Submitted,

Ted ScholtenPresident and CEO


Clinical Services & CNE Report – September 2019

Strategic Pillars & Directions

Quality

• AccreditationPreparing for Accreditation on October 7-10

th, 2019.

• OCP VisitOntario College of Pharmacists (OCP) survey of compliance to set standards is booked for September 23 & 24

th, 2019.

Riverside has been chosen as a pilot site.

• QI Reports QI Report submitted regarding the culture assessment survey completed by the participants of MoreOB. This

reflected a very different picture of the organization, compared to the worklife pulse survey. This survey identifiesspecific culture elements, which are: Open Communication, Learning, Empowering People, Teamwork, ValuingIndividuals, and Patient Safety. The scale is from 1 (Never True) to 5 (Always True). The results showed that in the sixcategories listed the scores were between 4.42-4.53. (4 being “often true” and 5 being “always true”).

QI Report submitted regarding ICHAT/ISBAR ((Identification, Current condition, History, Assessment andTreatment/Identification, Situation, Background, Assessment and Recommended Treatment) utilization.Communication has been identified as a major contributing factor in adverse events. The ICHAT/ISBAR tool is used toprevent communication errors and to improve consistent and effective communication. This audit was completed toidentify compliance with utilizing the ICHAT communication tool. Two physicians audited each time a nurse calledregarding a patient. It was identified that the first two components of the tool were completed 100% of the time,while 50% of the callers completed all the components of ICHAT.

QI Report submitted regarding the amount of times that we are debriefing post a delivery. Over a two month periodthis showed that we are debriefing 86.4% of deliveries.

• Patient Information BookletThe Patient Information Booklet has been updated. This booklet is located at every inpatient’s bedside.

• Surge Learning Quality PolicyPolicies & procedures are now in our surge program. Updating of policies & procedures have and continue to occur.Communication and reinforcement to staff has occurred and will continue.


• Director of Inpatient & Emergency ServicesJulie Cousineau, also known as Julie Barnard has started in this new position September 9, 2019.

• Obstetrical CourseWe are providing an in-house obstetrical course. Course will start the beginning of October and run until December. Theformat is following MoreOB and the model is one day of class/week with buddying or mentoring in between class sessions.

• RecruitmentHuman Resources are a challenge in various areas of health care and clinical services. Continued recruitment and hiring isoccuring.

• NOSM StudentsRHC was successful in recruiting three NOSM funded nursing students this summer which were located at LVGH. Thisconsisted of being on the nursing units in the morning, followed by project work in the afternoon. In the past years, a highpercentage of these NOSM students end up working for Riverside, after their program completion.

• EducationACORN (Acute Care of at-Risk Newborns) course provided.LEAP (Learning Essentials Approaches to Palliative Care) course September 9 & 10, 2019.MoreOB continued throughout the summer.RCCR (Regional Critical Care Response) Road Tour Education - September 19, 2019.

• Operational ReviewSenior Leadership sat in with interviewing departments with Big Health Care.

• Rainy River Health CentreRainy River Centre re-opened July 18, 2019. This re-opening was post the flood that occurred in January.

Partnerships

• Partnerships with Education SystemEducation partnerships continue with programs beginning this month. Partnerships include Fort Frances High School,Confederation College, and University Programs. Attended Seven Generations grand opening; communications forpartnering with their pre-health and nursing program was discussed.

Item 4.4


Clinical Services & CNE Report – September 2019

• Partnership Proposals1. A Proposal was submitted regarding “Rainy River District Joint Mobile Response” in partnership with CMHA (Canadian

Mental Health Association), OPP (Ontario Provincial Police) and Fort Frances Tribal Area Health Services (FFTHAS).2. A Proposal was submitted regarding “Partnering in Healing-Bridging the Gap towards a Rapid Access Addiction

Medicine (RAAM) Clinic”. This was done in partner with Fort Frances Tribal Area Health Services (FFTHAS) andNorthwestern Health Unit (NWHU).

• Managing Obstetrical Risk EfficientlyRHC MoreOB simulation lab for September was “Imminent Birth”. This was done in partnership with Rainy RiverAssociation of Professional Paramedics (RRAPP). The scenario was staged to have a delivery in the back of the ambulanceon the LVGH emergency ramp.

Advocacy

• Partnership ProposalsProposals submitted to the LHIN to expand services offered in partnership with our community partners to provideimproved services to our community.

• Operational ReviewParticipated in operational review with Big Health Care September 5 & 6, 2019.

Thank you to the Clinical Services leaders for their submissions that prove to be invaluable in the preparation of this report.

• Tammy McNally, Director Nursing Practice & Manager of Care Rainy River Health Centre

• Glenna Morand, Director Outpatient Services & Manager of Care Emo Health Centre

• Cindy Cole, Director Patient Safety & Perioperative Services

• Julie Cousineau, Director of Inpatient & Emergency Services

• Toni Benning, Manager, Laboratory

• Bernie Rittau, Manager, Diagnostic Imaging

• Marty Nelson, Health System Navigator

• Joelle Buist, Patient Experience & Flo Coordinator

• Jodi Jewell, Infection Control Practitioner

• Stephanie Cousineau, Pharmacist


Julie LovedayVice President, Clinical Services & CNE


Corporate Report – September 2019

Strategic Pillars & Directions


• Senior Team Changes – Barbara Harten, Vice President, Long Term Care & Administrator and Julie Loveday, VicePresident, Clinical Services & Chief Nursing Executive joined the RHC Senior Team on September 9, 2019. Barb and Juliebring a wealth of experience to our team and will be instrumental in charting our organization’s successful path forward.We ask that you join us in welcoming both Barb and Julie to our team.

• Right Size Funding & Operational Review – Big Health Care was onsite September 5-6 to conduct interviews with Directorsand review preliminary benchmarking results. Big Health Care is currently synthesizing the information they havecollected and are scheduled to return late September/early October to share their initial analysis, findings and discussdirection for recommendations with the Senior Team. The final report remains on schedule for completion by the end ofOctober, at which time the Senior Team and service departments will initiate validation and prioritization of therecommendations.

• Housing Donations – a meeting was held with the Foundation on September 10th

to confirm that the La Verendrye NonProfit Supportive Housing program is, in fact, funded through and part of RHC; only the buildings are part of the separateLa Verendrye Non Profit Supportive Housing Corporation.

• Reorganization – with the introduction of two new VP positions, RHC has initiated restructuring; however, clinicalmanagement and corporate services are also reviewing their structures and planning further reorganization to ensureproper alignment and the most effective use of leadership resources.

Partnerships

• Opioid Addictions Treatment Funding – A proposal titled “Partnering in Healing – Bridging the Gap towards a Rapid AccessAddiction Medicine Clinic (RAAM)” was submitted by RHC and Fort Frances Tribal Area Health Services (FFTAHS) throughthe Opioid Strategy Fund to increase access to community-based withdrawal management services. A full-timewithdrawal Management Clinical Coordinator (Registered Nurse) is being requested to provide clinical nursing supervisionand support to the Mino Ayaa Ta Win Healing Centre to support clients requiring long-term antibiotic therapy. Inaddition, a full-time Addictions Counselor for RHC has been requested to facilitate the evolution of a RAAM clinic byaccommodating walk-in/same-day appointments. The NW LHIN has communicated they will be contacting RHC in thenext few weeks to discuss our submission. An additional proposal, under the Federal Addictions funding program, isbeing prepared by RHC, FFTAHS and the Northwestern Health Unit to expand the speciality resources available to theRAAM clinic and to enhance the model to provide a level of support across the District. There is no indication regardingthe likelihood of success for this proposal at this time.

• Crisis Mobile Response Services Funding – RHC, the Rainy River District OPP, FFTAHS and CMHA Fort Frances partnered tosubmit a crisis mobile response services proposal to the NW LHIN. The Joint Mobile Response proposal is a Rainy RiverDistrict focused crisis response solution and is comprised of two components; Emergency Department and OPP crisisservices. The Emergency Department service provides for 24-7 crisis response coverage; including 8am-4pm Monday-Friday coverage by the Health System Navigator and after hours and weekend coverage by an on-call crisis responseworker. The second part of the proposal includes a CMHA-Fort Frances worker embedded in the Fort Frances OPPdetachment to support police services calls, conduct follow up and provide supports at the local jail. On September 17

th

the partners engaged with the NW LHIN to discuss this proposal; we anticipate approval in the coming weeks.

Quality

• Community Programs monthly meetings – starting on October 1st

a monthly meeting will be held with our communityservice leaders and the senior team to ensure a collaborative path forward for these programs. The presence of hospitaland long term care leadership and all RHC community program leads will allow us to advance our community programswith a highly integrative view. In early September senior team representatives attended a tour of the LaVerendrye NonProfit Supportive Housing program, including the transitional and crisis housing at the Nelson Street location and thesupportive housing at the Front Street location. In addition, a meeting is scheduled on September 19

thwith the RRDSSAB

housing director to discuss further partner opportunities.

• Senior Team Weekly Operations meeting – on September 11th

RHC began to hold weekly Senior Team Operationsmeetings, with a focus on priority issues and system improvement opportunities. This weekly meeting includes the seniorteam as well as finance, human resources, capital planning and quality-safety-risk-privacy to ensure well-balancedrepresentation.

• Energy efficiency – A team of representatives from Honeywell was onsite September 9-10 to conduct an initial review ofour physical sites to determine energy efficiency opportunities. Honeywell offers a program that will provide the funds toorganizations to implement priority projects; the financial return to Honeywell is provided through qualifying Federalgrants and the recovery of efficiency savings from the health care organization. This is just one opportunity beingexplored by RHC at this time.

Item 4.5


Corporate Report – September 2019

Advocacy

• Occupancy Clawbacks – A meeting is scheduled with the Assistant Deputy Minister of Long Term Care (ADM LTC) onSeptember 24

thto discuss the occupancy claw backs resulting from the closure of Rainycrest; this meeting was deferred

until all compliance were lifted at the Home. A portion of the 2018 occupancy recovery is scheduled to start in Octoberso it is prudent to discuss the 'Art of the Possible' with the ADM LTC. For RHC, the Art of the Possible means forgivenessof these claw backs by the MOHLTC.

Thank you to the following individuals for their contributions this report.

