Government of Ontario: Ministry of Health and Long-Term Care

Long-Term Care Division
Profile of Long-Term Care Facility

Name
Address
Identification no.
Telephone no.
Fax no.

Area office
Regional office

Emergency/disaster plan
Date tested

Approved/licensed capacity
No. of Special care beds
Facility CMI
Additional beds available
Accredited date
Award yrs

Strengths and Developments

List strengths and developments since the last review (attach pages as desired)

*Please attach a copy of your organizational chart.

Key Personnel*

1 Position titles of key personnel*
Name
Date of appointment

2 Position titles of key personnel*
Name
Date of appointment

3 Position titles of key personnel*
Name
Date of appointment

4 Position titles of key personnel*
Name
Date of appointment

5 Position titles of key personnel*
Name
Date of appointment

6 Position titles of key personnel*
Name
Date of appointment

7 Position titles of key personnel*
Name
Date of appointment

8 Position titles of key personnel*
Name
Date of appointment

9 Position titles of key personnel*
Name
Date of appointment

10 Position titles of key personnel*
Name
Date of appointment

11 Position titles of key personnel*
Name
Date of appointment

12 Position titles of key personnel*
Name
Date of appointment

13 Position titles of key personnel*
Name
Date of appointment

14 Position titles of key personnel*
Name
Date of appointment

Committees

List internal committees

1 Committee
Chair-person/person accountable
Frequency of meetings

2 Committee
Chair-person/person accountable
Frequency of meetings

3 Committee
Chair-person/person accountable
Frequency of meetings

4 Committee
Chair-person/person accountable
Frequency of meetings

5 Committee
Chair-person/person accountable
Frequency of meetings

6 Committee
Chair-person/person accountable
Frequency of meetings

7 Committee
Chair-person/person accountable
Frequency of meetings

Orientation tours

Resident involvement

Family involvement

Admission interdisciplinary team conference

Resident involvement

Family involvement

Annual interdisciplinary team conference

Resident involvement

Family involvement

Residents' council

Resident involvement

Family involvement

Family council

Resident involvement

Family involvement

Family nights

Resident involvement

Family involvement

Resident contracts

Resident involvement

Family involvement

Other

Resident involvement

Family involvement

Structural information

Type of rooms

Type of rooms (this refers to structural layout rather than what is charged as preferred accommodation)

Number of rooms with 1 bed
Number of rooms with 2 beds
Number of rooms with 3 beds
Number of rooms with 4 beds
Other (please specify)

Separate infirmarye

Room no.

Type of security system (please specify)

Year of construction

Opening date

Year(s) of renovation (if applicable)

No. of floors

Number of units and beds

1 Unit
Number of beds
Manager

2 Unit
Number of beds
Manager

3 Unit
Number of beds
Manager

4 Unit
Number of beds
Manager

5 Unit
Number of beds
Manager

Additional services provided to residents

Emergency medical coverage

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Pharmacy

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Laboratory

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Radiology

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Physiotherapy

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Occupational therapy

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Foot care

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Ophthalmology/Optometry

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Audiology

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Dental

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Denturist

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Respiratory technology

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Mental Health Serv. i.e. psychogeriatrics

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Transportation

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Other (specify)

Service provided Service provided
yes
no

Contract for service Contract for service
yes
no

Explanation if applicable

Community linkages

Volunteer program

Service provided Service provided
yes
no

Comments

Service groups

Service provided Service provided
yes
no

Comments

Language interpreters

Service provided Service provided
yes
no

Comments

Cultural interpreters

Service provided Service provided
yes
no

Comments

Advisory council

Service provided Service provided
yes
no

Comments

Community board

Service provided Service provided
yes
no

Comments

Faith communities

Service provided Service provided
yes
no

Comments

Other (specify)

Service provided Service provided
yes
no

Comments

Services provided to the community

Services provided to the community (e.g. meals on Wheels, Day Care programs, Short Stay programs)

Shared services (if applicable)

Do staff provide services such as laundry, housekeeping, dietary, maintenance to other than long term care residents? If so, how many?

General information

1 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

2 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

3 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

4 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

5 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

6 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

7 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

8 Name of union

Term of contract:
start date expiry date

Number of employees
Type of work

2308-69 (97/02)*