Personal Care Homes Standards Regulation

Personal Care Homes Standards Regulation, M.R. 30/2005 The Health Services Insurance Act , C.C.S.M. c. H35 Regulation 30/2005 Registered February 28, 2005 bilingual version (HTML) Table of Contents Section PART 1 DEFINITIONS 1 Definitions PART 2 BILL OF RIGHTS AND RESIDENT COUNCIL 2-4 Bill of rights 5-6 Resident council PART 3 ADMISSION 7 Who is eligible for admission 8 Information on admission PART 4 RESIDENT CARE 9 Right to participate in care 10 Resident's wishes 11 Initial care plan 12 Integrated care plan 13 Review of care plan 14 Staff to be made aware of plan 15 Freedom from abuse 16 Written restraint policy 17-18 Physical restraints PART 5 MEDICAL, NURSING AND PHARMACY SERVICES 19 Designated physician 20 Medical care of residents 21 Nursing services for residents 22 Nurse in charge of care 23 General nursing requirements 24 Pharmacy services 25 Administering medications 26 Limited supplies of medication 27 Health records PART 6 GENERAL SERVICES 28 Dietary services 29 Housekeeping services 30 Laundry services 31 Recreation 32 Spiritual and religious care program PART 7 MISCELLANEOUS 33 Temperature 34 Safety and security standards 35 Disaster management program 36 Infection control program PART 8 ADMINISTRATION 37 Person in charge of day-to-day operation 38-39 Qualified staff 40 Complaints 41 Compliance with policies and procedures 42 Reports about occurrences PART 9 COMING INTO FORCE 43 Coming into force PART 1 DEFINITIONS Definitions 1 The following definitions apply in this regulation. "Act" means The Health Services Insurance Act . («  Loi  ») "application and assessment form" means a form, approved by the minister, that must be completed before a resident is admitted to a personal care home. (« formulaire de demande et d'évaluation ») "designate" means a person designated by a resident as his or her designate for the purpose of this regulation, or, if the resident is not able to make a designation, a family member or friend who has a close personal relationship with the resident and is interested in ensuring his or her well-being. (« représentant ») "interdisciplinary team" means, at a minimum, representatives from the nursing, medical, dietary, pharmacy, recreation, housekeeping and laundry services at the personal care home. (« équipe interdisciplinaire ») "legal representative" means any of the following persons: (a) a proxy appointed by a resident under The Health Care Directives Act , to the extent of the proxy's powers under the health care directive; (b) a committee appointed for a resident under The Mental Health Act , to the extent of the committee's powers under the appointment; (c) a substitute decision maker for personal care appointed for a resident under The Adults Living with an Intellectual Disability Act , to the extent of the substitute decision maker's powers under the appointment. (« représentant légal ») "licensed practical nurse" means a person registered under The Licensed Practical Nurses Act . ( « infirmière auxiliaire » ) "operator" means the holder of a personal care home licence issued under the Act. (« exploitant ») "pharmacist" means a person licensed under The Pharmaceutical Act . (« pharmacien ») "physical restraint" means a manual or physical device that a resident cannot remove and that restricts his or her freedom of movement. (« dispositif de contention ») "physician" means a duly qualified medical practitioner. (« médecin ») "registered nurse" means a person registered under The Registered Nurses Act . (« infirmière ») "registered psychiatric nurse" means a person registered under The Registered Psychiatric Nurses Act . (« infirmière psychiatrique ») "resident" means a person admitted to and residing in a personal care home. (« résident ») "restraint" means any restriction of the voluntary movement of a resident, to ensure the safety of the resident or others. (« restriction ») M.R. 115/2025 PART 2 BILL OF RIGHTS AND RESIDENT COUNCIL BILL OF RIGHTS Bill of rights 2 The operator of a personal care home shall ensure that a residents' bill of rights is developed for the home in consultation with the residents and their designates. What the bill of rights must contain 3 The bill of rights must be consistent with the Act and this regulation and must, at a minimum, reflect the following principles: 1. Residents are to be treated with courtesy and respect and in a way that promotes their dignity and individuality. 2. Residents are to be sheltered, fed, dressed, groomed and cared for in a manner consistent with their needs. 3. Residents or their legal representatives have the right to give or refuse consent to treatment, including medication, in accordance with the law. 4. Subject to safety requirements and the privacy rights of other residents, residents are to be encouraged to exercise their freedom of choice whenever possible, including the freedom to do the following: (a) exercise their choice of religion, culture and language; (b) communicate with, and have contact with and visits to and from friends, family and others in private if desired; (c) choose their recreational activities; (d) choose the personal items to be kept in their rooms, when space permits; (e) select the clothing to be worn each day. 5. Residents are to be afforded reasonable privacy while being treated and cared for. 6. Residents are to be provided with a safe and clean environment. 