• Brenda Wood, Manager of Community Support Services, Assisted Living Services and Transportation

• Gwen Miller, Manager, LaVerendrye Non Profit Supportive Housing

• Lisa Belluz, Director, Counselling Services

• Ed Cousineau, Director of Capital Planning, Engineering & Environmental Services

• Simone LeBlanc, Director, Food Services & Coordinator, Quality, Safety, Risk Management and Privacy

• Jason Marchand, Director of Human Resources

• Carla Larson, Director of Financial & Patient Information Services

• Marie Brady, Director of Information Systems & Technology

• Barbara Harten, Vice President Long Term Care & Administrator

• Julie Loveday, Vice President Clinical Services & Chief Nursing Executive


Henry GauthierExecutive Vice President & Chief Operating Officer


Long Term Care Services Report - September 2019

Page 1

Strategic Pillars & Directions:

Quality

• Medication Management – implementation of the Medisystems PharmacyTransitions started August 27, 2019, ‘Go-live’/Final phase end of January/early February 2020.The Ontario Pharmacists Association (OPA) produced best practice guidelines to help homes maintain compliance withthe regulations related to medication management systems. These guidelines refer to the strip packaging that is beingimplemented.

• Prevented an outbreak for Respiratory illness from September 10th

to September 16th

- High alert was implemented toensure that there was compliance with preventive measures within all internal departments. (i.e. high touch cleaning;respiratory droplet precaution procedure in place; proper use of PPE etc.)

• MOH&LTC inspection Report issued on August 1, 2019 - 6 Written Notifications; 5 Voluntary Plan of CorrectionA corrective action plan is in development the week of September 17

thwith the date of completion before

September 25th

.

• Accreditation Activities – Monthly accreditation meeting, preparing Evidence box for Accreditation for next month.

• Post Admission Survey – Continue to conduct Post-Admission surveys regarding admission process. Survey themescollated and shared with staff & management.

• BIG Health Care – met along with senior administration with consultant team to provide insight into LTC operations,provided staffing/support schedules for nursing departments and all job descriptions. Further discussions to come.

• HCA Rotations – Line selections occurred August 12-16, 2019. Trial 12hr extended tour HCA schedules to commenceOctober 7, 2019. All fulltime lines now occupied. Combined some vacant new part-time lines to create an additional 7fulltime, as recruitment continues cross Canada and fulltime more appealing for this population of HCAs.

• Non-Violent Crisis Intervention (NVCI) – first course offered at Rainycrest, instructed by Rainycrest staff. Continue to bookmonthly and prioritize staff to receive training.

• Renovations/Upgrades – Rainycrest Infrastructure

• Special care unit - install window coverings, order has arrived and is in stock at Revco – installation later this week orearly next week

• Painting/New drapes/New signage etc. for the front lobby entrance – started September 18th

Residents/Families/POAs involved with selection of colours/specific ideas – over 200 ballots received

• Flooring replacement – front lobby – reviewing options – obtaining quotes

• Dining room furniture – table/chairs – specific type of tables to accommodate residents in wheelchairs

Organizational Health2019 Occupancy Report for the month of August:

Rainycrest: MTD YTD Basic Beds: 92.52% 76.55% (Occupancy Target: 97%) Interim Beds: 50.00 % 53.43% (Occupancy Target: 90%) Convalescent Beds: 00.00% 00.00% (Occupancy Target: 80%) Respite Beds: 100.00% 29.63% (Occupancy Target: 50%)

No potential applicants on wait listNext steps: revisit the convalescent program structure and process

Maintain above 97% long term care beds occupancy rate

EMO LTC Elcap Beds 100% MTD 98% YTDRainy River Elcap beds 100% MTD 98.6% YTD

• Ron Hagerty, Spiritual Care worker hired – 10 hrs/per week – liaise with the Ministerial Association and is an activeparticipants as a member of the Management Team

• Full time scheduler has been hired – start date to be determined

Case mix Index – helps to understand the characteristics/needs of the resident population

Item 4.6


Long Term Care Services Report - September 2019

Page 2

RainycrestApril 1

st2018 to March 31

st2019 CMI value: 1.1685

April 1st

2019 to June 30th

2019 CMI Value: 1.1747

EMOApril 2019 to June 30

th2019 CMI Value: 1.0768

Rainy RiverApril 1

st2019 to June 30

th2019 CMI Value: 1.0621

Partnerships

• Extendicare Assist Consultants:Brad Hall, Regional Director: September 9-13, 2019 (Done)Jennifer Bilbie, LTC Consultant: September 23-27, 2019Heather Khoury, LTC Consultant: September 30-October 4, 2019 > Data Accuracy ReviewKim Redeker, Dietitian Consultant: ongoing monthly conference call

• PSW Classroom – Partnering with Confederation College to coordinate 2nd PSW Classroom, not enough enrolment forcondensed curriculum. Now 5 HCAs (3 international, 2 local) in 2 year program. Will investigate opportunity for winterclass.

• Fort Frances High School Cooperative Program: Supporting a coop student in nursing department at Rainycrest thisfall/winter semester.

AdvocacyFamily Council meeting – September 2019

• Attended the Family Council Meeting as an opportunity to get to know each other better and to establish meaningfullines of communication. We are hoping at the meetings to deal directly with family concerns and ideas, to conveyneeded information to families and to decrease resident and staff turnover by creating workable ways to deal withfamily dissatisfaction.

Thanks to the management team for providing information on their departments for this report.


Barbara HartenVice President Long Term Care Services & Administrator


Chief of Staff Report – September 2019

From an inpatient perspective Riverside faired fairly well over the summer with no reports of crisis overflow. Our contingencyplan has only been tried in practice one time, in May 2019. Since then our medical staff has been trying to address the issuesthat have arose surrounding some of the technicalities that need to be clarified in order to reinstate our contingency plan. Thedecision to divert medical patients to another facility is always a difficult one, with many factors at play regarding who getstransferred, emergency versus acute versus those waiting for long term care. This has created much debate and the need for amore in-depth look at our options and order of operations during census crisis requiring the invoking of any contingency plan.

We welcome two third year clerkship medical students this year from the Northern Ontario School of Medicine, Jeremy Strainand Jilayne Jolicoeur. Both of these medical learners are from Fort Frances and we welcome them back to their homecommunity to continue their medical learning. Jeremy and Jilayne will remain in Fort Frances until April 2020 and will rotatethrough our physicians, surgeons and allied health care staff to ensure a comprehensive, inter-professional, communityengaged and culturally sensitive learning experience. The third year medical clerkship year through NOSM allows students toexperience rural medicine in Northern Ontario communities. Integrated learning combines different aspects of medicine on aweekly basis, as opposed to core rotations where they are immersed in only one aspect of medicine at a time. The third yearclerkship allows for a much smaller learner to preceptor ratio, with more hands on clinical experiences. In addition there is afocus on social accountability and ensuring that learners are immersed in the numerous health care challenges present in ourcommunity.

With Accreditation coming up in October, our medical staff has had several information sessions in order to better prepare forthis process. We continue to encourage questions and scenarios in the next few weeks leading up to the final date whenaccreditors are here.

Respectfully submitted,

Dr. M. KowalChief of Staff

Item 4.7


Governance Committee Report – September 2019

4.8.1 Board Work Plan *

4.8.2 Terms of Reference *

4.8.3 2019-20 Committee Work Plan *

4.8.4 Governance Policy Review Schedule *

4.8.5 2018-19 Board Professional Development Update *

4.8.6 2019-20 Board Professional Development Presentation Topics *

4.8.7 FIPPA Delegation of Authority Briefing Note *

Item 4.8


Board of Directors Work Plan 2019-20

1

STRATEGIC PILLAR: QUALITYGoal: RHC Delivers Optimal, Safe and Equitable Care.

Task Activity / Tactic Responsibility Timeline/Complete

Outcome / Accomplishment

Ensure that appropriate structuresare in place to assess and monitorthe quality of care provided at RHC,focusing on staff engagement andutilization of metrics

Ensure appropriate structures are inplace for risk identification andmitigation.

• Approve and review IntegratedPatient Safety, Quality and RiskFramework

• Align and participate in regularQuality reporting

• Morbidity & Mortality Review,relevant MAC updates

• Monitor lost-time, overtime• Review Board Quality, Safety,

Risk Policy and Terms ofReference annually

• Update/review Risk governanceprocesses

• Review critical incidents regularly

QSR/ Board

QSR

Chief of Staff

A/R & Board

Governance

Governance

QSR/Board

Annually

Quarterly

Quarterly

Quarterly

Sept

May

Quarterly

• A consolidated plan for patient /client/residentsafety, quality and risk at RHC

• Enhanced communication, education andcompetency at every Board meeting; institutedregular patient/client safety moments, storiesand experiences

• Enhanced awareness, competency andprogress with RHC quality indicators

• To see continuous improvement/performance

• To assess, evaluate and enhance the overallrisk management strategy and processes

• To ensure awareness and follow up of criticalincidents

Oversee and monitor thedevelopment of the RHC QualityImprovement Plan (QIP)performance and make adjustmentsas required

Ensure Standing Item discussionsof Quality Safety Risk are occurring.

• Oversee and approve the RHCQIP

• Monitor QIP performance• Work towards a single QIP

Board

QSR

Q1Annually

Quarterly

• Board awareness of corporate patient/clientsafety and risk management

• Identification of appropriate measures ofperformance

• Plans to address variances from performanceindicators are addressed

• Patient Safety data included in quarterly qualityreport

• 4 board members on Board QSR Committee,with1 Community rep/board member in waiting(if available)

• Board Member appointed as Committee Chair

Ensure Long Term CareCompliance

• Monitor VP Reports and otherprogress reports regularly

Board Monthly • To ensure Compliance directives are being metand any compliance issues are beingaddressed.

