i 2016 long-termcare home annual report ontario o a a · ontario 2016 long-termcare home_annual...

2016 Long-Term Care Home Annual Report

For the period from 2016-01-01 to I 2016-12-311

[ The uncharged portion of the Resident Co-payment Renenue for charges hetow the maximum bask accommodation rateASI5 outlined in the applicable legislation governing the tong-term care home end tot charges below the reduced basic

accommodation rate deternined by the Director tar the resident

Actual Occupancy of Awarded Oeds end Replacement “0” beds, andReptacennent “9”, C and Upgraded D” beds dunng the Onentabon end January to

A nl to JuneJuly tO

Total DaFill rate pedod in 2018 end the Pro-Move Occupancy Days for Classified March p

bDecember

“0 Replacement beds. (In be completed by Uceflsaes operating scch (1 a) (1 c)beds)

AS2OaActual Resident-days in tines ASS1 through A005 that was attributed to thorientation end Pitt-Rote period br awarded beds and replacement “0”beds, replacement “8”. -C- end Upgraded “D” beds, the Pre-Mova 0Occupancy Days for Classified “0” Raptacament beds, and the 90 day fillrate period tar specialized cnit beds.

A020bActual Shoe-stay Respite-days in tine Afi05 that wes attnbuted to awardebeds and replacement “0”, replacement “B”, “C” end Upgraded “0” beds 0during the Orientation end/or Fill rate Period and the PreuloveOccupancy Days for Classified “D” Replacement beds

Restdent-Days

Orientation/Fill-rate Period - Interim Shoe-Stay beds and ConvalescentJanuary to

April to JuneJuly to

Total DaygCere beds

March(fib)

December(ld(

(Is) (ic)S2Ie

Actual Interim Shod-Stay bed resident-days in lines A007-AS1O during th0

Fill-Rate Period

A02t bActual Convalescent Care bed resident-days in line A012 dunng the 00-

0day Orientation Period

Resident-Days

Actual occupenoy 01 beds approved tar Occupancy Redocbon ProtecSonJanuary10

April to JuneDecember

Total Days(ORP) (fib) (Id)

(la) )lc(

A022a Actual Resident-days in Ones A0D1-A004 during OAF Period 0

A022b Actual Resident-days in line A057-AO1S during ORP Period 0

ASO2c Actual Resident-days in line A012 during OAF Period 0

OntarioMnis&y or Health and Long-Term CareMn,stere cia Ia sarte et cm 5mw cc mesa durde

dDttTC Fealty C Operator Name

Hi 1483 Dearness Home for Senior CitizensJIIN Name

South West Local Health Integration Network

Section A - Level of Care (LOC) Ac”•al Resident Occupancy, Resident Revenue and Re.”ent Bad Debt

Resident Days Resident Revenue

January to July to Total Oays Basic FeesApnl to Jane Preferred Fees

Current Revenue Penod Marchlb

December 3)(la) (ic) (id) (2)

ASSICong-Stay-Private 11,831 11,825 23,997 47,653 2,788,081 1,046,331

A002Long-Stey-SemI-Frivate 91 91 144 326 19,065 2,614

A003Lang-Stay-easlc 9,854 9,780 19,992 39,626 1,890,081

ASS4 Long-Sley two-bed room (Shared by 0spouses)

ASOaShod-Stay-RespiteCare 156 123 232 511 19,398

aToed Level at Care LregStay and ShattStay-ReeptececeBeda Igurnatlinee 21 932 21 819 46365 88 118 4716825 1 Q5f) 9450601 threogbr 0000)

AOS7nterim Shod-Stay - Private 0

A008 o‘nterim Shod Stay - Semi-Private

A0fi9Interim Shod Stay - Basic

ASfifi

Interim Shod-Stay -two-bed roam 0tShared by spouses)

ASh TaedLevelatCar.barehnSba,f-i. o a a aba t5anelees060TthtemInAOt*ll

ASI2Convelesnent Cera flew 0

April 1,2017 otl9

Ontario 2016 Long-Term Care Home Annual ReportMinistry of Health and Long-Term Care For the period from I 2016—01—Oil to I 201 6-1 2—311Ministere de Ia Sante et des Sans de lonque duree

Section B - Actual Other Recoverable Revenue

Description Revenue For Ministry Use Only

(1) Recoverable Revenue(2)

Interest Earned

8002 Other LTC Home funding provided by Government

8003 Other

8004 Total - Actual Other Recoverable Revenue (Sum of lines BOOl through 8003) $0

MOHLTC Facility # Operator Name

H11483 Dearness Home for Senior Citizens

Section A - Level of Care (LOC) Actual Resident Occupancy, ResidentRevenue and Resident Bad Debt, continued

Prior Period Revenue Revenue For Ministry UseOnly

A030 Basic Revenue: July 1 1994 to December31 2015 79

Resident Bad Debt on 2016 Basic Accomodation Fees For Ministry Use Only

A040 Basic Accommodation Fees - Bad Debt 10,426

A041 Collection Costs

A042 Total Bad Debt Coats (A040 + A041) $10,426

April 1.2017 of 19

H $7 1 It $1 P1(I iii [2 H I I I’

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m -I 111ff

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I I I 3 I I .111’ I

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OntarioM ‘rosy of Heatth and Long—Terre Cute

2016 Long-Term Care Home Annual ReportFortheperiodfrom I 2016-01-Ofi to I 2016-12-31J

MOHLTC Fuc)rty C Operator Name

Hi 1483 Dearness Home for Sentor CitizensSection F - Actual Expenditures - Other Accommodation

Housekeeoino Services (HS)

LTC and interim LTC and interim Sub-Total Convalescent Care C000alesoent Sub-Total Fm MinistryBed Bed Fm unitry Us. or,e Arms-Length Care

AnrnsLength Non-Arms-t3

Transactions Non-Arms-Transactions Length Allowable (5) Length Allowable

(1) Transactions Expenditure Transactions(7) EWra

(2) (4)(6)

(8)

l° 722,028 722,028 0SalenesF002 290,567 290,587 0Employee BenefitsF053 5,370 5,370 0Purchased Serntcee

