S-4.2, r. 23 - Regulation respecting the information that institutions must provide to the Minister of Health and Social Services

Schedule Disposition versions

2022-04-14

SCHEDULE VII

(s. 5.3)

1. The institution referred to in section 5.3 provides the following information:

(1)  concerning the user:

(a)  the name of the user’s mother;

(b)  the reason for which the user’s health insurance number cannot be provided, where applicable;

(c)  the date of death, where applicable;

(d)  the address of the user’s permanent place of residence;

(e)  the address and code of the municipality of the place where the user is staying, where applicable;

(2)  concerning any identification of the user’s loss of autonomy using the tool Prisma-7:

(a)  the care and service program and the centre or sub-centre of activities to which the identification is associated;

(b)  the dates of beginning and end of the association of the identification with the centre or sub-centre of activities;

(c)  the dates of beginning and end of the user’s participation in the care and service program;

(d)  the sequential number assigned to the identification;

(e)  the date on which identification began and the date on which it is completed;

(f)  the result of the identification;

(g)  the permit number of the institution where the identification was conducted;

(h)  the number, on the institution’s permit, of the facility where the identification was conducted;

(3)  concerning any assessment of the user’s loss of autonomy using the multi-clientele assessment tool (OEMC) or the functional autonomy measurement system (SMAF) exclusively;

(a)  the assessment model used;

(b)  the care and service program and the centre or sub-centre of activities to which the assessment is associated;

(c)  the dates of beginning and end of the association of the assessment with the centre or sub-centre of activities;

(d)  the dates of beginning and end of the user’s participation in the care and service program;

(e)  the sequential number assigned to the assessment;

(f)  the date on which assessment began and the date on which it is completed;

(g)  upon any provision of information, the history of the statements of realization of the assessment and the dates on which those statements of realization have changed;

(h)  the results of the computation of the SMAF and social SMAF;

(i)  the results of the computation of incapacity and handicap for each element of the SMAF and social SMAF;

(j)  the type of resource-person who renders services to the user with respect to each element of the SMAF and an indication of the resource’s stability for each of those elements;

(k)  the Iso-SMAF profile;

(l)  the Euclidean distance;

(m)  the employment title of the provider who conducted the assessment;

(n)  the permit number of the institution that provides assessment services to the user;

(o)  the number, on the institution’s permit, of the facility that provides assessment services to the user;

(p)  the type of resource or living environment where the assessment was conducted;

(q)  the name and code of the local services network entered in the file of the user concerned by the assessment;

(r)  the name and code of the local services network where the residence of the user concerned by the assessment is located;

(s)  the type of living environment where the user concerned by the assessment is residing and, in the case of a facility maintained by an institution, a private seniors’ residence or another lodging resource, the name of that facility, residence or resource;

(t)  an indication that a case management worker participated in the assessment, where applicable;

(u)  for each element of the SMAF that was assessed:

i.  the items and technical aids used by the user to compensate for incapacity, where applicable;

ii.  an indication of whether the human resources available to compensate for the user’s incapacity meet the user’s needs, do not meet them, or meet them in part and, in the latter case, of whether that shortcoming is due to the quantity of services obtained, the quality of those services, or both;

(3.1)  concerning a user who underwent an assessment of his or her loss of autonomy using the OEMC or the SMAF:

(a)  the weekly frequency at which the user takes care of his partial or complete hygiene or at which it is provided to the user, and an indication of the mode of hygiene used;

(b)  an indication of whether the user is able to get around inside the living environment using a wheelchair;

(c)  an indication of whether the user is able to get around using a wheelchair, a 3-wheel scooter or a 4-wheel scooter within 20 m of the living environment;

(d)  an indication of whether the user uses stairs;

(3.2)  concerning a user who underwent an assessment of his or her loss of autonomy using the OEMC:

(a)  if the user is 65 years of age or over, an indication of whether examination of the file revealed a nutritional risk, and the level of risk identified;

(b)  an indication of whether static and dynamic synthesis of the file using the OEMC revealed signs of the following risks:

i.  if the user is under 65 years of age, the user’s nutritional risk;

ii.  the user’s risk of falling;

iii.  the risk of exhaustion of the user’s informal caregiver;

iv.  the user’s risk of wound;

v.  the user’s risk of suicide;

vi.  the risk of maltreatment toward the user and, when specified, the types of risks of maltreatment (physical, sexual, material or financial and psychological);

vii.  the risk of neglect toward the user;

viii.  the risk of the user’s rights being violated;

ix.  the user’s risk of fragility;