Oversee safety and risk • Monitor reporting via AEMSsystem

• Participate in QSR Rounding

QSR

QSR

Quarterly

Monthly

• Safety and Risk issues are being addressed /mitigated



2

Goal: RHC Improves Access to Care across Continuum


Outcome/ Accomplishment

Ensure and evaluate access toCare across the continuum

• Support SMT in pursuingadditional partnershipopportunities to improve accessto care

• Identify partnership opportunitiesfor the SLT to evaluate

• Advocate to funders/governmentas needed to address fundingrelated gaps that interrupt thiscontinuum

• Review of CCC

Governance

Governance/AR

QSR

Ongoing

Ongoing

Ongoing

• Enhance seamless patient/client transitionsacross the continuum of care

Oversee recommendations fromBIG Healthcare Review asappropriate

• Support SMT in pursuingrecommendations as appropriate

Governance/ AR Ongoing • Report from SMT at governance/ AR• Maximized integration of staff and funding• Seamless transition of client care and staffing

between facilitiesEnsure First Nations Engagement • Evaluate, participate, and

support SMT in First Nationengagement

Governance Ongoing • Culturally recognized and appropriate care forarea first nation clients

Ensure Improved corporatealignment in systems andprocesses across all sites

• Support New Payroll/ HR suite• Evaluate New Helpdesk program

to monitor and track

A&R Ongoing • Maximized integration of resources

Goal: RHC Commits to Continuous Quality Improvement.



Ensure Accreditation Canada award • Participate in the accreditationprocess

• Support the organization toachieve its mandate

• Monitor of Ethics Framework/decision making/TOR/membership (Business Plan)

Board

Board/CEO/Ethics Committee

Ongoing

Ongoing

• Be accountable and “maintain and improve tomeet current standards”

• Receive quarterly updates on accreditationrecommendations

• Ethics committee in place which reportsthrough Board QSR Committee regularly.

• Utilize Ethical Decision Making Tool for makingdecisions

Appoint professional staff on • Board reviews and approves MAC/Board Monthly or • To ensure appropriate credentialed staff are in



3

recommendations of the MAC based on recommendations as required placeAppoint Department Chiefs andHeads as required

• Board reviews and approvesbased on recommendations ofJoint Medical Staff

MAC/Board Annually • Completed via recommendation of Joint MedicalStaff and MAC

Ensure Implementation of QualityImprovement Plan (QIP) with focus onstaff engagement

• Implementation of Qualitymanagement tools

Governance Ongoing • Incorporating WL Pulse results and action planinto Strategic plan

Goal: RHC Enhances Patient/Resident/Client Experience



Board Quality, Safety, RiskCommittee reviews experiencesurveys

• Enhance further communityfeedback

Board/CEO/QSR/SMT

Ongoing • Both positive and negative patient/residentstories and experiences are shared at eachboard meeting.

• Enhanced Patients/Family Advisory Council withsunset of CAC

• Continue to engage LTC Residents councilsand Family Councils at 3 sites

STRATEGIC PILLAR: ORGANIZATIONAL HEALTHGoal: Strong governance and leadership capacity.



A board action plan is developed andimplemented annually that features:

• A proactive board recruitmentstrategy using a skills basedmatrix,

• Succession planning for keyleadership positions,

• On-going board orientation,education and training, a

• A robust feedback and evaluationprocess

• Develop a plan for boardsuccession

• Nominating Committee of theboard to:o recruit new board memberso further refine skills matrix

and inventory developed

Nominating/RecruitmentCommittee

January

June

• Qualified and skilled individuals who arecommitted to the corporation's vision, missionand values will be nominated to fill availablevacancies on the board

• Approval by all Board Members

• Exit interviews will be conductedwith departing board members

Chair &Vice-Chair

June • Collect the wealth of information through exitinterviews with departing board members

• Gain an honest assessment of the board’sperformance and ensure that all concerns areaired

• Recognize and appreciate an outgoing boardmember for their contributions to the board

• Help the board member have a positive closurewith the board



4

• Implement a brief evaluationform following the boardmeeting (board members only)

BoardGovernance

On-Going • Ensure meetings enhance board performanceand effectiveness

• Freedom of Information Report

• Privacy Delegation

BoardGovernance

March

June orSeptember

• Ensure compliance with Legislation

• Annual board motion

• Complete a Board ChairEvaluation survey

BoardGovernance

May • Form developed and applied annually• Results presented in June or September

• Review the Roles &Responsibilities of the BoardStatement & the BoardAccountability Statement

• Monitor Governance QualityMetrics

All boardmembers

Quality/Safety/Risk / Board

September

Quarterly

• Ensure the board exercises a governance role instrategic planning, financial oversight,risk/quality, CEO and Chief of Staff supervisionsand succession planning, communication, andgovernance

• Review governance metrics quarterly throughthe QSR Committee of the Board

• Complete an annual board self-evaluation survey

All boardmembers

May

June orSeptember

• Determine effectiveness of meetings• Review attendance and participation at

meetings• Recognize board achievements• Identify areas for improvement• Annual board self-evaluation survey (June)• Results included in board package for

discussion

• CEO Evaluation:Using up-to-date jobdescription/job outline, and anannual process for the CEO toset their goals and objectives forannual performance in specificand measurable terms. Such aprocess takes into account thegoals and objectives establishedin the existing strategic plan

Board/CEOevaluation

committee andboard members

June

June orSeptember

• Clarify expectations between the board and theCEO

• Provides feedback to the CEO as a basis forcontinuing positive performance and takingcorrective action

• Forms a basis for providing the CEO withdevelopmental support, where helpful

• Provides an objective and fair basis fordetermining compensation and bonus decisions

• Results shared with Board



5

• Chief of Staff Evaluation:Using up-to-date jobdescription/job outline, and anannual process for the COS toset their goals and objectives forannual performance in specificand measurable terms. Such aprocess takes into account thegoals and objectives establishedin the existing strategic plan

Board Chair,Vice-Chair and

COS

June

June orSeptember

• Clarify expectations between the board and theCOS

• Provides feedback to the COS as a basis forcontinuing positive performance and takingcorrective action

• Forms a basis for providing the COS withdevelopmental support, where helpful

• Provides an objective and fair basis fordetermining compensation and bonus decisions

• Results shared with Board

• Complete a Committee Self-Assessment Survey

All boardmembers

June/September

• Obtain feedback on effectiveness of committees• Complete in June with reporting and discussion

in September

• Executive compensation Board Annually • Executive compensation which will be requiredto be linked to achieving improvement targetsset out in the annual quality improvement plan(Excellent Care for All Act 2010)

• Policies related to governancewill be kept current

• Establish Policy ReviewSchedule

All boardmembers

Ongoing • Ensure compliance with new or changedregulations, legislation, specific mandates byregular review of current policies, and approvalof new policies

• Ensure ongoing, regular policy review

• Approve committee terms ofreference and committeeworkplans

Committees/Board

Annually • Regular review and revise as necessary at eachcommittee meeting with recommendationsbeing forwarded to the Board for approval

• RHC By-laws to be kept current

• Develop an ad-hoc group toreview by-laws, policies andboard workplan

BoardGovernance

Board & CEO

January

February

• Review of by-laws completed annually, withrevisions made as needed

• By-laws and policies are in compliance with thePublic Hospitals Act, Excellent Care for All Act,OHA prototype by-laws, etc.

• Annual Meeting Process All boardmembers

June • Receive reports• Approve audited statements• Approve by-law revisions, if needed• Appoint an auditor

• Board Orientation provided fornew board members

New boardmembers

August orSeptember

• New board members understand theirresponsibilities

• Board orientation

• Mentoring for new boardmembers

All boardmembers

September • Cohesive engaged Board



6

• Education for Board Members All boardmembers

Ongoing • Encourage/support board members withparticipation in learning opportunities activities:

• Accessibility to books, articles, manualsgovernance

• Monthly education component in board package• Conferences, workshops, webinars, etc.

communicated to board members regularly• Departmental and other relevant presentations• Individual board members prepared to discuss

the education articles monthly• Record members continuing education and

attendance

• Ensure and monitor a processfor supporting qualified staff whoaspire to the CEO position

All boardmembers

CEODirector, HR

Ongoing • Ensure that in the event of a CEO vacancy themost highly qualified, appropriate individual isavailable

• Maintain CEO Succession Plan Policy andProcedures (model after OHA Conference –Ottawa example)

Strategic Plan and Refresh • Fall Retreat to ensure clearStrategic Plan direction

• Regularly review and update thestrategic plan

• Review progress on specificstrategic pillars

Board/SeniorTeam

Annually

Quarterly

• Strategic Plan Retreat October 4th

and 5th

2019• Corporation is on track and makes adjustments

accordingly• Quarterly updates to the Board

Goal: Supports and maintains a healthy, engaged contemporary workforce

Tasks Activity / Tactic Responsibility Timeline/Complete


Ensure development of a values-based, teamwork culture

• Assess current state ofalignment with existing values

• Strategic Plan roll-out Spring/Summer/ Fall with re-educationre-branding Mission, Vision,Values, Strategic Direction

governance November

January

• Assess and communicate current state

• Improved awareness, understanding andimportance of values in RHC corporate culture

Monitor and evaluate an HR ledTalent Management Plan

• Monitor key metrics reportedthat feed into plan: e.g.) labourdemographics & successionplanning, recruitment and

Governance Ongoing • Assurance of Succession Plan in continuity withAccreditation standards

• Completed Performance Evaluation with goalsand objectives



7

retention strategies,professional development plan,performance management plan,updated HR policies, training oncultural competency

• Continue monitoringPerformance conversationscompletion

AR Quarterly

• Ensure high quality

• Current CEO assessment ofinternal succession capacity

CEO/Governance

Annually • Ensure that the Board members are aware ofinternal succession

Monitor, participate and evaluaterecognition and appreciation activitiesutilized with staff, volunteers,physicians, etc.

• Utilize feedback from Work-LifePulse Themes that areincorporated into Strategic Plan

• Continue established practicesof recognition and appreciation

Board Ongoing • Summer Staff Volunteer Appreciation BBQs,• Holiday Spaghetti lunches• Annual Years of Service Awards Dinner• Foundation Events

Goal: Create and maintain effective and timely communication with all internal and external stakeholders .



Ensure timely communication with allinternal and external stakeholders

• Further define, sustain andexpand the StrategicCommunications Plan

• Ensure development of anAnnual Report to thecommunities we serve

CEO/Board/Communication

Lead

Annually • To enhance corporate communicationthroughout Riverside facilities and ensureregular structures in place

• Keep external stakeholders up to date on keyRHC issues and success stories

• Ensure visibility of CEO/SMT at all Riversidesites and ensure strong public profile in thecommunities we serve.

Ensure continued advancement of acorporate intranet for Board and Staffto enhance communication

• Enhance communication with aBoard intranet portal

Governance Ongoing • Enhanced communication• Security of Documents

Address cultural sensitivity incommunications

• Review current practices in allcommunication tools

GovernanceQSR

Ongoing • Enhanced signage in English/ Ojibway• Evidence of Education to Board Members

Ensure Reflected best practices onRHC Website

• Reflect transparency ingovernance by listing educationcompleted by Board members

Governance Spring • Ensure corporation transparency to the public.