79,917 79,917 0SuppliesFOGS 2,415 2,415 0Equipment - NewP006 0 0Equipment - Replacements

0 0Equipment - Leasing

0 “- 0Equipment - MaintenanceF009 0 0Education & Training - Supplies and ServicesPOlO 525 525 0Allendance Costs Meetings Conventions and TrainingFOil Other 0 0

Provide description.Th 0 0Expenditure Recoveries (enter as negative)P013 Totat Housekeeping Services

$1 100 842 $0 $1100842 $0 $0 $0(Sum of tInes FOOl through P012)

Apnri 1.2017 of 19

OntarioMimetey of HeoltS end Long-Term Care

MirmtAro da in Sontd et do. Sons do lonwe dorée

2016 Long-Term Care Home Annual ReportFortheperiodfrom I 2016-01-Oi’ to 2016-12-31!

MOHLTC Feobty C Operator Name

Hi 1483 Dearness Home for Senior Citizens

Section F - Actual Expenditures - Other Accommodation, continued

Sultdlng and Prop.dy-Op.ratlons and Malnt.nanc. (B&P.OM)

BedNms-LongthTransadnons

(1)

LTC anr3lntoflm Sub-Total Po9u. Con esnent Core Con ae000nt Sub-Total Miraetryus.Bud 4y Arms-Length Care Cray

Non-Nm.- (3) Trane0000nu Non-Pam.-Length

A8owab)e 5T AKowableTronsarSons

Espenditurereran enS rn Expandéore

(4) (6)

P017SalarIes 164,283 164,283 0

roleEmployee Benefits 0

F019Purchased Services 3.043 3,843 0

P020supptes 42,976 42,976 0

P021Equipment - New 0 0

P022qquipment - Replacements 0 0

F023Equipment - Leasing 20,810 28,810 0

P024Equipment - Maintenance 90,422 90,422 0

P025Building and Property - Maintenance 204,545 204.545 0

P026Education & Training - Supplies and Services 0 0

P027tiendance Casts - Meetings, Conventions end Training 0 0

P028 ,)iherPrnorde description 0 0

p029Expenddore Recoveries lester as nngative) 0 0

F030 Total Building and Property - Operations and Maintenanceloom of lines P017 through P829) S582.332 50 $582,332 $0 $0 $0

Apni 1,2017 of 19

Ontario 2016 Long-Term Care Home_Annual ReportMinnb’y of Health and Long-Term Care For the period from 2016-01-Oil to 2016-12-31Mirrothre do Ia Sunib H des Soirm do longue dorée

MOHLTC Fani)dy # Operator Name


Section F - Actual Expenditures - Other Accommodation, continued

_______ _________ _______ _________ ________ _________

CrC arrd Interrer CTC and Intenm Sub-Total Pun Uteedry COnVaIOncOrmI Care CeeverS Sub-Total For Mirdotry ItoBed Bed dee Only Nrns-Cength Cure Dirty

Nrrw-Cength Non-Annms- Transachons Non-Amnm-Lnngth

_____________________________________________________________________

Transactions Length Allowable (5) Transactions AllowableDietary Services (OS) 1) Transactions

Exp.ndilt.tr.(6)

17) Expenditure(4) (8)

P034

Salaries1514326 1 514 326

P035

0

Employee Benefits535 593

P036

0

Pumhaned Sensices1,832 1,832

P037

0

Supplies68,039 68,039

P036

0

Equipment- New0

P039

0

Pquipment - Replacements52,251 52 251

P040

0

Equipment - Leasing0

P041

0

Equipment. Maintenance23,149 23,149

P042

0

Education & Training - Supies and Sendces 0

P043

0

A8endance Costs - Meetings, Connentions and TraIning 1,411 1 411

p54k Umer

, 0

Pravide description0

P045Rxpenditure Recoveries (enter as negative)

(11,165) (11 165)

P046

, 0

Total Dietary Services(Sam of lines P034 through P045)

$2,185,436 $0 $2,185,436 $0 $0 $0

April 1,2017 of 19

Ontario 2016 Long-Term Care Home Annual ReportMinratry nI Inland and tnog-Ierm Care For the period from 2016-01-01 to 2016-12-31Mrrrrstëre dod Sante Ct des Soars de loogue dsree

IMOHLTC Fucthty# Oparutor Name IHi 1483 IDeamess Home for Senior Citizens ISection F - Actual Expenditures - Other Accommodation, continued

LTC arrd Interrnr LTC and lrrterim Sub-Total On MrOSSY U Conoaleenont Care Convalescent Sub-Total Minedry UstBed Bed Only kma-Length Care Only

Sotrs-Lergth Non-Arms- (3) Transactions Non-Mra-LengthTransacuons Length Allowable (5) Transactrons AllowableLaundry and Linen Services (C & CS) (1) Transantens Expenditure (6)

(7) Expsnddlire(2) (4) (8)

FOSSSalaries 357.204 357204 0

P051Employee Benerits 123,630 123,830 0

P052Purchased Services 0 0

F054Laundry Supplies 22,607 22,807 0

P055Equipment - New 0 0

P056Equipment - Replacements 33,289 33,289 0

P057Equipment - Leasing 0 0

F058Equipment-Maintenance 10350 10,350 0

FOSSEducation & Training - Supplies and Services 0 0

FOBSNttendance Costs - Meetings, Conventions and Training 0 0

F061 ,jlherProurde descnption Linnon 20,065 20,065 0

F062Expenditure Recoveries (enter as negalive) 0 0

P063 Total Laundry and Linen Services(Sum of lines FOSS through P002) $567,565 $0 $567,565 $0 $0 $0

April 1, 2.017 . Page Sot 19

Ontario 2016 Long-Term Care Home Annual Report

________

M,vic5’ of Health cr0 Lov0-Torr cue For the period ftom I 2016-01-Oil to 201 6-12-311M,ietère dab Sent6 .1 deS 0ev, do lengee dub,

MOHLTC Fudry N Coerator Nanal


Section F -Actual Expenditures - Other Accommodation continued

CIC ceO Intoner LTC and Intanre Sob-Total to, Uewey us. C novont Core Coentont Sob-Total Fur Idirdaby Lisaend Set Ood 6m,n-Leot Cute

Ages-Length Non3otno- (3) Fr. thoe, Noe3mth-

______________________________________________________________________________________

TrOns.000ns Length d,9oWe (5) Length ASowats.G.naral and Admintstrattv. (G&A) (I) Trans.otons TrunacoSOns

(7) EOps.diIW.(4) (6)

P067setaties

330,094 330,494 0

F061Fmpla9ee Beneits

90,965 90,965 0

r069Purchased Seolces

17193 17,193 0

P070liene9sment Fees

0 0

P071tttecatedAdmholsbatlonCo.ts

0 0

10072Audit Fees

3,106 3,506 0

P073Lea.) and Other ProfessIon.) Fee,

5 0

P079Funeral and Burl.)

