Long before COVID-19 sickened at least one-third of the residents at a long-term care home in Maple Ridge, the facility — owned by a profitable investment trust — had struggled to meet provincial standards.

A routine inspection of the 35-bed Willow Manor Care Centre in February, around the time the first cases of COVID-19 were identified in the province, found four violations that needed to be corrected.

The licensing officer identified problems with dirty equipment and a shortage of staff with up-to-date first aid certificates. In a third of cases, people were being held in restraints without the written consent on file from either their representatives or their doctors, both of which are required.

At the time of the inspection, it had been almost a year since a licensing officer last looked at the facility. That visit found that in some cases, the home wasn’t keeping residents’ care plans current and had failed to meet the requirement to weigh residents at least once a month.

The March 2019 report noted the Community Care and Assisted Living Act and Residential Care Regulations set minimum standards that must be met by all licensed care facilities “to ensure the health and safety of vulnerable individuals in care.”

“The responsibility rests with Willow Manor Care Centre to provide for the health and safety needs of all individuals in your care at all times.”

The admonishment should not have come as a surprise. A year earlier, in January 2018, licensing had found three violations. When a facility changes managers it is required to notify a health officer within 30 days, but owner Chartwell Retirement Residences hadn’t reported a former manager’s resignation for nine months.

There were also concerns about six cases where medicines had been dispensed without proper authorization.

And the care home was failing to follow the province’s immunization and tuberculosis control programs, which require records to be kept showing employees are in compliance. For a quarter of the employees there were no such records.

In all cases, the facility was ordered to correct the violations. There is no indication in the publicly available reports that they did not.

A call to the facility manager was returned by a spokesperson at the company’s head office who provided information on the COVID-19 outbreak, but did not respond by publication time to questions about past licensing violations.

On Thursday, Chartwell Willow, with a capacity of 35 residents, was caring for 11 people with COVID-19 and there had been two deaths. Three staff members associated with the facility also had tested positive for the virus. (Chartwell Willow is an alternate name for the facility used in some documents.)

Owner Chartwell Retirement Residences is a publicly traded real estate trust that describes itself as “Canada's largest owner and operator of seniors living residences with 196 residences and 29,300 suites under management.”

According to its website, on Thursday Chartwell had active COVID-19 outbreaks associated with 21 of its residences, including two in B.C. Outbreaks at another 11 Chartwell residences had been deemed over.

“Today more than ever, the top priority of every member of the Chartwell organization is the safety and well-being of our residents and staff,” it said.

A statement from CEO Vlad Volodarski said, “Chartwell has always maintained strong infection control and management protocols and practices. In response to COVID-19, we moved rapidly to significantly enhance and complement these practices and protocols.”

Company spokesperson Sharon Ranalli said in an email that measures put in place include “enhanced resident monitoring including temperature and symptom checks,” screening of staff, use of personal protective equipment and isolation strategies. “We continue to follow all recommendations of the Chief Medical Officer and Public Health.”

Chartwell Retirement Residences’ share price has tumbled from a pre-pandemic high of $15.79 to a recent low of $6.25.

Even with the collapse in price, the company is worth about $1.8 billion. Last year it had revenue of nearly $911 million. And it was profitable with an operating margin of more than 10 per cent.

In B.C., about 35 per cent of long-term care is provided by for-profit operators like Chartwell. The rest is split between non-profits and facilities run directly by the province’s health authorities.

Pandemic shines a spotlight on long-term care

Across Canada and around the world, the pandemic has taken a major toll in homes where elderly people live in groups. There are 19 facilities with ongoing outbreaks in B.C. Another 10 have made it through outbreaks that have been declared over.

About half the deaths from COVID-19 in B.C. and Canada have been in long-term care homes. The pandemic has highlighted staffing issues and the government has ended the widespread practice of allowing people to work part-time in multiple homes, which increased the risk illness would spread.

In B.C., the government is topping up wages so workers get the standard amount for unionized staff and is re-organizing schedules so people working at a single site can get full-time hours.

Some advocates are now calling for an end to the involvement of private businesses in the sector. In B.C., they are finding support from Premier John Horgan. Others see the call as a political attack on a sector that has more pressing needs than changes to the ownership model.

The laws and regulations governing B.C.’s long-term care homes are detailed and complex and operators have to show they meet more than 200 conditions.

Licensing and inspections are a key part of a system that sees large amounts of public money transferred to private and non-profit providers to care for people who, in many cases, are elderly, vulnerable and unable to self-advocate.

While it’s not unusual for inspections to find violations at care homes, the reports are a window into what was happening before the pandemic at care homes that have since had COVID-19 outbreaks.

The Amica Edgemont Village in North Vancouver, for example, had five infractions in June. A 2018 inspection found it had failed to meet the requirement that “All persons admitted comply with the Province's immunization and TB control programs.”

The Windermere Care Centre was found out of compliance with that same requirement in January 2018.

Haro Park Residential Care in Vancouver was cited in 2017 for not meeting the requirements of the immunization and tuberculosis programs and in both 2018 and 2019 for failing to regularly review employee performance to make sure they met requirements and demonstrated the competence required for their duties.

The Lynn Valley Care Centre in North Vancouver has a history of multiple violations, including issues with keeping rooms clean. At least 20 deaths have been linked to the outbreak in the care home.

Langley Gardens was the subject of a complaint in 2019. “Licensing determined that the facility was not operated in a manner that promoted the health, safety and dignity of a person in care, when staff failed to meet the needs of a person in care,” provincial inspectors reported.

They found “that a staff failed to demonstrate the competencies necessary to support a person in care with their nutritional needs.”