7. Residents may communicate and meet with their legal representative as often as necessary and in private if desired. Bill of rights to be respected and promoted 4(1) The operator shall ensure that the bill of rights is respected and promoted in the personal care home. 4(2) The bill of rights must be posted in standard CNIB print (Arial 14 font) in locations that are prominent and easily accessible by residents and staff. RESIDENT COUNCIL Resident council 5(1) The operator shall ensure that reasonable assistance is given to residents and their designates to help them establish and maintain a resident council. 5(2) The purpose of the resident council is to provide a forum where issues that concern residents can be discussed, including the services provided to residents in the personal care home. 5(3) The resident council may consist of residents, their designates and any other persons that the council considers appropriate. Suggestions and concerns raised by the council 6(1) The operator shall ensure that a concern raised by the resident council is addressed, including an investigation of the concern if necessary, and that a response, or a preliminary response, is provided to the council at or before its next meeting. 6(2) The minutes of the council's meetings, must — unless the council decides on another method of communicating the information — be posted in standard CNIB print (Arial 14 font) in a location that is prominent and easily accessible by residents and staff. PART 3 ADMISSION ELIGIBILITY FOR ADMISSION Who is eligible for admission 7(1) If a bed is available in a personal care home, any person who meets the eligibility requirements described in clauses 3(a) and (b) of the Personal Care Services Insurance and Administration Regulation is entitled to be admitted, unless it can be demonstrated that safe and adequate care cannot be provided to the person in the home. 7(2) When determining whether safe and adequate care can be provided, the needs of the person must be considered as well as the staffing and physical facilities of the personal care home. 7(3) The person's needs are those described in the completed application and assessment form and as determined by any contact between the staff of the personal care home and (a) the person and his or her designate or legal representative; and (b) any other person or entity that has provided health care to the person. 7(4) A bed designated for short term respite care is not available under subsection (1). INFORMATION ON ADMISSION Information for residents on admission 8(1) The operator shall give the following information to each resident before admission or, if that is not possible, on admission: (a) a copy of the residents' bill of rights; (b) a copy of the personal care home's philosophy and mission; (c) a description of the ways in which the resident and his or her designate and legal representative can participate in assessing, planning, providing, monitoring and evaluating the resident's care; (d) information about the resident council; (e) information respecting the policies relating to complaints, abuse and restraints; (f) financial information, including the availability and administration of resident trust accounts and government financial assistance programs; (g) an orientation to the facility, including safety and security systems; (h) information respecting health care directives. 8(2) If a resident has a legal representative, the operator shall also provide the information under subsection (1) to the legal representative. PART 4 RESIDENT CARE RIGHT TO PARTICIPATE IN CARE Resident's right to participate in care 9 The operator shall ensure that a resident and his or her designate and legal representative are given an opportunity to participate in assessing, planning, providing for, monitoring and evaluating the resident's care. CARE PLANS Resident's wishes 10 The operator shall ensure that the resident's wishes are considered when a care plan is developed or amended under this Part. Initial care plan 11 Within 24 hours after admission, the operator shall ensure that the following basic care requirements for the resident are documented: (a) medication, treatment and diet orders; (b) the type of assistance required for activities of daily living; (c) any safety or security risks. Integrated care plan 12(1) Within eight weeks after admission, the operator shall ensure that each member of the interdisciplinary team assesses the resident's needs and that a written integrated care plan is developed to address them. 12(2) The integrated care plan must include the following information: (a) the type of assistance required with bathing, dressing, mouth and denture care, skin care, hair and nail care, foot care, eating, exercise, mobility, transferring, positioning, being lifted, and bladder and bowel function, including any incontinence care product required; (b) mental and emotional status, including personality and behavioural characteristics; (c) available family and community supports; (d) hearing and visual abilities and required aids; (e) rest periods and bedtime habits, including sleep patterns; (f) safety and security risks and any measures required to address them; (g) language and speech, including any loss of speech capability and any alternate communication method used; (h) rehabilitation needs; (i) preferences for participating in recreational activities; (j) religious and spiritual preference; (k) medications and treatments ordered by a physician; (l) food preferences and diet orders; (m) any special housekeeping considerations for the resident's personal belongings; (n) whether the resident has made a health care directive; (o) any other need identified by a member of the interdisciplinary team. 12(3) Where appropriate, the integrated care plan must also state care goals and interventions that may be taken to achieve these care goals. Review of the integrated care plan 13(1) As often as necessary to meet the resident's needs but at least once every three months, the operator shall ensure that appropriate interdisciplinary team members review the integrated care plan and amend it if required. 