0

P075Supplies

42,535 42,535 0

P076Oqiclament and Furnlslikoge - New

0

P07,9qig)pment and Furnishings - Replacements

0

P078Ogslpmenl and Fundshhnga - LeasIng

0 0

P079Oqidpment ed Fundebhtga-Metntenence 10,733 10,733 0

P991Joense Fees end Dues 0

P062unau#ing Fees

560,970 560.975 0

P093Acoreditalion Fees 7,964 7,904 0

P084Auaocla6on MembershIp.

14,679 14,679 0

P099di,calan and Training - Supplies and ServIces

0 0

PoleAeondance Costs - Macfeign, Convenlon, end Training 10,656 1 5.604 0

P087‘lonererluma and DonatIon.

0 0

FI oThynidan es-cal coverage )fet the component abovethe NPC allocatIon)

0 0 .‘ ‘

p999 091WProvide descelpiton 0 0

P096!upendithre Recoveries )ostaral nagnlve)

(33,516) 133,516) 0

Post .‘oal General Nod Adnthitsta.Bn.‘SumelHn.aFOSlUirsughFOlO)

$1,104,250 $0 $1,104,256 , $0 50 $0

Aped 1,2017

of 19

OntarioMrnistry of Health and Long-Term Care

Mlndtere de Ia Sante Ct des Soins de lonoun dared

Fib Total Other Accommodation(Line F013 * Line F830* Line F046 + Line Ft63 + Line F091 + Line $6372168P1891

$0 $6372168 $0 $0 $0

$0

El it Total tnadmtssable Expenditures, Other Accommodation(Line F057+Ltne F103+Line F194cLine F105*Line F106( $0 $0 $0 $0 $0

F1i2ITotaI Other Accommodation after Inadmissable Eopenditures(Ltne I $63721681 $01 $6372168File- Line Fill)

For Interim beds

The Urgent Priorities Fund (UPF) andior funds only (exclude For convalescentConvalescent care beds oniyreallocated from other sectors Care Beds) (2)

(1)

Report under column 1 the total eligible enpensen under the Olher

Fl 16 Accommodation envelope for Interim Short-Stay beds funded through theUPFand/or tunds reallocated from other sectors. Report under column 2the fetal eligible expenses under the OtherAccommodation envelope forConvalescent Care beds funded through the UPFandlnr funds reallocated1mm other sectors. Note: The expenses must also be reported on linesFOOl through P109, as npplicable).

For LTCIlntenmbeds unty (eeclude cEnhanced Transition Support Funding Cmvalescent Care

L

III

Fl 17Report the total eligible expenses tunded ftnm lhe Enhanced TransitionSupport Funding. The expenses must also be reported on lines FOOlthrough Ff09, as applicable.

2016 Long-Term Care Home Annual ReportForthepeñodfrom I 2016-01-Oi’ to I 2016-12-311

MOHCIC Faoitey# Operator Names

Hi 1483 Dearness Home for Senior CitizensSection F - Actual Expenditures - Other Accommodation continued

LTC and Interim LTC and lntenmn Sub-Total FOr Mrnesy une- Convatesoent Care Convotencent Care Sub-Total ynr Mmfl8Oy

Bed Bed Only Ammo-Length Non-Arms-Length Lfue OnlyAims-Length Nun-Arms-Length 13t Transactions Transactruns

. Tronsaclions Transac0nns Allowable (5) (6) AllowableFacility Costs (FC) (1) (2) Enpendilure p.nditure(4) 1 )

0597

Utilities 831743 831743 0

F09fInsurance 0 0

F099 -

CommunIcations 0 0

P100Municipal Property Tax 0 0

P102Rent 0 0

F103Mortgage Interest 0 0 h

Ff04Interest on Operating Line of Credit 0 0 i

(-105Other Interest 0

:,

P106Amortization/Depreciat(xn o

iO JmerProvide description 0 0

F1O8Eypenditure Recoveries (enter an negative) 0 0

e ttnrougti P108) $831 743 $0 $831 743 $0 $0 $0

April 1,2017 of 19

Ontario 2016 Long-Term Care Home Annual ReportMinistry of Health and Long-Term Care For the period from I 2016-01—01 I to I 201 6-12-31 IMinistère de Ta Sante et des Some de Tongue durée

Replacement Category “D”Beds and Replacement “B”,“C” and Upgraded “0” beds

0l

I



Section G - Awarded Beds and Replacement “D’ Beds

To be completed by

operators who operated Number of Date of Ministry Ministry Number of Bed- Funding Total Funding

Awarded beds, Replacement Beds Admission of Approved Approved Days in 2016 Per Diem for

“0’, beds, EDAP beds, andFirst Resident to Orientation Fill Rate eligible for for Construction

Re lacement “B” “C” andthe Beds in Days Days Construction Constmctio Costs

P , column (1) Funding n CostsUpgraded ‘0 beds (yyyy-mm-dd)

Awarded Beds andEDAP beds

(1) (3) (4a) (5) (7)

0001 Phase Al

G002 PhaseA2

0003 PhaseA3

0004 PhaseA4 —

GODS PhaseA5

G006 EDAP

0050 Subtotal

0051 Phase Ri

0052 Phase R2

0053 Phase R3

G054 Phase R4 (B and C beds)


0056 Phase R6 (B and C beds)



0059 Phase R9 (B and C beds)

0060 Phase RiO (LHIN beds)

G098 Subtotal

G099 Total

C

IEEl I

April 1,2017 Page ii of 19


_______ _______

MmtNtry of Health and Cong-Term Care Forthe period from 12016-01-01 I to 12016-12-31 IMromtitre de lx SoniC et desMOHCTC Fxoility # Operotor Name,

HI 1483 Dearness Home for Senior Citizens

Section I: Part A.