8

Goal: Lifelong Learning

Tasks Activity / Strategy Responsibility Timeline/Complete

Outcome/ Accomplishment

Ensure Board ProfessionalDevelopment is provided

• Develop a board professionaldevelopment plan annually

• Board mentorship

Chair/Board Annually • Topics reviewed in September of each year witheducation sessions set for each board meeting

Ensure appropriate professionaldevelopment/ resources for CEO andChief of Staff

• Meet obligations of CEOContract ie: professionaldevelopment

• Ensure Chief of Staff hasopportunities for professionaldevelopment

Chair/Board Ongoing • Evidence of Education completion

Goal: Appropriate Use of Resources (human, technological, physical, financial)



Ensure Board fiduciaryresponsibilities are met

• Review and approve annualoperating plan assumptions

A/R and Board Annually • Evidence of compliance per schedule

• Review annual audit plan andinternal audit plan


• Approve compensation forauditors

• Approve compensation for Chiefof Staff


• Approve all SAA agreements Board March/April • Evidence of compliance per schedule

• Review and approve annualoperating and capital plans

Board Annually • Evidence of compliance per schedule

• All legislative compliancereviews and attestations

Board As required • Evidence of compliance per schedule

• Year-end audit/financialstatements

Board June • Evidence of compliance per schedule

• Senior Team Expense andBoard expense reports

A/R & Board Annually • Evidence of compliance per schedule

• Report on recommendations ofauditors

A/R & Board Annually • Evidence of compliance per schedule

• Review monthly financial A/R Monthly • Evidence of compliance per schedule



9

statements/reports

• Review Investment Policy A/R & Board Annually • Annual review and revise if necessary

• Line of Credit Board fromAudit/Resources

September • Annually review, amend if necessary andapprove line of credit with financial institution

• CEO Certificate of Compliance Board Quarterly • All applicable government laws and remittancesare processed

• Ensure use of Ethical DecisionMaking Framework - The EthicsFramework is developed to helpguide decision making

• Cyber policies and insurancescoverage

Board/SMT

Audit/Resources

Ongoing

Ongoing

• Recognition by NW LHIN of necessaryoperating requirements of a multi-site, multi-sector corporation (right size funding)

• Decision Framework developed and beingutilized.

• Annual review completed with insurance agent/broker of

• Pre-meeting with Auditors CEO/CFO/Audit& Resources

March/April • To discuss engagement and audit plan

• Post-audit meeting CEO & CFO June • To discuss audit results

• Board meeting with auditorswithout staff

Audit/Resourcesand/or Board

June • Governance best practice

Ensure appropriate physical facilitiesare in place

• Monitor process for a MasterOperating/Master Capital Planfor all facilities, with LTC beingthe first priority

Audit/Resources/Board

Fall • Progress the development of the MasterOperating/Master Capital Plans

STRATEGIC PILLAR: PARTNERSHIPSGoal: RHC will take an active role in strategic and transparent relationships with local and regional partners.



New partnerships developed thatcreate a more integrated regionalhealth system

• Enhance RHC profile atregional health care venues

• Continue to explorecollaborative opportunities thatcan be supported with existingresources

Board ChairCEO

SeniorLeadership

Ongoing • Represent RHC at appropriate regional healthsystem planning events, functions

• Seek/obtain leadership positions on regionalboards/committees to enhance RHC’s span ofinfluence

• Improved access to more outreach/satelliteservices from specialized service providers

• Continue to focus on governance to governanceactivities/meetings with our partners

• Continue to strive to the NWLHIN Blueprint for change and

Board/SMT Ongoing • Alignment with NWLHIN HSBP



10

provincial strategy

Goal: Advancement of Regional & Sub-Regional Priorities and Needs



Participate in the Ontario HealthTeam (OHT) development.

• Participate in the NW OHT &Sub Region Planning as theNW LHIN designated districtcampus

• Progress the OHT withCommunity Partners locally/regionally

CEO ordesignate

CEO/Designateand Board

designate asappropriate

Ongoing

Ongoing

• Identify and engage key stakeholders• Develop and sign Memorandum of

Understanding with Partners• Where appropriate, develop voluntary

integration plans for submission to NW LHIN

• Work in partnership to maximize appropriateservice utilization

Continue to pursue sharedgovernance opportunities

• Review and approval of aMemorandum of Understandingwith our System Partners

Board • Approved a Memorandum of Understandingwith system partners

• Developed and approved a RRDW Rural HealthHub Vision, Mission, Values and principles

Goal: Leverage mutual opportunities for enhancements for services as they arise.



Ensure ongoing engagement with allsystem partners to share resources

• Gateway to Health - singleaccess to all District Services

CEO/SMT • Increase awareness of programs/servicesacross the District

Increase awareness about range ofcommunity programs and value ofcurrent partnerships

• Share and leverage currentlevel of integration in allengagements

Board/ CEO/SMT

Ongoing • Continued Collaboration

STRATEGIC PILLAR: ADVOCACY

Goal: To recognize the challenges of our rural, remote, northern location





11

Board & SMT utilize an AdvocacyFramework to ensure successfuldelivery of Health & HumanResources, Capital Planning andRight Sized Funding

• Educate Board and SMT onAdvocacy requirements

• Board & SMT advocate forRight-sized funding

• Engage our LHIN partners,MPP, First Nations,municipalities, etc.

Board/CEO /SMT

Ongoing • Identified parties for specific advocacy efforts• Evidence of engagements ongoing with LHIN,

MOH, Regional Providers, First NationRepresentatives, Municipal leaders, Local MPP,and OHA.

• Establishment of Committees for MOP/MCPadvancement


RIVERSIDE HEALTH CARE FACILITIES INC.Emo, Fort Frances, Rainy River

BOARD OF DIRECTORS

BOARD GOVERNANCE COMMITTEE

MANDATE:

To ensure the continued accountability of the Board Directors. This will be achievedthrough designing and recommending policy to the Board on matters relating to Boardeffectiveness: Board development; Board structures; Board recruitment, Board Self-evaluation and retention policies and governance practices to continually improveBoard performance. The committee shall serve as an executive committee in matters ofBoard urgency - exercising the full powers of the Board and reporting its actions at thenext meeting of the Board

TERMS OF REFERENCE:

The role of the Board Governance Committee is to ensure the continuedaccountability of the Board of Directors. Key elements include:

• Board Structure• Board Effectiveness• Board Development and Education• Governance Procedures• Board Evaluations

• Board Committees• Board Chair

POLICY AGENDA:

Board Structure• Board process & meeting format - openness to public/media• Advisory Committees to the Board (community, employee, professional)• Corporation members on standing hospital committees• Conjoint meetings with hospital management and staff - planning/information• Review and make recommendations to the Board concerning board

composition, board size, board structure, governance policies, and by-law amendments.

Board Effectiveness• Outline of Roles / Expectations for Board Chair, Board Members• Powers of Committees versus powers of the Board• Definition of management versus governance• Process and development of Board Workplan and recommend to the Board• Establish and implement an Evaluation framework to monitor and measure

success of individual board members, the board as a whole, Board Chair, Board


Committees and Committee Chairs• Exit Interviews• Governing Body Standards & Philosophy• Risk Management - To address such items as: Items respecting public trust

and legal proceedings, insurance, & reputational risk• Executive Management• Quarterly Accreditation Update• Quarterly Risk Management Reports - focus on demonstrating public trust• Monitor the Board of Directors performance as it relates to expectations

of government, public, and Accreditation bodies• Establish Board Evaluation Protocol and Metrics to conduct on-going evaluations

of the Board's effectiveness as it relates to its structure, attendance, processes,and goal attainment

Board Development• Orientation process for new board members• Budget for board professional development activities• Process for identifying information requirements• Continuous Quality Improvement of board processes• Oversee board education to ensure board receives periodic education

on governance, industry issues and the organization's operations• Methods to attract and identify board member skills and characteristics• Board member recruitment and selection methods• Nominations• Recommend for approval Board orientation and development plans• Organize, with the input of the CEO and Chair, the Board's annual retreat.

Governance Procedures• Ensure a strategic planning process is undertaken with Board involvement

and eventual approval by the board• Manage the budget assigned to the Board of Directors• Review and recommend revisions to the Corporate By-Laws at regular intervals• Recommend to the Board strategies to deal with intra-hospital and other

Board-to-Board relationships across the community• Liaise with the Local Health Integration Network (LHIN)• Develop a process to oversee performance & compensation of President & Chief

Executive Officer and Chief of Staff, and report to the Board• Oversee Chief Executive Officer recruitment, selection and succession planning• Review and recommend to the Board, the CEO's annual objectives• Provide advice and support to the Chair, CEO and Committee Chairs as required

Board Chair• Ensure succession planning for the office of board chair• Oversee and implement the Board's process for selecting a board chair

and recommend an individual for election by the board as Chair; and• Make recommendations to the board for Vice-Chairs and other board officers


Board Committees• Ensure periodic review and evaluation of committee performance and terms of

reference, and make recommendations to the board as required, and• Recommend to the Board, with the input of the Chair, nominees for all

board committees and committee chairs.

Administrative Lead Administrative SupportChief Executive Officer Senior Management member as required.

Meetings Committee CompositionQuarterly and as required Board Chair

Board Vice-ChairBoard Secretary-TreasurerChief of StaffThree (3) directors to ensure compositionincludes a representative from each catchmentarea, wherever possible

Reviewed: 09/03; 07/06; 09/09; 11/15, 09/16, 09/17, 09/18, 09/19Revised: 05/08, 09/16


RIVERSIDE HEALTH CARE FACILITIES, INC.