13(2) The operator shall ensure that each team member reviews each integrated care plan annually and that any amendments required to meet the resident's needs are made. Staff to be made aware of current plan 14 The operator shall ensure that the staff who provide direct care and services to the resident are aware of the resident's current care plan. If the method of communicating the plan includes preparing a summary for staff to refer to, the operator shall ensure that the summary accurately reflects the current plan. FREEDOM FROM ABUSE Freedom from abuse 15(1) The operator shall establish safeguards to prevent residents from being abused. 15(2) The operator shall establish a written policy that sets out (a) the safeguards established to prevent residents from being abused; and (b) the appropriate action to be taken when abuse is alleged. 15(3) In this section, "abuse" means mistreatment — whether physical, sexual, mental, emotional, financial or a combination of any of them — that is reasonably likely to cause physical or psychological harm or death to a resident, or loss of property belonging to the resident. USE OF RESTRAINTS Written restraint policy 16 The operator shall establish a written restraint policy in accordance with guidelines approved by the minister. Physical restraint may be used only if risk of serious harm 17(1) Except in accordance with this section and section 18, no operator shall permit a physical restraint to be used to restrain a resident without the consent of the resident or his or her legal representative. 17(2) If a resident's behaviour may result in serious bodily harm to himself or herself or to another person, the operator shall ensure that (a) an assessment is done to determine the underlying cause of the behaviour; and (b) positive methods of preventing the harm are explored. 17(3) If positive methods of preventing harm have been explored and determined to be ineffective, a physician, a registered nurse, a licensed practical nurse or a registered psychiatric nurse may order a physical restraint to be used. M.R. 49/2009 Requirements for use of physical restraints 18(1) Every physical restraint must meet the following requirements: (a) be the minimum physical restraint necessary to prevent serious bodily harm; (b) be designed and used so as to (i) not cause physical injury, (ii) cause the least possible discomfort, and (iii) permit staff to release the resident quickly; (c) be examined as often as required by the restraint policy referred to in section 16. 18(2) If a physical restraint is used, the operator shall ensure that the following information is recorded in the resident's health record: (a) a description of the assessment done to determine the potential for serious bodily harm to the resident or another person, and a description of the positive methods to prevent harm that were determined to be ineffective, signed by the person who directed the physical restraint to be used; (b) the type of physical restraint used; (c) each time the resident and the physical restraint is checked; (d) the time and date when use of the physical restraint is discontinued and the reason why. 18(3) The operator shall ensure that the use of each physical restraint is reviewed regularly. At a minimum, the use must be reviewed whenever the resident's care plan is reviewed. 18(4) The operator shall ensure that the use of a physical restraint is discontinued as soon as the reason for its use no longer exists. PART 5 MEDICAL, NURSING AND PHARMACY SERVICES MEDICAL SERVICES Designated physician 19 The operator shall designate a physician to be responsible for the overall coordination and evaluation of medical services for the personal care home. Medical care of residents 20 The operator shall ensure that (a) a physician supervises each resident's medical care; (b) a physician examines each resident as often as the resident's condition requires; and (c) the professional staff and residents have access to a physician 24 hours per day, seven days per week to provide emergency care and consultation as necessary. NURSING SERVICES Nursing services for residents 21 The operator shall ensure that nursing services are organized and available to meet residents' nursing care needs, in accordance with guidelines approved by the minister and consistent with professional standards of practice. Nurse in charge of care 22(1) The operator shall designate a registered nurse or a registered psychiatric nurse to be in charge of administering nursing services in the personal care home. 22(2) If a personal care home has 60 beds or more, the operator may require the nurse designated under subsection (1) to also be in charge of administering other services at the personal care home. But the operator shall not require that nurse to supervise nursing care in the home or, except in an emergency, provide clinical services to residents. 