Line IaOl- The Nurse Practitioner In Long-Term Care Home Program

In eooordonoe with the Long-Term Core (LTd Norso Pr00800ner (NP) Pregrem Fonding P01y, report on line 1.01 Sedry, Benetfo, end 000rhrmd oods from the Nors. Proo000nerpoedon forth. penodhoer lorrs.ry 1,2018th Deoenrbm 31.2018.00 NOT REPORT THESE COSTS IN SECTIONS C THRU F of tho Long-Torts Core Home AnnoI Report

Expenses for 12 months, ]enuary 1, 201610 Desember 31,2016

In oroord.noe roth the Anendng hors. Pre000oner. fl Lono-Tenn Core Home. Ind0500 Fnndng Potoy, re000 on Ino rSib Solo0. Benelts, ond Oxethood roots from the Nor,. Preshloner ponbon ionthe p.nod from Jenoory 1,20l 8 to O.oember3l, 2018.00 NOT REPORT THESE COSTS IN SECTiONS C THRU F of the Cong-Term Core Home Annool Report

Expenses for 12 r’ronlhs, Janua 1, 201010 Dexernb—’ 31, 2016

laOlb $0

OvolflesdExpenses -

Seleen Benefits openetino Total Costs

• laOl ] - $0

jgfo Attendlop N-irs, Praclitleler to Cnnq-Term “ti, Hpmg InItIative

Salons Resents

OverheadEepenses -

operating Total Casts

April 1,2017 of 19


_________

Ministry of Heahh and Long-Term care For the period from I 2016-01-Oil to I 2016-12-311

Ministdre de Ia Sante et des Soins de lonque durde

MOHLTC Facility # - Operator Name:


Section I: Part B One-time Funding and Other Initiatives.

Please use column D to report the expenses applicable to and funded from the funding initiatives below. The expenses reported incolumn D must not be included in Sections C thw F and Section I: Part A of the LTCH Annual Report.

The items reported in Section I: Part B are to be limited to the expenses thatwere incurred from January 1,2016 thru December 31,

2016 only for funding that is received directly by the LTC Home based on the funding provided in the LTCH Payment Calculation Notice.The expenses reported in Section I, Part B are reconciled via alternate processes and shall be exduded from the calculation used todetermine the Allowable Subsidy in the 2016 Overall Reconciliation.

Line Funding Initiative Description Expenses(A) (B) (C) fD)

Report expenses for salaries and wages of nurses from January 1,

Nurse Led Outreach 2016 to December31, 2016 to ensure timely access to care by LTC

lblHome residents and avoid emergency room and hospital admissions.

Report expenses eligible for reimbursement incurred from January 1,

. 2016 to December 31, 2016 by LTC Homes for supplementary staffing,High Intensity Needs Fund IHINF) Claims-Based . . 58.061

exceptionat wound care, preferred accommodahon and transportation

1b2 for dialysis.Report expenses eligible for reimbursement incurred from January 1,

Laboratory Services Claims 2016 to December 31, 2016 for phlebotomy services purchased by LTI 12,7051b3 Homes.

Report expenses eligible for reimbursement incurred from January 1,, . 2016 to December 31, 2016 tot the purchase of computer hardwareRAI-MDS one- time funding

and software, including RAI-MDS software, to meet CIt-Il reporting

1b4 requirements.

Report expenses eligible for reimbursement incurred by the home fromPentoneal Dialysis January 1, 2016 to December31, 2016 for the provision of services to

1b5 Pentoneal Dialysis residents.

, . Report expanses eligible for reimbursement incurred by approvedLTCH Centre of Learning, Research and Innovation. homes from January 1 2016 to December31, 2016 to operate a LTCHProgram funding

1b6 Centre of Learning, Research and Innovation program.

Report expenses eligible for reimbursement incurred by the home fromLHIN funding from outside the Ministry’s OSO investment to January 1, 2016 to December31, 2016 from funding provided by thesupplement staffing salaries as well as any additional LHIN to supplement staffing salaries as well as any additional indirectindirect and start-up costs associated with BSO. and start-up costs associated with BSO with funding from outside the

1b7 Ministry’s BSO investment.

use lines lBs through Ia; i, column D to report expenses eligible for reimbursementincurred by the home from January 1, 2016 to December31, 2016 for any one-time and

One-time and proiect funding project funding. based on the funding provided in the LTCH Payment Calculation NoticePlease report separate each funding item and provide a description below. e.g. WaterQuality Testing, one-time start-up costs for designated specialized unit beds.

1b8 Description:

1b9 Descriptior°’

. .. --

IblO - Qesciiptioit.”

‘-:

Ibil ‘:DèècritIon:Total Expenses from Section I, Part B (sum of lines Ibi to lbll) 70.766

April 1.2017 Page l3of 19

Ontario 2016 Long-Term Care Home Annual ReportMinistry of Health and Long-Term Care For the period from! 2016—01—01 I to I 201 6-1 2-31 IMinistère de Is Sante at des Soins de longue dutde


H11483 Dearness Home for Senior CitizensSection K(a) Calculation ot Maximum Resident-Days and Accredited Bed-Days tot Classitied and Unclassitied beds trom

January 1 to December 31. (Excludes Interim Short-Stay beds and Convalescent Care beds)KOOl (a) Is the Home Accredited? Accreditation Start Accreditation End

Date (if yes) Date (if yes)

Nol I Yesix I I 2016-06-24 2019-06-30

Please mark chsice with X (yyyy-mm-dd) (yyyy-mm-dd)