Governance Committee of the Board

Annual Reporting Schedule - Workplan for 2019-20

September October November December

Terms of Reference ReviewBoard & Committee WorkplansStrategic Plan Quarterly UpdateGovernance Policy ReviewBoard ProfessionalDevelopment UpdateBoard Development TopicsBd Role & Resp. ReviewFIPPA Delegation of AuthorityBoard WorkplanPeer Assessments Discussion

Orientation Evaluation ResultsGovernance Policy ReviewAccreditation Quarterly UpdateBoard Meeting EvaluationResultsCOS Succession PlanBoard Professional Dev. Update

Community EngagementInitiativesRisk Management UpdateGovernance Policy ReviewUpdate on CEOPerformance Goals

No Meeting

January February March

Strategic Plan UpdateGovernance Policy ReviewAccreditation UpdateBy-Law ReviewStrategic Communications PlanReviewBoard Meeting EvaluationResultsGovernance FunctioningTool/Audit ReviewMembers Complete Gov.Functioning Tool again

Nominations/RecruitmentCommittee UpdateCEO/COS Performance ReviewProcessBoard Retreat PlanBoard Meeting EvaluationResultsGovernance Policy ReportingSchedule

Freedom of InformationReport (PHIPPA & FIPPABreaches)Annual MeetingDate/ProcessStrategic Plan UpdateBoard Chair/Vice-ChairSuccession PlanningNom/Recruitment Update

April May June

Review/revise Board EvaluationToolsAuxiliary Engagement UpdateNom/Recruitment UpdateBoard Meeting EvaluationResults

Nomination/RecruitmentCommittee ReportBoard Self-EvaluationGovernance Policy ReviewBoard Orientation ReviewCEO Goals & Objectives

Board Chair EvaluationBoard Comm EvaluationsBoard Workplan ReviewExit Interview ResultsBoard Self EvaluationSurvey ResultsStrategic Plan UpdateBoard Mtg Eval. ResultsBoard Attendance ReviewCEO Evaluation


Governance Policy Review Schedule

As at January 2019

Section Date Reviewed & Approved at

Board

Next Review Date

(2 year review rotation)

Section 1: Governance/Strategic January 25, 2018 January 2020

Section 2: Workplace of Choice January 24, 2019 February 2021

Section 3: Provider of Choice January 24, 2019 February 2021

Section 4: Accountability May 24, 2018 May 2020


Date Board Member Name of the Session Where was the session held

28-Aug-18 Jon Begg New Board Member Orientation LVGH

Carlene Steiner New Board Member Orientation LVGH

Cindy McKinnon New Board Member Orientation LVGH

Joanne Ogden New Board Member Orientation LVGH

27-Sep-18 Jan Beazley MARSH Risk Consulting - Board Education Session LVGH

Joanne Ogden MARSH Risk Consulting - Board Education Session LVGH

Doug Robinson MARSH Risk Consulting - Board Education Session LVGH

Jon Begg MARSH Risk Consulting - Board Education Session LVGH

Carlene Steiner MARSH Risk Consulting - Board Education Session LVGH

Shanna Weir MARSH Risk Consulting - Board Education Session LVGH

Cindy McKinnon MARSH Risk Consulting - Board Education Session LVGH

Jordan Forbes MARSH Risk Consulting - Board Education Session LVGH

24-Oct-18 Jon Begg NW LHIN Governance to Governance Session - Videoconference LVGH

Carlene Steiner NW LHIN Governance to Governance Session - Videoconference LVGH

Jan Beazley NW LHIN Governance to Governance Session - Videoconference LVGH

26-Oct-18 Jan Beazley MARSH Risk Consulting - Education Session on the Board Risk Tool LVGH

Joanne Ogden MARSH Risk Consulting - Education Session on the Board Risk Tool LVGH

Doug Robinson MARSH Risk Consulting - Education Session on the Board Risk Tool LVGH

Cindy McKinnon MARSH Risk Consulting - Education Session on the Board Risk Tool LVGH

Shanna Weir MARSH Risk Consulting - Education Session on the Board Risk Tool LVGH

22-Nov-18 Jan Beazley Ethics Presentation Rainycrest LTC

Joanne Ogden Ethics Presentation Rainycrest LTC

Doug Robinson Ethics Presentation Rainycrest LTC

Jon Begg Ethics Presentation Rainycrest LTC

Peter Howie Ethics Presentation Rainycrest LTC

Shanna Weir Ethics Presentation Rainycrest LTC

Cindy McKinnon Ethics Presentation Rainycrest LTC

Jordan Forbes Ethics Presentation Rainycrest LTC

24-Jan-19 Jan Beazley Mental Health & Addictions Services Presentation LVGH

Doug Robinson Mental Health & Addictions Services Presentation LVGH

Board of Directors Professional Development Tracking

2018-19 Term


Jon Begg Mental Health & Addictions Services Presentation LVGH

Carlene Steiner Mental Health & Addictions Services Presentation LVGH

Shanna Weir Mental Health & Addictions Services Presentation LVGH

Cindy McKinnon Mental Health & Addictions Services Presentation LVGH

Jordan Forbes Mental Health & Addictions Services Presentation LVGH

Peter Howie Mental Health & Addictions Services Presentation LVGH

28-Feb-19 Jan Beazley QSR Framework LVGH

Jon Begg QSR Framework LVGH

Doug Robinson QSR Framework LVGH

Carlene Steiner QSR Framework LVGH

Cindy McKinnon QSR Framework LVGH

Jordan Forbes QSR Framework LVGH

Peter Howie QSR Framework LVGH

28-Mar-19 Jan Beazley QIP LVGH

Jon Begg QIP LVGH

Doug Robinson QIP LVGH

Carlene Steiner QIP LVGH

Jordan Forbes QIP LVGH

Peter Howie QIP LVGH

Joanne Ogden QIP LVGH

25-Apr-19 Jan Beazley Rainycrest LTC Tour Rainycrest LTC

Jon Begg Rainycrest LTC Tour Rainycrest LTC

Doug Robinson Rainycrest LTC Tour Rainycrest LTC

Carlene Steiner Rainycrest LTC Tour Rainycrest LTC

Peter Howie Rainycrest LTC Tour Rainycrest LTC

Shanna Weir Rainycrest LTC Tour Rainycrest LTC

07-May-19 Jon Begg Northern & Rural Health Leadership Conference Toronto

23-May-19 Doug Robinson Rainy River Health Centre Tour/Walk About Rainy River Health Centre

Joanne Ogden Rainy River Health Centre Tour/Walk About Rainy River Health Centre

Carlene Steiner Rainy River Health Centre Tour/Walk About Rainy River Health Centre

Peter Howie Rainy River Health Centre Tour/Walk About Rainy River Health Centre

Shanna Weir Rainy River Health Centre Tour/Walk About Rainy River Health Centre

Jordan Forbes Rainy River Health Centre Tour/Walk About Rainy River Health Centre

Cindy McKinnon Rainy River Health Centre Tour/Walk About Rainy River Health Centre


25-Jun-19 Jan Beazley Draft Financial Statements Presentation – BDO LVGH

Joanne Ogden Draft Financial Statements Presentation – BDO LVGH

Doug Robinson Draft Financial Statements Presentation – BDO LVGH

Jon Begg Draft Financial Statements Presentation – BDO LVGH

Carlene Steiner Draft Financial Statements Presentation – BDO LVGH

Shanna Weir Draft Financial Statements Presentation – BDO LVGH

Cindy McKinnon Draft Financial Statements Presentation – BDO LVGH

Jordan Forbes Draft Financial Statements Presentation – BDO LVGH

Peter Howie Draft Financial Statements Presentation – BDO LVGH


Board Professional Development Topics

2019-20

• Financial Literacy (September 2019 Board presentation)• Mandate of PC Government• Board and Social Media Communication• The Long Term Care Homes – Public Inquiry – Resident Safety –Barb Harten could possibly

provide a high level overview of this in the future• Health Equity – Health Unit Presentation – J. Begg


BRIEFING NOTE

TO: RHC Governance Committee

FROM: Ted Scholten

DATE: September 3, 2019

RE: Freedom of Information and Protection of Privacy Act(FIPPA) Delegation of Authority

SUMMARY

• Pursuant to FIPPA, the Board Chair of a public hospital is accountable for most ofthe hospital's decisions under the Act. The Board Chair also bears the responsibilityfor overseeing the administration of FIPPA within that hospital. While the BoardChair is ultimately accountable, FIPPA permits the Board Chair to delegate (a) theauthority to exercise his or her powers under FIPPA, and (b) the responsibility forcarrying out the duties imposed on the Board Chair by FIPPA.

• Delegation means empowering an officer so that he or she has control over how aduty is carried out or whether and how a power is exercised. Delegation can be madeto one or more officers of the hospital. Once delegated, the Board Chair need not beinvolved in any later decision to exercise a delegated power or undertake a delegatedduty. The main compliance activity under FIPPA focuses on the annual report RHCsubmits to the Office of the Information and Privacy Commissioner of Ontario. Thisactivity is identified in the annual Governance Work Plan.

• Noteworthy is that this is an exception with regards to the statement “the CEO isthe Board’s only employee.”

RECOMMENDATION

THAT the Governance Committee recommend to the Riverside Health Care Board ofDirectors approval of the delegation of authority from the Board Chair to the QualitySafety Risk Management & Privacy Coordinator for fiscal year 2019-20.