22(3) If a personal care home has fewer than 60 beds, the operator may assign additional responsibilities to the nurse designated under subsection (1). General nursing requirements 23(1) The operator shall establish written nursing policies and procedures relating to the care needs of residents. 23(2) The operator shall ensure that space, equipment and supplies are available to facilitate the professional, educational and administrative activities of the home's nursing services. PHARMACY SERVICES AND MEDICATIONS Pharmacy services and medications 24(1) In clause (2)⁠(a), " pharmacist " includes a corporation or other legal entity that (a) contracts with an operator to direct and be accountable for pharmacy services in a personal care home; and (b) designates one or more individual pharmacists to provide pharmacy services for the personal care home. 24(2) The operator shall (a) appoint or contract with a pharmacist to direct and be accountable for pharmacy services for the personal care home; (b) ensure that the pharmacist maintains a medication profile of each resident; (c) ensure that the pharmacist and other relevant members of the interdisciplinary team review the medications and treatments ordered by a physician for each resident at least every three months; (d) ensure that the pharmacy services for the personal care home are consistent with residents' needs and the scope and complexity of the care offered at the home; (e) ensure that emergency and after-hours pharmacy services are available for residents; (f) ensure that accurate and comprehensive drug information is available to medical, nursing and other staff of the personal care home as required; (g) establish written policies and procedures for pharmacy services for the personal care home that provide for the following: (i) transmitting medication orders to the pharmacy, (ii) handling medication from the point it is procured until it is administered, including delivery, automatic stop orders, recommended times of administration and self-administration by residents, (iii) reporting, documenting, and follow-up of medication incidents, adverse reactions and refusal of medication, (iv) providing medications for residents who are on planned social leave and for persons who are receiving respite care in the personal care home, (v) security of all medications, including appropriate security measures for narcotic and controlled drugs and medications kept at a resident's bedside; (h) by using a current photograph, ensure that each resident's identity is confirmed before staff administers medication; (i) ensure that the overall medication use in the personal care home is monitored; and (j) ensure that the need for education programs about medications, including education for nursing staff and residents, is assessed and that appropriate programs are developed. Administering medications 25(1) The operator shall ensure that when staff administer medications to a resident, such medications are administered (a) only on a physician's order, or the order of a registered nurse made in accordance with The Registered Nurses Act and its regulations; (b) only by a physician, registered nurse, registered psychiatric nurse or licensed practical nurse in accordance with their respective standards of practice; and (c) only after the resident's identity has been confirmed. 25(2) When a physician or registered nurse who is not on-site at the personal care home gives a medication order by telephone, the operator shall take reasonable steps to ensure that it is confirmed in writing on the next visit to the home by the physician or registered nurse. 25(3) The operator shall (a) take reasonable steps to ensure that all medication orders are legible and up to date; and (b) ensure that the person who administers medication records it immediately in the resident's medication administration record, unless the medication is self-administered. Limited medication supplies 26 The operator shall ensure that (a) a monitored dosage or unit dosage system for drug distribution is adopted and implemented in the personal care home; (b) the personal care home has immediate access to a supply of medications for emergency use; (c) there is at least one locked, properly equipped, designated medication storage and preparation area, and that it is clean, well-organized and maintained; (d) medications (other than those that are self-administered) are stored in a locked medication storage and preparation area in a manner that protects them from heat, light and other environmental conditions that may adversely affect them; (e) medications that a resident self-administers and keeps in his or her room are stored so that they are not accessible to other residents; (f) medications requiring refrigeration are kept in a refrigeration unit used for medication storage, consistent with the established standards of practice defined by the College of Pharmacists of Manitoba; (g) the pharmacist conducts regular audits of medication kept at the personal care home and removes and properly disposes of any expired, unused and discontinued medications; and (h) the pharmacist conducts regular