. Days MaximumFrom To Operating Maximum

Accredited(yyyy-mm-dd) (yyyy-mm-dd) Capacity Resident-Days

DaysKiOla Klolb KlOlc 0(.lOld KiOle KlOlf

K102a K102b K102c KIQ2d K102e 1(1021

January K103a K103b K103c K103d K103c KiO3f

To K104a K104b K104c K104d K104e K104f

March K105a K105b K105c K1fI54 KIOSe K105f

K106a K106b K106c K106d K106e KW6f

K107a K107b K107c t(lGld 107e K107f

KiOSa K108b KlOsc XW8d 1(106* KlO8f

Orientation Days K109a K109b K109c K[OOd K109e uClOOf

Total January to March (sum o lines KIOl through Kl09) KilOd KllOe KilOf

Killa KIlIb Kilic Kilid Kille Klllf

April K112a K112b Kll2c Klt2d K112e 1(1121

To Kll3a Kil3b Kll3c Klt3d K113e Kll3f

June Kll4a K114b K1l4c Kll4d K114e K114f

K115a Kll5b KllSc K115d KilSe Kll5f

K116a Kil6b Kll6c K116d K116e K116f

Kli7a K117b Ktl7c K117d K117a K117f

Kll8a Kli8b Kll8c Klt8d KIlSe Kll8f

Orientation Days Kll9a Kil9b K119c KilOd K119e K119f

Total April to June (sum of lines Kill through Ki 19) K120d K120e K120f

Kl2la K121b K121c KlZld K121e K121f

K122a 1(1221, Kl22c K122d Kt22e K122f

Ki23a K123b K123c K123d K123e Kl23f

K124a K124b K124c Kl24d K124e K124f

K125a Kl25b K125c K125d K125e 1(1251

K126a Ki26b Kl26c K126d K126e K126f

Kl27a Ki27b Kl27c Kl27d K127e K127f

July Kl28a Kl28b K128c K128d 26* 1(1281

To Kl29a Kl29b Ki29c Kl29d 29e K129f

December K130a K130b K130c K130d 30c K130f

Kl3la Kl3ib K131c KI3ld K131e 1(1311

Kl32a K132b Kl32c K132d 32c K132f

K133a K133b Ki33c K133d 33e K133f

Kl34a K134b Kl34c K134d 34, K134f

K135a Kl35b Kl35c K135d 135C 1(1351

K136a K136b Ki36c K13M 136. 1(1361Ki37a K137b K137c K137r1 Ki37f

Kl38a Kl3sb K138c K138d 138. K138f

Orientation Days Kl39a K139b Kl39c K139d 139. K139f

Total July to December (lines Kl2l through Kl39) K140d 140e K140f

Total January to December (lines KllO+Kl20+Kt40) K141d K141e K141f

April 1,2017 of 19

2016 Long-Term Care Home Annual ReportFor the periodI2Ol6-01-01I to I 2016-12-311

OntarioMinistry of Health and Long-Term Care

Ministére de Ia Sante at den Soins de Iongue duree


HI 1483 Dearness Home for Senior CitizensSection K(b) Calculation of Maximum Resident-Days and Accredited Bed-Days for InterimShort-Stay Beds from January 1 to December 31

KOO1(b) Is the Home Accredited? Accreditation Start Accreditation End


Nol I Yes IX I I 2016-06-24 2019-06-30

(yyyy-mm-dd) (yyyy-mm-dd)

. MaximumFrom To Operating Maximum

. Days Accredited(yyyy-mm-dd) (yyyy-mm-dd) Capacity Resident-Days

KtOlg KtOlh Kioli KiOlj KiOlk KIOtI

K102g KiO2h K102i 1(102] 1(102k KW2I

January KtO3g KiO3h K103i 1(103] 1(103k 1(1031

To KiO4g KiO4h KiO4i K104j 1(104k 1(1041

March K105g KiO5h KiO5i K105j 1(105k 1(1051

KiO6g K106h K106i 1(100] 1(106k tUO6t

Kl07g KIOTh K107i K107J 1(107k 071

Fill Rate Admission P KtOig KiOih KiO8i KI08j 1(108k K0*C

Orientation Period K109g KiO9h K109i 1(109] M09k 1C1k.

Total January to March (sumofiinesKi0i_throughK109kltf IQlOk

Kilig Ktilh Kilti K111J

April K112g K112h Kii2i 1(112] - r 121

To Ki 13g Ki t3ti KI 13i K113] KlI5k 1(1131

June K114g K114h K114i 1(114] Kt141 1(1141

Kitlg Klt5h Kli5i KH5J 1(115k 1(1151

K116g K116h Klt6i 1(136] - 116k 1(1161

K117g Ktt7h K117i 1(117] 1(117k 1(1171

Fill Rate Admission P 1(1185 Kit8h Kitsi 1(tlsji. 1(118k 1(1181

Orientation Period Kli9g K119h K119i 1(119] 1(119k 1(1191

Total April to June (sum of lines Kilt through Ki i9) 1(120] 1(120k 1(1201

Ki2lg Kl2lh Kl2ti 1(121] 1(121k 1(1211

Ki22g Kt22h K122i i(J22j i1122k 1(1221

K123g K123h Ki23t5:

1

K124g Ki24h K124i

Ki25g K125h K125i

K126g K126h K126i

K127g Ki27h Ki27i

July Ki2ig K128h K128i

To Ki29g K129h K129i

December Ki3Og Ki3Oh Kl3Oi

Ki3Ig Ki3th Kl3ii

Kl32g Ki32h Kt32i

K133g Ki33h Ki33i

K134g K134h Ki34i

K135g Kt35h Ki35i

Ki36g K136h Ki36i

Kt37g K137h K137t

Fill Rate Admission P Ki38g Ki38h Kt38i

Orientation Period Kt39g K139h K139i

Total July to December (lines 1(121 through Ki

Total January to December (lines K11O+Ki20+1

April 12017 of 19

Ontario 2016 Long-Term Care Home Annual_Report

________

Ministry of Health and Long-Term Care For the period from I 201 6-01—Oij to I 2016—12—311Ministôre do Ia Sante at des Soins do ionaue durée


Hi 1483 Dearness Home for Senior CitizensSection K(c) - Calculation of Maximum Resident-Days and Accredited Bed-Days for Convalescent Care BedsFrom January 1 to December 31