Audit & Resources Committee Report – September 2019

4.9.1 Financial Report – August 2019 *

Item 4.9


LHIN - Base Funding A-1 $25,872,723 $10,780,301 $10,682,456 ($97,845) -0.91%

Bundled Care A-2 $651,610 $271,504 $191,725 ($79,779) -29.38%

LHIN - One Time Funding A-3 $162,080 $67,533 $116,969 $49,436 73.20%

MOHLTC - One Time Funding A-4 $222,275 $92,615 $92,618 $3 0.00%

Other Revenue MOHLTC - HOCC A-5 $488,505 $203,544 $175,902 ($27,641) -13.58%

Paymaster A-6 $426,839 $177,850 $500,647 $322,798 181.50%

Cancer Care Ontario A-7 $10,052 $4,188 $2,178 ($2,010) -48.00%

Recoveries & Miscellaneous A-8 $1,400,005 $583,335 $769,512 $186,177 31.92%

Amortization of Grants/Donations Equipment A-9 $320,000 $133,333 $110,717 ($22,616) -16.96%

OHIP Revenue & Patient Revenue from Other Payors A-10 $1,640,505 $683,544 $774,911 $91,368 13.37%

Differential & Copayment A-11 $968,015 $403,340 $477,229 $73,890 18.32%

TOTAL REVENUE A-12 $32,162,609 $13,401,087 $13,894,865 $493,778 3.68%

Compensation - Salaries & Wages A-13 $18,024,753 $7,555,581 $8,023,509 $467,927 6.19%

Benefit Contributions A-14 $4,960,161 $2,079,191 $2,121,010 $41,819 2.01%

Future Benefits A-15 $163,200 $68,000 $74,625 $6,625 9.74%

Medical Staff Remuneration A-16 $1,443,525 $601,469 $639,526 $38,057 6.33%

Nurse Practitioner Remuneration A-17 $122,800 $51,167 $44,805 ($6,362) -12.43%

Supplies & Other Expenses A-18 $4,872,095 $2,030,040 $2,005,489 ($24,551) -1.21%

Amortization of Software Licenses & Fees A-19 $69,135 $28,806 $14,536 ($14,270) -49.54%

Medical/Surgical Supplies A-20 $788,077 $328,365 $294,794 ($33,571) -10.22%

Drugs & Medical Gases A-21 $783,807 $326,586 $626,591 $300,005 91.86%

Amortization of Equipment A-22 $705,000 $293,750 $266,167 ($27,583) -9.39%

Rental/Lease of Equipment A-23 $144,364 $60,152 $52,896 ($7,255) -12.06%

Bad Debts A-24 $82,000 $34,167 34,246$ $80 0.23%

TOTAL EXPENSE A-25 $32,158,917 $13,457,273 $14,198,193 $740,920 5.51%

SURPLUS/(DEFICIT) A-26 $3,692 $1,538 ($303,328) ($304,867) -19817.98%

YTD Budget

YTD Actual Dollars

Over(Under) YTD

Budget

YTD Actual Percent

Over(Under) YTD

Budget

Fund Type 1 - LHIN Funded - Hospital Services

REVENUE


YTD Actual2019/2020 Annual

Budget

April 1, 2019 to August 31, 2019

Submitted By: Henry Gauthier, Senior Director, Corporate Services (CFO/CIO) Printed: 2019-09-13 at 8:30 AM AUGUST 2019 Financial Report FINAL.xlsBoard of Directors - Open Session September 26, 2019 46 of 63

YTD Budget

YTD Actual Dollars

Over(Under) YTD

Budget

YTD Actual Percent

Over(Under) YTD

Budget


YTD Actual2019/2020 Annual

Budget

April 1, 2019 to August 31, 2019

TOTAL REVENUE B-1 $1,523,053 $634,605 $653,128 $18,523 2.92%

TOTAL EXPENSE B-2 $1,523,053 $634,605 $653,255 $18,650 2.94%

SURPLUS/(DEFICIT) - DUE To LHIN B-3 $0 $0 ($127) ($127) 0.00%

TOTAL REVENUE C-1 $203,436 $84,765 $90,940 $6,175 7.28%

TOTAL EXPENSE C-2 $203,436 $84,765 $89,127 $4,362 5.15%

SURPLUS/(DEFICIT) - DUE To Other C-3 $0 $0 $1,813 $1,813 0.00%

TOTAL REVENUE D-1 $1,465,516 $610,632 $532,610 ($78,021) -12.78%

TOTAL EXPENSE D-2 $1,465,516 $610,632 $532,538 ($78,093) -12.79%

SURPLUS/(DEFICIT) - DUE To LHIN D-3 $0 $0 $72 $72 0.00%

TOTAL REVENUE E-1 $12,767,160 $5,003,650 $4,298,482 ($705,168) -14.09%

Compensation & Benefits E-2 $11,266,297 $4,722,585 $4,425,958 ($296,627) -6.28%

Supplies E-3 $1,315,360 $548,067 $583,486 $35,420 6.46%

Service Recipient Specific Supplies E-4 $0 $0 $0 $0 0.00%

Sundry E-5 $700,226 $291,761 $194,161 ($97,600) -33.45%

Equipment E-6 $230,000 $95,833 $200,347 $104,513 109.06%

Contracted Out E-7 $37,140 $15,475 $183,618 $168,143 1086.55%

Building & Grounds E-8 $26,350 $10,979 $4,828 ($6,151) -56.03%

TOTAL EXPENSE E-9 $13,575,373 $5,684,700 $5,592,398 ($92,302) -1.62%

SURPLUS/(DEFICIT) including unfunded liabilities E-10 ($808,213) ($681,050) ($1,293,915) ($612,865) 89.99%

Less: Unfunded Future Benefits E-11 $0 $0 $33,750 $33,750 0%

Less: Unfunded Amortization Expense E-12 $0 $0 $3,238 $3,238 0%

SURPLUS/(DEFICIT) excluding unfunded liabilities E-13 ($808,213) ($681,050) ($1,256,927) ($575,877) 84.56%

Operating Surplus(Deficit) - Hospitals &

Long Term Care ONLY ($804,521) ($679,511) ($1,560,255)

Total Operating Margin - Hospitals & Long

Term Care ONLY -1.79% -3.69% -8.58%

Fund Type 2 - LHIN Funded - RainyCrest

Long Term Care

Fund Type 2 - LHIN Funded - RainyCrest Community Support Services

(Home Support, Assisted Living, Adult Day, Meals on Wheels)

Fund Type 3 - Other Ministry/Agency Funded - Non Hospital Services

Partner Assault Response - Family Violence

Fund Type 2 - LHIN Funded - Counselling & Non Profit Housing Programs

Mental Health - Case Management - Housing - Addictions - Problem Gambling

Submitted By: Henry Gauthier, Senior Director, Corporate Services (CFO/CIO) Printed: 2019-09-13 at 8:33 AM AUGUST 2019 Financial Report FINAL.xlsBoard of Directors - Open Session September 26, 2019 47 of 63

BRIEFING NOTE

TO: RHC Board of Directors

FROM: Ted ScholtenDATE: September 20, 2019SUBJECT: Community Advisory Council (CAC) DissolutionSUMMARY

The CAC was initiated when RHC’s Corporation Bylaws were changed and wemoved from an open membership board to a closed one. CAC’s purpose was toensure the voice of the community was still heard. In most other facilities thePatient Family Advisory Council (PFAC) serves as the sounding board forensuring community feedback on programs, services, satisfaction trends, etc. Infact in the Northwest, no other CACs exist. At the time of our decision to form aCAC, our PFAC was still in its infancy. Now that the PFAC is a regular meeting,the CAC has been deemed to be redundant.

Remaining members will be informed of the CAC dissolution and applications tojoin PFAC will offered to those with interest in continuing to serve.`

NO RECOMMENDATION: For Information purposes

Item 4.11


Riverside Foundation for Health Care

Board of DirectorsMinutes of Meeting

DATE: Monday, June 24, 2019 TIME: 11:30 a.m.

LOCATION: LVGH Board Room

PRESENT: Kim Jo Bliss Susan IrvineAllison Cox Janet LambertBev Langer Bill GushulakDeane Cunningham Delaine McLeodLivia Lundon Tammy KellarRob Georgeson Ted ScholtenPaul Brunetta Carlene Steiner

Teleconference Carla Larson

1. Call to Order

Bill Gushulak called the meeting to order at 11:44 a.m. Sandra Beadle recorded theminutes of this meeting. Bill introduced Janet Lambert as the new LVGH Auxiliary rep.Welcome Janet.

2. Adoption of Agenda

IT was,MOVED BY: Susan Irvine SECONDED BY: Bev LangnerTHAT the Agenda be approved as circulated.

CARRIED.

3. Conflict of Interest

There was no Conflict of Interest.

4. Approval of Minutes

IT was,MOVED BY: Livia Lundon SECONDED BY: Carlene SteinerTHAT the minutes from the May 27, 2019 meeting be accepted as circulated.

CARRIED.

5. Correspondence

There was no Correspondence

Item 4.12


6. On-Going Business

6.1 Planned Giving Launch

Tabled. Allison has pulled together a sub committee consisting of Paul and Rob. Shewill be in touch with them shortly to start planning.

6.2 Garden of Life

There has not been much movement on this. Allison spoke with David Loewen to see ifutilizing our own man power would reduce the costs. David was receptive and said hewould take a look at the quote and be in touch. Allison will follow up.The Garden has been planted and is being maintained by Tammy and some helpers.Allison is recommending a budget of $20,000 be established to move forward with theupdates. This would be used to fix the current garden, expand the current garden andcreate a circular flower bed in the round-about. With a set budget, we can move aheadwith plans and secure landscaping to be completed in the fall.

It was,MOVED BY: Kim Jo Bliss SECONDED BY: Bev LangnerTHAT a budget not to exceed $20,000 be approved for upgrades and expansion of the currentGarden of Life located at the LaVerendrye Hospital site, as well as to create a circular garden inthe round-about.

CARRIED

6.3 Donor Walls

Allison has reached out to 3 additional companies that specialize in digital donor walls,the major take away has been that it is difficult to obtain quotes when we don’t have abudget set as each company has a myriad of options available.

BAS Sign Solutions – Allison has not had anyone contact her after emailing them andfilling in their online form.

Planned Legacy – Based out of Winnipeg, their rough estimate is $25,000 per location!The largest monitor is 55” and it doesn’t include any enclosure around the monitors. Thesoftware is basically an advanced slideshow that runs on a flash drive. There is notability to update the flash drive remotely.

Envision – They specialize in architectural design and utilizing the existing space for aseamless and eye catching wall. Pricing is very dependent on budget as each project iscompletely individualized. The examples shown were stunning, but very costly.

Allison said she felt that Digitality is still our best bet but she was glad she reached out toother companies to compare.


It was decided to go ahead with Digitality. Allison will contact them saying yes to all 4sites and she will get a price. If she needs a motion after a cost is received she will do soby email. There was discussion about the current walls but they will not be able toremain up. Allison will continue to move ahead with Digitality.

6.4 Canada Day Cash Lottery

June 22, 2018 - $27,230.00June 24, 2019 - $32,417.00Worth noting on June 26, 2017 (sell-out year) was $32,000 at this time so we are ahead ofschedule to sell out this year. We are at exactly 80% of ticket sales. Assuming that atleast half of those tickets are sold it is safe to say we are at 85%.

BBQ on June 27th

Allison, Bill, Tammy, Delaine and Natalie are all signed up to be at the BBQ. Deane willalso be attending and probably Larry Cousineau. There is also a volunteer from the OPPthat is going to attend. Allison will do a facebook Ad please share if you see it. There isalso a paid ad . The forecast looks great. A Special Occasion food permit has beenissued. Maintenance will be dropping off and picking up the BBQ to Rainy Lake Square,we will set up in the early morning to ensure we get the same location as last year.Allison will be putting in the Webb’s order. It was decided to order the same as last yeareven though it is not mall days. Allison will bring tables, tent, decorations, food and allBBQ supplies, tickets and all sales supplies. Tammy and Bill are bringing coolers.