audits of medication storage areas and takes any action necessary to ensure that medications are properly stored in accordance with this section. M.R. 90/2017 HEALTH RECORDS Health records 27(1) The operator shall maintain a health record in the personal care home for each resident that includes the following information: (a) admission information that includes (i) a completed application and assessment form, and (ii) any other information provided by the resident and his or her designate or legal representative and any person or entity that has provided health care to the resident; (b) current information about the resident's care that includes the following: (i) the initial care plan and the integrated care plan and any amendments made to them, (ii) medications and treatments ordered by a physician, (iii) medications and treatments administered, (iv) information about the use of restraints as required by subsection 18(2), (v) interdisciplinary progress notes, (vi) the results of ongoing clinical monitoring, (vii) consent forms where necessary, (viii) the resident's health care directive, if any, (ix) a copy of any committeeship order under The Mental Health Act , appointment of a substitute decision-maker under The Adults Living with an Intellectual Disability Act or enduring power of attorney, (x) the date of discharge, transfer or death. 27(2) The operator shall ensure that all the documentation in a resident's health record is (a) accurate, legible, up to date, complete and not misleading; (b) written by the person who made the observation or who provided or supervised the care or treatment, or that person's supervisor; (c) written as soon after the event recorded as possible; (d) identified by the date and time of the entry; and (e) identified by the signature and professional designation of the person making the entry, or by such other means of identifying the person as may be approved by the minister. M.R. 115/2025 PART 6 GENERAL SERVICES DIETARY SERVICES Dietary services 28(1) The operator shall provide an organized dietary service for residents. 28(2) The operator shall ensure that (a) the meals served to each resident are flavourful and appetizing; (b) the meals, nourishments and supplements served to each resident (i) meet the resident's nutritional needs, taking into account the recommended daily allowances set out in Canada's Food Guide to Healthy Eating , (ii) are in accordance with any therapeutic and other diet orders pertaining to the resident, and (iii) whenever possible, take into account the resident's culture, religious practice and food preferences; (c) a cycle menu is prepared for meals for each day during a specified period (a minimum of three weeks) that provides a variety of foods and offers choices; (d) menus are communicated to residents in a timely manner; (e) at least three full meals or equivalent are offered to each resident at reasonable intervals in each 24-hour period; (f) between-meal nourishment and beverages are offered to residents, including at least one offer of nourishment and beverages not less than two hours after the evening meal; (g) each resident is served meals in a group dining area, unless the resident is unable or does not wish to take meals in such an area; (h) as much as reasonably possible, the environment of a group dining area facilitates the enjoyment of meals and the social aspects of dining; (i) a group dining area is supervised by staff who are trained to respond to and assist a resident who is choking; (j) residents are served their meals in a way that promotes independent eating; (k) assistance with eating is provided when required, in a manner that promotes dignity and safety and encourages interaction with the staff member who provides the assistance; and (l) a dietitian registered under The Registered Dietitians Act is available for consultation as necessary. 28(3) The operator shall ensure that the weight of each resident is (a) recorded within seven days after admission; and (b) monitored and recorded monthly thereafter; and that an appropriate intervention is initiated when a resident experiences significant weight change. HOUSEKEEPING SERVICES Housekeeping services 29(1) The operator shall ensure that a housekeeping service is in place to provide a clean and well-maintained environment for residents, staff and visitors. 29(2) At a minimum, the operator shall ensure that (a) all floors, stairs, walls, ceilings, doors, windows, window coverings, sinks, toilets, furniture and equipment in the personal care home are cleaned as often as may be necessary to keep them clean and to minimize odours; (b) all bathing facilities in the personal care home, including hydrotherapy units (whirlpools), tubs, showers, shower chairs and lift chairs are cleaned and disinfected after each resident use; and (c) there is an organized pest control program in the personal care home. LAUNDRY SERVICES Laundry services 30 The operator shall ensure that a laundry service is in place to meet residents' linen and personal clothing needs, and that (a) an effective system is in place for regularly collecting residents' soiled personal clothing and for laundering and returning the clean clothing to their rooms so that a sufficient supply of clean clothing is always available; (b) soiled linen is collected regularly and a sufficient supply of clean linen (including sheets, pillow