K001(c) Is the Home Accredited? Accreditation Start Accreditation End


Nol I YesiX I I 2016-06-24 2019-06-30

(yyyy-mm-dd) (yyyy-mm-dd)

. MaximumFrom To Operating Maximum Resident

. Days Accredited(yyyy-mm-dd) (yyyy-mm-dd) Capacity Days

KtOlm KlOln KiOlo K101p K101q KlOlr

K102m K102n KtO2o K102p K102q K102r

January K103m K103n K103o K103p K103q KtO3r

To K104m KtO4n K104o K104p K104q K104r

March K105m K105n KlOSo K105p K105q K105r

K106m K106n K106o KIOdp K106q K106r

K107m KtO7n KtO7o K107p K107q K107r

K108m K105n KIOSo K108p K108q KI0$r

Orientation Period K109m K109n K109o K109p K109q K109r

Total January to March (sum of lines KIOl through Kl09) KilOp KI lOq Ki lOr

Kilim Kilin Killo Ktllp Klltq KIlIr

April K112m K112n K112o K112p Ktt2q K112r

To Klt3m Kltln Klt3o K113p K113q KIt3r

June K114m K114n Ktt4o K114p K114q K114r

K115m K115n Klt5o K115p Ktt5q liJl5r

K116m K116n Kti6o ktl€p Ktloq K116r

K117m K117n Kll7o Klllp K117q K1t1i

KttSm K118n Ktl$o Kllp KllSq K18r

Orientation Period K119m K119n K119o K119p KtlOq K119

Total April to June (sum of lines Kt 11 through Kt 19) K120p K120q K120r

K121m K121n K121o Kl2Ip K121q K121r

Kt22m K122n K122o K122p K122q K122r

K123m K123n K123o K123p K123q K123r

K124m K124n K124o K1249 K124q K)24r

K125m K125n K125o Ki2p K125q K125r

Kt26m K126n K126o 1C126p- K126q K126r

K127m K127n K127o K127p K127q i21r

July K128m K128n Kt2So K12p Ki28q K128r

To K129m K129n K129o K129p K129q K129t

December K130m K130n Kt3Oo K)30p K130q K130r

Kt3lm Kt3in K131o K131p K131q Kl3lr

K132m K132n K132o K132p K132q K132r

K133m K133n K133o K133p K133q K133r

K134m K134n Ki34o K134p K134q K134r

Kt35m K135n K135o K135p K135q K135r

K136m K136n K136o K136p K136q K136r

K137m K137n K137o Ki37p K137q K137r

K138m K135n K138o KlJSp K138q K138r

Orientation Period K139m Kl3qn K139o K139p K139q K139r

Total July to December (lines K121 through K139) K140p Kl443i K140r

Total January to December (lines Ki l0+Kt20+K140) Kl4Ip K141q Kt4lr

April 1,2017 of 19

I 2016-12-311

MOHLTC Facility # Licensee Name


EE Check if no accrual amounts as of December31 2016

Section 0 - Accrual Report

NURSING AND PERSONAL CAREPlease complete lines 0001 through 0020, as applicable. Do not Opening Payment Current Period Closing Accrual Balance

include any cost related to the administration of employee and union Accrual Settlements in Accrual

agreements e.g, the cost of conducting union negotiations, arbitration Balance 2016 (4) = (1(-)2)+(3)

hearings,and pay equity negotiations must be reported in the Other (1)1

Accommodation envelope.

0001 Salaries - Collective Agreement Settlements (5,459) 18023 57,601 34,1190002 Salaries - Pay Equity (PB): a0003 Satanes - Vacation Pay 0

0004 Salaries - (Payroll): 0

0005 Total Salaries (sum of lInes 0001 through 0004) ($5 4591 $18 023 $57 601 $34 119

0006 Employee Benefits 16,565 4,147 10,673 23,091

0007 Other (specify): 00008 Other (specify). 00009 TOTAL NURSING AND PERSONAL CARE

(sum of lines 0005 through 0008) $11,108 $22,170 S88,274 $57,210

DETAILS OF COLLECTIVE AGREEMENT SETTLEMENTS FOR NURSING AND PERSONAL CARE (Line 0001)(A) (B) (ci (0) (B) (F) (0)

is the settlement arbitrated. Please Enter date of contract Enter expected date of Enter contract Enter the Enter the Enter as a percentage, the

check YES or NO with an “X” settlement. If contract contract settlement (yyyy- settlement name of the accrued settlementfnegotiated rate

not settled leave blank mm-rid): expiry date or union: amount: used to determine the

and proceed to column expected accrued amount:

(C) contract

(yyyy-cnm-dd(: settlement

expiry date

fyyyy-mm-dd):

0010 ‘N ‘“V0011 N Yes

0012 No Yes

0013 NO YesPlease ensure the most recent arbitration settlements era tekefi into consideration when estimating accruals for expected contract settlements.

DETAILS OF PAYROLL ACCRUALS FOR NURSING AND PERSONAL CARE (Line 0004)Salaries AccrualsExpenditure Line Closing Accrual Description / Details of Accruals

Balance

0014 Unifor- RPN/PSW/ HCA 34,119 ‘Dontract expired JuneSO.2016 and agreement not finalized u

00150016 Total (sum of lInes 0014 through 0015)

$34,119 Cotumn 4 line 0004 is not equal to sum of line 0014 to 0015

Employee Benefits AccrualsEmployee Benefits (Individual (at not required) Closing Accwa Description / Details of Accruals

Balance

Total tDontract expired June3O,2016 and agreement not finalized u

Column 4 line 0006 is not equal to line 0017

Other AccrualsExpenditure Line (specify) Closing Accrua Desci,pbon I Details of Accruals

Balance

0018 Unifor - RPN/PSW/ RCA 23,091 Contract expired June3O,2016 and agreement not finalized u

0019Sum of column 4 lines 0007 to 0008 is not equal to sum of

0020 Total (sum of lines 0018 through 0019) $23,091 lines 0018 to 0019

OntarioMinistry St Heath and Long-Term Care

Mlnislitre de I. Sante Cl des Soins de lsngue durde

2016 Long-Term Care Home Annual ReportFor the period from 2016-01-Oil to

April 1,2617 of 19




Program and Support ServicesPlease complete lines 0101 through 0120, as applicable. Do not Opening Payment Current Penod Closing Accrual Balance

include any cost related to the administration of employee and union Accrual Settlements in Accrual. Balance 2016 (4) = (1)-(2)+)3)

agreements e.g, the cost of conducting union negotIations, arbitration(2) (3)

hearings,and pay equity negotiations must be reported in the Other (1)Accommodation envelope.