Ticket Pick Up/Drop OffIf you still have a book of tickets please ensure that they are returned to Allison no laterthan Friday, June 28th. Some tickets will have to be picked up at store locations onSaturday, Livia volunteered to do this so Allison doesn’t have to drive in. Bill will get theticket drum from the Legion. Allison is looking at purchasing a larger ticket drum.

Canada Day ParadeAllison and Bill are the only people signed up to walk the parade and sell at the SortingGap on July 1st is there anyone else that can help out? They need at least 2 more people.The Colour Run begins at 9:00am at the Sorting Gap so Allison will have the tent set upby then and it will remain up for the duration of the parade. All sellers are to meet at thetent by 9:00 a.m.

Canada Day – PointAllison, Bill and Natalie will be at the Point selling and completing the draw, this shouldbe plenty. Following the parade, the tent and all supplies will be moved to the Point.Draw is to take place at 3:00pm and Allison will live stream it on Facebook.

6.5 Capital Equipment List

The Capital Equipment sub-committee is meeting directly following the Board Meetingto determine what items the Foundation is going to support within the $500,000 budgetset by the board.


6.6 Other

None.

7. New Business

No new business

8.0 Standing Reports

8.1 Finance Report

Carla gave the Finance Report via teleconference. She reported on the Revenue &Expense Summary from April 1, 2019 to April 30, 2019 and April 1, 2019 to May 31,2019.Carla said the YTD Actual to April 30th was $18,863 because there were no equipmentpurchasing coming thru yet. May is slightly higher at $59,194 due to the Canada DayLottery Revenues.The Contribution from New Gold is reflected for Physician Recruitment, the transfer offunds hasn’t happened yet. This is an “in and out” transaction.Allison and Dawn continue to work on the report that will reflect allocation of funds.

It was,MOVED BY: Kim Jo Bliss SECONDED BY: Susan IrvineTHAT the Finance Report be accepted.

CARRIED

8.2 Physician Recruitment and Retention Report

Ted reported:• RFMLP will pay travel stipends for ER docs (Non HFO). We need to set

agreements and accounting of how to proceed with this. With the GPA callremuneration adjustment, two major roadblocks to recruitment and retention havebeen successfully addressed.

• We have a physician currently working in the US as Family Med working onlicensure in Ontario. WE arranged for agent with HFO to assist.

• Dr. Mokone. Recruiting site visit to Emo in April. Very little communication withher, same with Dr. Whatley.

• Lincoln Dunn, Counselor from the Twp of Emo requested to be on committee,will attend the next meeting.

• Full report in Ted’s report attached.

It was,MOVED BY: Kim Jo Bliss SECONDED BY: Delaine McLeodTHAT the Physician Recruitment update be accepted.

CARRIED


8.3 Special Event Committee Report

The next meeting is on Tuesday, July 9th. They will be working on the fall event.

It was,MOVED BY: Livia Lundon SECONDED BY: Susan IrvineTHAT the Special Event Committee Report be accepted.

CARRIED

8.4 Hospital Auxiliaries Update

Bev reported for the Rainy River Auxiliary, they had their meeting in the gazebo withTed and Henry in attendance. They were very glad to have them there. That meeting wasbasically their wind-up for the summer, they discussed the plants and the flowers at thehospital and upkeep over the summer. They are hoping the renovations will be completeand they can resume their meetings back at the hospital in the Fall.

Susan reported for the Emo Auxiliary. Summer is here and the volunteers in the cafeteriaare finished this week, the student Kiera Govier will take over until August.Their Strawberry social was very successful. The residents are happy to have the doorinto the gazebo working and are using it. The Woolards are happy as Larks that Mrs.Woollard’s bed is working. This bed was an individual donation from Mr. Wollard forhis wife while she remains in hospital and it will be left there for others to use.

Janet report for the LaVerendrye Hospital Auxilairy. The Strawberry Social sold 6800,they sold out for the first time in history, there were more take outs than usual. They alsostarted a facebook page and it has boosted interest in the auxiliary which is nice and theyhave seen 22 new members this year. They will not be committing to capital equipmentuntil after the Foundation picks what they are funding. They had their big donation of$72,000 last year. They may pick a larger item and set up a payment system.

Rainycrest – we still do not have a representative from Rainycrest.

It was,MOVED BY: Tammy Kellar SECONDED BY: Paul BrunettaTHAT the Auxiliary updates be accepted.

CARRIED

8.5 Foundation Director Report

Mary Biddeson Estate – an interim disbursement of assets in the amount of $13,862.39will be received once all beneficiaries have signed releases. The final disbursement willoccur once the final income tax return has been filed.

Emo Thrift Store – The Emo Thrift Store is interested in purchasing a chair for theChemo Department. This has been approved by management and once a quote isreceived it will be sent to the Thrift Shop for approval. Once the entire process is


complete, Allison would like to have some media coverage on the donation.

Some updates have been made to the office space including frosting on more of thewindows, a sign above the windows and a bulletin board at the entrance door to advertiseon. This has greatly reduced the number of people attempting to register and approachingwith general RHC inquiries. The photocopier/printer that was located in the office hasbeen relocated to a central location which removes the need for people to access theFoundation Office. IST will be installing a printer in the office for small print jobs.Allison is also waiting on a new tablet as hers no longer detects wifi and can only be usedwhen plugged directly in to a port. In an attempt to fix the current tablet, IST had torebuild it and were unable to reinstall Income Manager on it. Allison has been withoutIM for 3 months now and will continue to engage IST to get this resolved.

Allison and Dawn have begun the process of identifying the various funds that need to betracked and how to best lay out funds moving forward. As both Allison and Dawn arewithout Income Manager this project has reached a roadblock and not much can be doneon it until we have the software installed on our computers. Carla will follow up withMarie as well as Dawn needs IM too and this is becoming critical.

Allison attended the LaVerendrye Auxiliary Strawberry Social and their AGM. She islooking forward to working with the new president Shirley Scoffield.

It was,MOVED BY: Deane Cunningham SECONDED BY: Rob GeorgesonTHAT the Foundation Director Update be accepted.

CARRIED

8.6 Riverside Corporate Report

Ted

Ted Reported:• Patient Census at LVGH has continued to be at elevated in the 40s – 50s although we

have finally dipped to the high 30s this past week. A third round of Orthopedic servicesis planned for July 8-9.

• There has been an extension of the deadline for Ontario Health Teams (OHT) from theMinistry. There were several submissions received and all submissions are being fullyreviewed.

• The search for Rainycrest Administrator continues. There was a scheduled on-siteinterview but it was cancelled due to the candidate having a family emergency.

• Ted attended the regular Kenora Rainy River Regional Laboratory Program Board ofDirectors and AGM in Dryden. Ted has agreed to a 2 year term as Chair on this Board.There is a Fall Symposium being hosted in Fort Frances September 17-19.

• Northwest Health Alliance has approved plans to dissolve the Northwest Health Alliance,operations will be assumed by Thunder Bay Regional Health Sciences Centre.

• The OHA President Anthony Dale is planning a tour of the Region in July. Tentativedates for Riverside are July 8-9.


• The CEO Jean Bartkowiak from Thunder Bay Regional Health Sciences Center is alsoplanning a regional tour this summer.

It was,MOVED BY: Livia Lundon SECONDED BY: Delaine McLeodTHAT the Riverside Corporate Report be accepted.

CARRIED

8.7 Other

None

9. Next Meeting

The next regular meeting will be on Monday, September 30th – AGM * pending BDOAudit completion date.

10. Adjournment

It was,MOVED BY: Deane CunninghamTHAT the meeting be adjourned at 12:51p.m.

CARRIED.

_________________________________Bill Gushulak, Chair

/sb

26/06/2019


Auxiliary Report – September 2019

Emo

The Emo and District Hospital Auxiliary held its September meeting and planned the Fall Tea and Bazaarto be held October 18, 2019 from 1:30 to 3:30 pm at the Emo Legion. Privacy curtains have not yet beeninstalled. Why?

La Verendrye General Hospital

See Attached.

Rainycrest

No Report.

Rainy River

No Report.


Item 4.13

LAVERENDRYE GENERAL HOSPITAL AUXILIARY

EXECUTIVE MEETING

Tuesday, September 3, 2019

Meeting was called to order at 1 P.M. in Main Floor Conference Room.

PRESENT: Shirley Scofield, Dolores Fraser, Janet Lambert, Marnie Cumming, Judy Webster, Bev Bond,

Helene Cone, Joyce Lafreniere, Joy Lockman, Sandra Robertson, Laureen Vandetti, and Diane Glowasky

REGRETS: Linda Booth and Donna Penney

Auxiliary Pledge was read.

AGENDA was accepted as amended with additions under Old Business: Coke Machine, Strawberry

Social/Raffle Ticket Reports, Capital List, and Transfer Funds. Also, under New Business: Fall Tea

MINUTES were accepted as read with addition of Allison Cox and Sandra Robertson were in attendance

Financial Report accepted as read.

BUSINESS ARISING:

STRAWBERRY SOCIAL/QUILT RAFFLE – Best sales for shortcake were home deliveries. Full report to be

submitted. Quilt raffle brought in $1522. Lorna Robertson won the quilt.

CAPITAL REQUESTS- were reviewed for our 2019-2020 donation to Foundation.

MOTION: THAT THE AUXILIARY PLEDGE FOR 2019-2020 TO PURCHASE PANIC ALARMS FOR

LVGH LAB, SPD, SWITCHBOARD IN THE AMOUNT OF $5500 AND PANIC ALARM PENDANTS

FOR LVGH NURSING FOR $21,500. Moved by Janet Lambert. Seconded by: Judy Webster.

CARRIED

TRANSFER OF FUNDS: In order to cover costs of Cleaner/Disinfector funds from Raffle Account were

transferred to Riverside Foundation.

MOTION: TO TRANSFER $10,000 OUT OF THE RAFFLE ACCOUNT TO RIVERSIDE FOUNDATION

TO PAY FOR PLEDGE OF WASHER/DISINFECTOR. MOVED BY Judy Webster SECONDED BY:

Dolores Fraser. CARRIED

COKE MACHINE IN LOBBY: Plan is to continue to store machine as replacement unit and discontinue

plans to place unit in lobby entrance. Continue to correspond with Simone LeBlanc re cafeteria

operations of existing Coca Cola unit for 24 hour access to unit.