cases, blankets, towels, washcloths, napkins or clothing protectors and incontinence care products) is always readily available to meet the residents' care and comfort needs; (c) soiled linen and personal clothing are placed into laundry bags or covered carts at point of service and taken to laundry or storage areas in closed laundry bags or covered carts; (d) clean and soiled linen and personal clothing are kept separate at all times; (e) incontinence care products are laundered separately from other laundry; and (f) an effective system is in place for washing and drying linens and personal clothing, including washer equipment that has automatic programming to dispense cleaning products. RECREATION Recreation 31(1) The operator shall ensure that (a) recreational activities for both persons and groups are available to meet residents' physical, emotional, cultural and social needs; (b) recreational activities are available to residents who are unable to leave their rooms; (c) recreational activities are available during some evenings and weekends; (d) recreational areas with suitable equipment and materials to enhance residents' quality of life are available to residents; and (e) information about the current recreational activities available is posted in large print in a prominent and easily accessible location in the personal care home. 31(2) Subject to safety requirements and the privacy rights of other residents, the operator shall ensure that residents are assisted to participate in the recreational activities referred to in subsection (1). SPIRITUAL AND RELIGIOUS CARE Spiritual and religious care program 32 The operator shall ensure that an organized spiritual and religious care program is provided to respond to the spiritual and religious needs and interests of residents. PART 7 MISCELLANEOUS Temperature 33 The operator shall take reasonable steps to ensure that the temperature in residential areas of the personal care home is kept at a minimum of 22°C. Safety and security standards 34(1) The operator shall ensure that the environment of the personal care home is maintained so as to minimize safety and security risks to residents and to protect them from potentially hazardous substances, conditions and equipment. 34(2) Without limiting the generality of subsection (1), the operator shall ensure that (a) nurse call systems are installed and maintained in proper working order within resident rooms, resident washrooms, and bathing facilities; (b) open stairwells are safeguarded in a manner that protects residents; (c) all outside doors and doors to stairwells accessible to residents are equipped with an alarm or a locking device approved by the fire authority under the most recent version of the Manitoba Fire Code made under The Fires Prevention and Emergency Response Act ; (d) windows cannot be used to exit the personal care home; (e) handrails are properly installed and maintained in all corridors, and grab bars are properly installed and maintained in all bathrooms and bathing facilities; (f) all potentially dangerous substances are labelled and stored in a location that is not accessible to residents; (g) all equipment is used, stored and maintained in a manner that protects residents; (h) domestic hot water temperature in resident care areas is not less than 43°C and not more than 48°C; (i) the personal care home is kept clean, and combustible materials are stored separately and safely; (j) exits are clearly marked and kept unobstructed at all times; (k) facility grounds and exterior furniture are safe for resident use; and (l) a system is in place whereby all residents who may wander are identified and all staff are so notified. 34(3) To ensure compliance with this section, the operator shall establish an ongoing safety and accident prevention program that includes the following: (a) maintenance programs for resident safety devices, ventilation, heating, electrical equipment and all other equipment used by staff and residents; (b) protocols relating to hazardous areas; (c) a policy governing electrical appliances to be used or kept by residents in their rooms. M.R. 115/2025 Disaster management program 35(1) The operator shall establish a disaster management program that at a minimum consists of (a) processes and procedures for the facility, its residents, and staff to identify, manage and prepare for risks and vulnerabilities from hazards; and (b) a disaster response plan to ensure staff are able to protect and care for the residents during an emergency. 35(2) The disaster response plan established under subsection (1) must be developed in consultation with appropriate authorities and community agencies, and must (a) provide direction and outline the procedures to be followed in response to internal and external threats to the personal care home, including, but not limited to, (i) severe weather, floods and other natural events, (ii) failure of the heating, water or electrical supply, and other equipment or technological problems, and (iii) bomb threats or other threats of violence or harm arising from the actions of persons; (b) outline specific operational roles, responsibilities and lines of authority for personal care home staff; (c) outline procedures to be followed in evacuating and relocating residents to a safe temporary or long-term location; (d) outline procedures to be followed in searching for a missing resident; (e) include procedures to alert staff and residents of disasters; (f) include procedures to locate, acquire, distribute and account for services, personnel, resources, materials and facilities required during a disaster response; (g) outline procedures for returning evacuated residents to the personal care home or for placing them in safe temporary or long-term accommodations; and (h) identify a program for the restoration of services, programs and infrastructure at the facility following a disaster. 