0101 Salaries - Collective Agreement Settlements: (4,798) 1,657 3,542 (2,913)

0102 Salaries - Pay Equity (PB): 0

0103 Salaries - Vacation Pay: 0

0104 Salaries - (Payroll): 0

0105 Total SalarIes (sum of lInes 0101 through 0104) ($4,T9Si $1,657 $3,542 ($2,9’tSl

0106 Employee Benefits 205 295 656 5660107 Other (specify): 0

0108 Other (specify): 00109 TOTAL PROGRAM AND SUPPORT SERVICES

(sum of lInes 0105 through 0108) ($4,593) $1,952 $4,198 ($2,36T(

DETAILS OF COLLECTIVE AGREEMENT SEULEMENTS FOR PROGRAM AND SUPPORT SERVICES (L ne 0101)(A) (B) (C) (Dl (E) (F) )G)

Is the settlement arbitrated. Please Enter date of contract Enter expected date of Enter contract Enter the name Enter the Enter as a percentage, thecheck YES or NO with an X settlement. If contract contract settlement (yyyy- settlement of the union: accrued settlemenUnegotiated rate

not settled leave blank mm-rid): expiry date or amount: used to determine theand proceed to column expected accrued amount:

(C) contract(yyyy-mm-dd): settlement

enpiry date)yyyy-mm-dd):

.,j ;:n i0110 N

0111 No0112 “ No

0113 No YesiPlease ensure the most recent arbitration settlements are taken into consideration when estimating accruals for expected contract settlements.

DETAILS OF PAYROLL ACCRUALS FOR PROGRAM AND SUPPORT SERVICES (Line 0104)Salaries AccrualsExpenditure Line Closing Accrual Description I Details of Accruals

Balance

0114 Unifor - RPN/PSW/ HCA (2,913) Contract expired June3O,2016 and agreement not finalized un01150116 Total (sum of lines 0114 through 0115) Column 4 line 0104 is not equal to sum of line 0114

($2,913) to 0115

Employee Benefits AccrualsEmployee Benefits (individual list not required) Closing Description I Details of Accruals

AccrualBalance

Total 566 Contract expired June3O,2016 and agreement not finalized un

Other AccrualsExpenditure Line (specify) Closing Description I Details of Accruals

AccrualBalance

0118

0119

0120 Total (sum of lines 0118 through 0119) $0

OntarioMinistry of Heath and Long-Term care

Ministére de Is Sante et des Soins do lonqae duree

2016 Long-Term Care Home Annual ReportFor the period from I 2016-01-Oil to I 2016-12-311

April 1,2017 of 19

2016 Long-Term Care Home Annual Report

_______

Forthe period from I 2016-01-Oil to 2016-12-311

OpeningAccrualBalance

(1)

so

PaymentSettlements in

2016(2)

so

Current PeriodAccrual

(3)

o

Closing AccruaBalance

(4) =

0

0

0

0

so

0206 Employee Benefits o

0207 Other (specify): 0

0208 Other (specify): 00209 TOTAL OThER ACCOMMODA11ON

(sum of lInes 0205 through 0208) $0 $0 $0 $0

DETAILS OF PAYROLL ACCRUALS FOR OTHER ACCOMMODATION (To be completed by red-circled homes) (Line0204)Salaries Accruals

0216 Total (Sum of lines 0214 through 0215)$0

Employee Benefits (individual list not requited) Closing Description I Details of AccrualsAccrualBalance

[ Total

Other Accruals

Expenditure Line (specify) Closing Description I Details of AccrualsAccrualBalance

0218

0219

0220 Total (sum of lines 0218 through 0219) $0

OntarioMinistry of Heath and Long-Term Care

Misistère dee Sante et des Soins de longue durCe

MOHLTC Facility # Licensee Name:


Other Accommodation - To Be Comoleted by Red-Circled Homes


0201

Please complete lines 0201 through 0220 as applicable. Include any

cost related to the administration of employee and union agreements

e.g, the cost of conducting union negotiations, arbitration hearings,and

pay equity negotiations must be reported in the Other Accommodation

envelope.

nnSalaries - Collective Aqreement Settlements:

0203

elede- Pay Equity )PE):

0204

Salaries - Vacation Pay:

Salaries - (Payroll):

0205 Total Salaries (sum of lInes 0201 throuoh 02041

is the settlement arbitrated. Pleasecheck YES or NO

DETAILS OF COLLECTIVE AGREEMENT SETTLEMENTS FOR OTHER ACCOMMODATION (To be completed by red-circled homes) (Line 0201)

(A) (B) (C) (Dl (E) (F) (G)

Enter date of contractsettlement. if contractnot settled leave blankand proceed to column

)yyyy-mm-dd):

Enter expected dale ofcontract settlement )yyyy

mm-dd):

Enter the nameof the union:

Enter contractsettlement

expiry date orexpectedcontract

settlementexpiry date

)yyyy-mm-dd):

Enter theaccruedamount:

Enter as apercentage, thesettlemenUneg

otiated tateused to

determine theaccruedamount:

Expenditure Line

10214

into consiaerstion wnen estimating accruals tar expectea contract settlements.

10215

ClosingAccrualBalance

Description I Details of Accruals

April 1, 20t7 of 19

OntarioMinistry of Health and Long-Term Care

Ministère de a Sante et des Soins de longue durée

MOHLTC Facility#

HI 1483Section P - Notes to the Report

Significant Accounting Principles

Basis of Accounting

2016 Long-Term Care Home Annual Report_______For the 2016-01-Oil to I 2016-12-31?

Licensee Name

Dearness Home for Senior Citizens

Sections A through G, Section I, and Section 0 of the report have been prepared in accordance with generallyaccepted accounting principles (GAAP) and applicable legislation, regulations, policies and directives.