A 2018 inspection of Langley Lodge, a facility with capacity for 139 residents, found a number of violations, including five fire extinguishers that had expired two months earlier. It also found that in three of eight employee records reviewed, their professional registrations had expired a year or two earlier.

A call to end for-profit ownership

In the midst of the pandemic, the Canadian Centre for Policy Alternatives has called for removing the profit motive from long-term care.

“Many of these issues were occurring, and [there were] pretty significant staffing challenges, before COVID-19, but it’s really brought those to light,” said Andrew Longhurst, a research associate with the B.C. office of the CCPA.

“Over the medium and long-term, the B.C. government should end its reliance on contracting with for-profit companies and transition exclusively to non-profit and public delivery of seniors’ care,” wrote Longhurst and Kendra Strauss, a labour studies professor at Simon Fraser University.

They traced the current state of the sector to provincial legislation passed in 2002 and 2003, and only recently repealed, that stripped job security from the contracts of unionized health-care workers and allowed work to be contracted out. The changes let employers lay off workers and drive down wages, they concluded.

Their review cited the February 2020 report A Billion Reasons to Care by BC Seniors Advocate Isobel Mackenzie that found that despite receiving similar funding from the government, for-profit long-term care operators were spending about $10,000 less each year per resident than their non-profit counterparts.

That report also found that for-profit care homes generated $34.4 million in profit, 12 times as much as non-profits did.

It makes little sense to pay companies during the pandemic to top up wages to levels that they were already funded to pay, Longhurst and Strauss wrote.

“In practice, the top-up means these operators will be rewarded for overcharging the public,” they wrote. They argued companies should instead be compelled to pay the unionized wage rate without receiving additional funding and that in the future the companies should be required to return to operating within the public sector labour relations structure. Labour contracts for most publicly funded health workers are negotiated with the Health Employers Association of BC, but changes in the early 2000s let operators negotiate labour agreements outside of that umbrella group. At the same time, changes to laws allowed for more contracting out in the sector and reduced protections for workers.

“The COVID-19 crisis is exposing the long-term impacts of policies aimed at cutting costs and expanding the role of for-profit companies in the seniors’ care sector in B.C.,” they wrote. “Reduced pay and benefits and understaffing are bad for workers; they are also bad for vulnerable older people who depend on those workers to meet their daily needs.”

In an interview, Longhurst said owners seeking to make a profit have different priorities beyond quality of care.

“All of these concerns speak to the fact a lot of these business practices and the requirement to return a profit to investors, it’s really hardwired into the business model in how these companies operate.”

There’s lots of evidence from within the province and around the world on the question, he said.

“When we look at the academic, peer-reviewed research literature on resident health outcomes by ownership type, we generally see better outcomes in non-profit and publicly delivered care and inferior outcomes generally in for-profit owned facilities.”

There needs to be more accountability on how public dollars are spent, Longhurst said. Money provided for direct care should only be spent on that care and health authorities should be given the power to require facilities to provide detailed expense reports.

“If we want to be prudent with public dollars going forward, we need to be thinking about how we transition away from for-profit care delivery and really strengthen and build capacity in the non-profit and public sector,” he said. “The government is trying to address that in mere weeks, something that has played out over two decades.”

In recent comments, Health Minister Adrian Dix has said the government needs to make sure standards are high throughout the sector, regardless of ownership.

He made a similar point earlier this year as the government, amid concerns about “unacceptable” care, took over operation of a fourth Retirement Concepts long-term care home, a chain owned by Anbang Insurance Group headquartered in China.

Mike Klassen, vice-president of public affairs for the BC Care Providers Association, agrees. The association represents both for-profit and not-for-profit care home operators.

He argues it’s wrong to say private ownership provides a lower standard of care.

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“There’s no foundation,” he said. “Most of the stuff here is pretty baseless... If you listen to the discussion around what bedevils the seniors care sector, it really boils down to a few key issues, and one of them is not ownership.”

“If you look across the country where we have different models of care, COVID-19 has not made any distinction as to whether it is a government-owned and operated, a privately-owned and operated, a non-profit or otherwise.”

Klassen said the key challenges are around staff shortages, which was a problem long before the pandemic, and older homes where up to four residents share a room. “Older care home stock has been a big problem, particularly back east.”

Improving the older homes will require convincing the federal government to invest, he said.

Klassen said the association pushed the government to end the practice of people working at multiple long-term care homes during the outbreak. It had organized two forums and published a 10-point plan in 2018 for addressing the staff shortage, he said.

Klassen said private providers weren’t alone in having a hard time attracting workers. Health authority job boards have lots of postings for positions in homes they run, he said. “They are all struggling to find staff.”

Klassen said it’s good news that more care homes are being declared free of COVID-19.

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And he criticized the Canadian Centre for Policy Alternatives’ report.

“When you look at a lot of Canadians right now, they’re rallying together, essentially politics is at a low roar,” he said. “You don’t see the opposition necessarily trying to attack government and here we have a decidedly political position being taken during the middle of a public health crisis, so I’ll leave it to others to decide how ethical that is.”

The CCPA position did, however, get a receptive response from Horgan.

“We have always, as a political party, had concerns about the direction that long-term care took at the turn of the century, back in 2001-2002,” Horgan said Wednesday. “I think some of the challenges that we anticipated are being graphically highlighted during this time of pandemic.”

Some changes have already been made, he said, pledging there will be no return to employees working at multiple sites.

And there will be more changes coming based on what the government has learned during the pandemic, Horgan said.

“We need to make sure that they’re as efficient as possible, as cost-effective as possible and, most importantly, as safe as possible.”