35(3) The disaster management program established under subsection (1) must (a) document the objectives, requirements and schedule to ensure appropriate training is provided to staff; (b) ensure training for all staff on methods to lift and transfer residents to safety; (c) ensure instruction on staff roles and responsibilities under the personal care home's disaster response plan; (d) ensure records are maintained that document the training conducted; and (e) include a process to exercise, test and evaluate all components of the disaster management program, at specified periodic intervals, and to implement improvements as required. Infection control program 36 In order to prevent or control the spread of infection in the personal care home, the operator shall implement an infection control program that includes (a) surveillance of nosocomial infections with review of data at regular intervals; (b) establishing policies and procedures designed to minimize or eliminate transmission of infectious disease; (c) education for staff about infectious diseases, their modes of transmission and methods of prevention; and (d) a contingency plan for outbreaks of infectious diseases with delineated responsibilities for staff, including the reporting requirements under The Public Health Act . PART 8 ADMINISTRATION Person in charge of day-to-day operation 37 The operator shall designate a person to have overall responsibility and authority for the day-to-day operation of the personal care home. Qualified staff 38 The operator shall ensure that all staff of the personal care home have appropriate qualifications to carry out the responsibilities of their positions. Staff education 39(1) The operator shall provide an organized orientation and in-service education program for all staff of the personal care home. 39(2) The operator shall ensure that each new employee signs an acknowledgment of the information received in the orientation. 39(3) The operator shall ensure that the orientation and in-service education programs are evaluated at least annually and revised as necessary to ensure that they are current and meet the learning needs of the staff. 39(4) The operator shall make available health-related resources, including books, journals and audio-visual materials, to staff and volunteers at the personal care home. Complaints 40(1) The operator shall establish a written policy for dealing with complaints made by residents and others about the home's care, services or environment, in accordance with any guidelines established by the regional health authority for the health region in which the personal care home is located. 40(2) The operator shall post an outline of how to lodge a complaint in a prominent and easily accessible location in the personal care home. 40(3) The operator shall keep such records respecting the receipt and handling of complaints as may be required by the regional health authority for the health region in which the personal care home is located. 40(4) An operator, other than a regional health authority, shall provide to the regional health authority for the health region such information respecting complaints received as the authority may require, in the time and in the form the authority requires. 40(5) A regional health authority shall provide to the minister, as required by the minister and within the time and in the form specified, reports respecting complaints received by personal care homes in the health region, including reports provided to the authority under subsection (4). Compliance with policies and procedures 41 The operator shall ensure that any policy or procedure required by this regulation is complied with. Reports about occurrences 42(1) An operator that is not a regional health authority must provide to the authority for the region reports about occurrences in or related to the personal care home that have resulted in actual or potential (a) loss of life, limb or function; (b) loss or damage to property; or (c) harm or risk not described in clause (a) or (b); in accordance with the policy approved by the authority. 42(2) A regional health authority must provide to the minister reports about occurrences in or related to personal care homes in the region that have resulted in actual or potential (a) loss of life, limb or function; (b) loss or damage to property; or (c) harm or risk not described in clause (a) or (b); in accordance with the policy approved by the minister. PART 9 COMING INTO FORCE Coming into force 43(1) Subject to subsection (2), this regulation comes into force on the day that sections 1 and 4, clause 11(d) and sections 13 to 15 of The Health Services Insurance Amendment Act , S.M. 1998, c. 53, come into force. 43(2) Sections 9 to 14, 21, 22, 24 to 27, 34, 35, 37 and 39 come into force on August 1, 2005. February 22, 2005 Minister of Health/ 22 février 2005 Le ministre de la Santé, Tim Sale