If there is no trust account, please check hereF

and please explain:

April 1,2017

Ontario 2016 Long-Term Care Home Annual ReportMinistryofHealthandLong-TermCare Forthe period from I 2016-01-Oil to I 2016-12-311Ministére de Ia Sante at des Soins de longue durée


HI 1483 Dearness Home for Senior CitizensSection Q - Licensee’s Statement and Approval

The information contained in Sections A through G, Sections I and K, and Sections 0 and P of this Long-Term CareHome Annual Report of (legal name of Licensee)

Dearness Home for Senior Citizens

for the Period from January 1,2016 to December 31. 2Ol6was provided by management.

This Report has been prepared in conformity with the basis or bases of accounting described in, Section P - Notes to the

Report and adheres to the technical instructions and guidelines as provided by the Ministry of Health and Long-Term Care.

The information contained in this report is in accordance with the L-SAA, any direct funding agreement between theMinister and the licensee, and all applicable policies pertaining to the program funding provided to the home for theperiod being submitted.

Sections C thru F of the report excludes expenditures, as applicable, for: the development of new long-term care beds awardedby the Ministry, the redevelopment of a Category “D” Home, and redevelopment of Replacement “B”, “C” and Upgraded “D”beds. Sections C thru F also excludes, as applicable, expenditures funded from the initiatives reported on in Section I: Part Aand Part B.

Systems of internal accounting control are maintained in order to assure the reliability of this financial

information. These systems include formal policies and procedures, the careful selection and training of qualified

personnel, and an organization providing for appropriate delegation of authority and segregation of responsibilities.

Approved by the Licensee on the 25th

____________________________________—

By: O

witnesatharine Saunders, City Clerk NAME:Ar.Jt,LA )n,%STITLE: Ib,.lLC C-1bL

(If charitable or municipal corporation, affix corporate seal where Licensee is a municipality or a non-profit corporation. Where the

Licensee is a for profit nursing home provide a witness signature.)

day of September 2017

April 1,2017

SCHEDULES OF REVENUES AND EXPENDITURES

CORPORATION OF THE CITY OFLONDON

DEARNESS HOME

For the period from January 1, 2016 to December31, 2016

KPMG LLP140 Fullarton Street Suite 1400London ON N6A 5P2CanadaTel 519 672-4800Fax 519 672-5684

INDEPENDENT AUDITORS’ REPORT

To Management of the Corporation of the City of London and the Minister of Health and Long-Term

Care

We have audited the schedules of revenues and expenditures contained in Sections A through G,

Section I and Section 0 of the Corporation of the City of London Dearness Home Long-Term CareFacility (Dearness”) Annual Report (the Report”) for the period from January 1, 2016 to December

31, 2016. This Report has been prepared by management in accordance with the reporting

provisions of the 2016 Long-Term Care Annual Report Technical Instructions and Guidelines (theTechnical Instructions and Guidelines”) which form part of the Report, and in accordance with the

Local Health Integration Network (LH IN”) Service Accountability Agreement.

Management’s Responsibility for the Schedule

Management is responsible for the preparation of the Report in accordance with the financialreporting provisions in the Technical Instructions and Guidelines, and for such intemal control asmanagement determines is necessary to enable the preparation of the Report that is free from

material misstatement, whether due to fraud or error.

Auditors’ Responsibility

Our responsibility is to express an opinion on the Report based on our audit. We conducted ouraudit in accordance with Canadian generally accepted auditing standards. Those standards requirethat we comply with ethical requirements and plan and perform the audit to obtain reasonableassurance about whether the Report is free from material misstatement.

An audit involves performing procedures to obtain audit evidence about the amounts anddisclosures in the Report. The procedures selected depend on our judgment, including theassessment of the risks of material misstatement of the Report, whether due to fraud or error. Inmaking those risk assessments, we consider internal control relevant to the entity’s preparation of

the Report in order to design audit procedures that are appropriate in the circumstances, but not

for the purpose of expressing an opinion on the effectiveness of the entity’s internal control. An

audit also includes evaluating the appropriateness of accounting policies used and the

reasonableness of accounting estimates made by management, as well as evaluating the overallpresentation of the Report.

KPMG LLP is a Canadian limited liability partnership and a member firm of the KPMG network ofindependent member firms affiliated with KPMG International Cooperative IKPMG Internationall. aSwiss entity.KPMG Canada provides services to KPMG LLP.

We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis

for our audit opinion.

Opinion

In our opinion, Sections A through G, Section I and Section 0 of the Report present fairly in all

material respects, the revenues and expenditures of the Corporation of the City of LondonDearness Home Long-Term Care Facility for the period from January 1, 2016 to December 31,2016 in accordance with the Technical Instructions and Guidelines referred to above.

Basis of Accounting and Restriction on Use

Without modifying our opinion, we draw attention to note 1 to the Report, which describes the basisof accounting. The Report is prepared, on behalf of the LHIN, to enable the Ministry of Health andLong-Term Care to calculate the allowable subsidy for Dearness for the January 1, 2016 toDecember 31, 2016 funding period. As a result, the Report may not be suitable for anotherpurpose. Our report is intended solely for the directors of Dearness, the Ministry of Health andLong-Term Care, and the LHIN and should not be distributed to or used by parties other than thedirectors of Dearness, the Ministry of Health and Long-Term Care and the LHIN.

Chartered Professional Accountants, Licensed Public Accountants

September 25, 2017

London, Canada

DEARNESS HOMENotes to the Report

For period from January 1,2016 to December31, 2016

1. Basis of accounting:

Revenues and expenditures are reported in accordance with the 2016 Long-Term CareFacility Annual Report Technical Instructions and Guidelines, dated April 1, 2017 as providedby the Ministry of Health and Long-Term Care, using the accrual basis of accounting.

2. Significant accounting policies:

(i) The accrual basis of accounting recognizes revenues as they become available andmeasurable; expenditures are recognized as they are incurred and measurable as aresult of the receipt of goods or services and the creation of a legal obligation to pay.

(ii) Minor capital asset purchases are reported as expenses in the year of acquisition.

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