CORRESONDENCE:

Fort Frances High School – thank you for two bursaries for 2019. Recipients were Samantha Berg and

Brandon Larson. Copy of Commencement Program attached.

Coca Cola Canada letter of increased rates to $75 hr. plus $66 per visit to repair/service units.

Riverside Foundation – tax receipt for Cleaner/Disinfector and information pamphlet for upcoming

Foundation Black and White Gala

DIRECTOR AND COMMITTEE REPORTS:

GIFT SHOP – Karen Robinson has organized several Pop-Up Shops. Need new phoner to schedule

workers. Next meeting of Shop Committee is Sept. 20, 2019

MEMBERSHIP: Revised Membership forms distributed and will be in use for this year. As of today,

there are 22 paid members. Three are new members

SOCIAL – Luncheon is Sept. 9, 2019. Guest speaker is Robert Lidkea, Optometrist. Judy Webster will

chair the luncheon as Shirley Scofield is away. Joy Lockman will say grace.

LOTTERY – Deposit of $1607 in June and August. Balance August 31 is $14,667.27. Presently applying

for a new license for 2019-20. Will order 12 deals (this is 3 less than usual as consistent extensions have

been applied for in past years).

ADVERTISING AND PROMOTION – no report. Position is vacant.

NEWSLETTER – Please have your reports/articles in by last week of September at latest so Newsletter

can go into print and be ready for distribution for first week of October. E-mail is

[email protected]

SICK AND VISITING - no report. Several bereavements have occurred over summer as well as a get well

soon and thinking of you. Shirley Scofield will pass info on to Donna

HISTORIAN – Will provide photos to Newsletter for cleaner/disinfector. And will provide article on

Unseen Volunteer. Article will be on Helen Pattison and Mary Cooper’s work behind the scenes at the

Strawberry Social.

PATIENT SERVICES – No longer providing kits for St. Andrew’s and none requested for Emerg. Judy

Webster has taken over baby kits as Eloise Camirand and Sharon Debenedet have retired. There have

been 26 baby kits distributed since July 8, 2019 and there are 50 new babies expected for the month of

September.


FOUNDATION – Canada Lottery was sold out. Next event is Fall Gala Black and White Event in October.

Foundation is in need of a Rainycrest Rep.

NEW BUSINESS:

CONVENER FALL TEA – Mary Jane Pearson is unable to do Tea this year for health reasons. Joy Lockman

and Helene Cone will Co-Convene.

ADJOURNMENT:

Meeting adjourned at 3 PM.

Next meeting will be October 1, 2019 at 1PM in Ground Floor Meeting Room.

_____________________________ ________________________________

Shirley Scofield, President Janet Lambert, Secretary


BOARD MEMBER CONSOLIDATED CONFIDENTIALITY, ACCOUNTABILITY AND ROLES AND

RESPONSIBILITIES STATEMENT

BOARD MEMBER CONFIDENTIALITY STATEMENT

Riverside Health Care Facilities Inc. By-laws - Article 16:

"Every Director, Officer, Board committee member, member of the Medical Staff and Dental Staff and employee of the Corporation shall respect the confidentiality of matters brought before the Board, before any Board committee, or dealt with in the course of the Medical Staff or Dental Staff member’s or employee’s activities in connection with the Corporation, keeping in mind that unauthorized statements could adversely affect the interests of the Corporation."

Board Governance Policy GOV-I-20 – RHC Board Confidentiality Policy:

The directors owe to the corporation a duty of confidence not to disclose or discuss with another person or entity, or to use for their own purpose, confidential information concerning the business and affairs of the corporation received in their capacity as directors unless otherwise authorized by the board.

Responsibility

Every director shall ensure that no statement not authorized by the board is made by him or her to the press or public.

Confidential Matters

All matters that are the subject of closed sessions of the board are confidential until disclosed in a session of the board that is open to the public.

All matters that are before a committee or task force of the board are confidential unless they have been determined not to be confidential by the chair of the relevant committee or task force.

All matters that are the subject of a session of the board that is open to the public are not confidential.

Public/Media Statement

Notwithstanding that information disclosed or matters dealt within a session of the board that was open to the public are not confidential, no director shall make any statement to the press or the public in his or her capacity as a director unless such statement has been authorized by the board.

BOARD MEMBER ACCOUNTABILITY STATEMENT

The Riverside Health Care Facilities Inc. Board of Directors is accountable to members of the Corporation for acting consistently with the Articles of Incorporation, the By-laws, applicable legislation, the common law as it governs healthcare organizations and the achievement of its mission and vision. The Directors exercise the power vested in them in good faith and honesty in order to further the purposes for which the corporation was created. They act in what they consider to be the best interests of the organization, each exercising his or her unfettered discretion in decision making, ex-officio directors fulfill the same duty to the corporation. Directors do not place themselves in a position where their personal interests conflict with those of the Corporation.


Item 8.1

The Directors establish objectives that are within the capacity of the Corporation’s plant and resources. The board strives to maintain a balance within its medical and other staff to ensure a broad base of expertise while attaining the most efficient utilization of the facilities and resources of the Corporation.

In choosing between competing demands on scarce resources, the Board of Directors has established the following accountabilities.

To Members of the Corporation For acting consistently with the Articles of Incorporation, the By-laws, applicable legislation, the common law as it governs corporations and the achievement of its mission and vision

To Patients/Clients/Residents For safe, family-centred care and best practices

To Ministry of Health & Long-Term Care For expenditure management compliance with policies and regulations, data quality and performance management

To Local Health Integration Network For compliance to accountability agreements and other applicable components of the Local Health System Integration Act

To the Foundation For donor stewardship and support

To Staff, Volunteers and Medical Staff For transparent processes and CEO, Chief of Staff and Medical Advisory Committee evaluation

To Partners For collaboration

To Communities We Serve For advocacy, communication and expectation management

BOARD MEMBER ROLES & RESPONSIBILITIES STATEMENT

Responsibility of the Board:

The board is responsible for the overall governance of the affairs of Riverside Health Care Facilities Inc.

Each Director is responsible to act honestly, in good faith and in the best interests of the organization and in so doing, to support the organization in fulfilling its mission and discharging its accountabilities.

Strategic Planning and Mission, Vision and Values:

The board participates in the formulation and adoption of the organization’s mission, vision and values.

The board ensures that the organization develops and adopts a strategic plan that is consistent with the organization’s mission and values, which will enable the organization to realize its vision. The board participates in the development of, and ultimately approves the strategic plan.

The board oversees organization operations for consistency with the strategic plan and strategic directions.

The board receives regular briefings or progress reports on implementation of strategic directions and initiatives.

The board ensures that its decisions are consistent with the strategic plan and the organization’s mission, vision and values.


The board annually conducts a review of the strategic plan as part of a regular annual planning cycle.

Quality and Performance Measurement and Monitoring:

The board is responsible for establishing a process and a schedule for monitoring and assessing performance in areas of board responsibility including:

- Fulfillment of the strategic directions in a manner consistent with the mission, vision and values - Oversight of management performance - Quality of patient care and organizational services - Financial conditions - External relations - Board’s own effectiveness

The board ensures that management has identified appropriate measures of performance.

The board monitors organization and board performance against board-approved performance standards and indicators.

The board ensures that management has plans in place to address variances from performance standards indicators, and the board oversees implementation of remediation plans.

Financial Oversight:

The board is responsible for stewardship of financial resources including ensuring availability of, and overseeing allocation of, financial resources.

The board approves policies for financial planning and approves the annual operating and capital budget.

The board monitors financial performance against budget.

The board approves investment policies and monitors compliance.

The board ensures the accuracy of financial information through oversight of management and approval of annual audited financial statements.

The board ensures management has put measures in place to ensure the integrity of internal controls.

Oversight of Management including Selection, Supervision and Succession Planning for the CEO and Chief of Staff:

The board recruits and supervises the CEO by:

Developing and approving the CEO job description

Undertaking a CEO Recruitment process and selecting the CEO

Reviewing and approving the CEO’s annual performance goals

Reviewing CEO performance and determining CEO compensation

The board ensures succession planning is in place for the CEO and senior management.

The board exercises oversight of the CEO’s supervision of senior management as part of the CEO’s annual review.

The board develops a process for selection and review of the Chief of Staff and ensures the process is implemented and followed.

The board reviews Chief of Staff performance and sets Chief of Staff compensation.

The board develops, implements and maintains a process for the selection of department chiefs and other medical leadership positions as required under the Corporation by-laws or the Public Hospitals Act.


Risk Identification and Oversight:

The board is responsible to be knowledgeable about risks inherent in hospital operations and ensure that appropriate risk analysis is performed as part of board decision-making.

The board oversees management’s risk management program.

The board ensures the appropriate programs and processes are in place to protect against risk.

The board is responsible for identifying unusual risks to the organization for ensuring that there are plans in place to prevent and manage such risks.

Stakeholder Communication and Accountability:

The board identifies hospital stakeholders and understands stakeholder accountability. The board ensures the organization appropriately communicates with stakeholders in a manner

consistent with accountability to stakeholders.

The board contributes to the maintenance of strong stakeholder relationships.

The board performs advocacy on behalf of the hospital with stakeholders where required in support of the mission, vision and values and strategic directions of the hospital.

Governance:

The board is responsible for the quality of its own governance.

The board establishes governance structures to facilitate the performance of the board's role and enhance individual director performance.

The board is responsible for the recruitment of a skilled, experienced and qualified board.

The board ensures ongoing board training and education.

The board periodically assesses and reviews its governance through periodically evaluating board structures including board recruitment processes and board composition and size, number of committees and their Terms of Reference, processes for appointment of committee chairs, processes for appointment of board officers and other governance processes and structures.

Legal Compliance:

The board ensures that appropriate processes are in place to ensure compliance with legal requirements.

Amendment:

This statement may be amended by the board.

I, _______________________________ , agree to comply with the Riverside Health Care Facilities Inc. Board Confidentiality Policy, code of conduct and accountability statement.

Signature Date

Original: 09/08 Reviewed: 09/11; 01/18, 09/18, 05/19 Revised: 05/14, 09/18, 05/19