(c)  regarding the user’s state of health:

i.  the user’s body mass index;

ii.  the weight fluctuations observed in the user during the year preceding the assessment;

iii.  an indication of whether the user has a medical history;

iv.  an indication of whether the user was hospitalized during the year preceding the assessment and the reason for that hospitalization, where applicable;

v.  an indication of whether the user fell during the year preceding the assessment and the number of falls, where applicable;

vi.  an indication of whether the user expresses a fear of falling, or an indication that the user is unable to answer that question;

vii.  the symptoms experienced by the user with regard to the user’s sensory, genitourinary, digestive and motor functions, the condition of the user’s skin, and the user’s mood or anxiety disorders, suicidal ideation, agitation or disruptive behaviours;

viii.  an indication of whether the user has a mental health problem and, if so, of whether that problem is taken in charge;

ix.  an indication of whether the user has experienced trauma and, if so, the type of trauma;

x.  the reason why the user has difficulty taking medication, where applicable;

xi.  the type of side effects experienced by the user after taking his or her medication, where applicable;

xii.  the extent to which the user felt weak during the 4 weeks preceding the assessment, or an indication that the user is unable to answer that question;

xiii.  an indication of whether the user is followed by a family physician;

xiv.  an indication of whether the user is followed by a medical specialist;

xv.  an indication of whether the user is followed by a health or social services professional who is not a physician;

(d)  regarding the user’s lifestyle:

i.  the user’s appetite level;

ii.  an indication of whether the user feeds orally, enterally or parenterally, or through a combination of those methods;

iii.  an indication of whether the user eats the following foods for breakfast:

I)  fruits or fruit juice;

II)  eggs, cheese or peanut butter;

III)  bread or cereal;

IV)  milk;

iv.  the nature of the user’s feeding problems, where applicable;

v.  the user’s type of dentition;

vi.  the weekly frequency at which the user consumes alcohol;

vii.  the weekly frequency at which the user walks for at least 10 minutes;

viii.  the weekly frequency at which the user plays sports for at least 10 continuous minutes;

ix.  the weekly frequency at which the user engages in moderate activity;

x.  an indication of whether the user has ceased or significantly reduced a social activity he or she engaged in during the year preceding the assessment and the reasons therefor, where applicable;

(e)  regarding the user’s psychosocial state:

i.  an indication of any previous event experienced by the user that is likely to significantly impact his or her lifestyle and the date of each event identified, where applicable;

ii.  an indication of whether the user is surrounded by a family or social network;

iii.  an indication of whether the user is assisted by an informal caregiver;

iv.  regarding each informal caregiver of the user, where applicable:

I)  an indication of whether he or she is the main informal caregiver or another type of informal caregiver;

II)  an indication that he or she is 75 years of age or over, where applicable;

III)  the date on which he or she began providing services to the user;

IV)  an indication of whether he or she cohabits with the user;

V)  an indication of whether his or her income is sufficient to meet his or her needs;

VI)  his or her state of health;

VII)  the nature of his or her relationship with the user;

VIII)  his or her employment status;

IX)  the nature of the problems with regard to his or her role in the user’s life, as stated by the user or observed by the provider, where applicable;

X)  the weekly frequency at which he or she is involved with the user;

XI)  an indication of whether he or she is satisfied with his or her situation;

XII)  an indication of whether the user has agreed to have the institution communicate with the informal caregiver concerned;

v.  the nature of the user’s family dynamics;

vi.  the type of contact between the user and his or her social or family network, and the frequency of that contact;

vii.  the state of the relationship between the user and his or her social or family network;

viii.  the nature of the social support that the user receives from his or her social or family network;

ix.  the types of maltreatment of which the user seems to be a victim, where applicable;

x.  the emotional state expressed by the user;

xi.  the user’s perception of his or her general situation;

xii.  the nature of the means used or not used by the user in order to get his or her situation under control, or an indication that the user is unable to answer that question;

xiii.  the nature of the user’s problems with regard to his or her intimate and emotional life, where applicable;

xiv.  the nature of the user’s problems with regard to the practices and obligations related to his or her religion, where applicable;

xv.  the type of the user’s current occupation;

xvi.  the user’s civil status;

xvii.  an indication of whether the user lives with a partner with or without children, is a single parent, lives alone, lives with a relative, or lives with a non-relative, or an indication that that information is not available;

xviii.  the user’s number of years of education;

(f)  regarding the user’s economic situation:

i.  an indication of whether the user’s income is sufficient to meet his or her needs, or an indication that the user is unable to answer that question;

ii.  the nature of the user’s problems with regard to finances or payments;

iii.  the user’s sources of income;

(g)  regarding the physical environment in which the user lives:

i.  the nature of the elements whose absence or presence in the user’s living environment is likely to cause a risk of falling, where applicable;

ii.  the nature of the user’s problems with regard to accessibility inside his or her living environment;

iii.  an indication of whether the user avoids going up stairs or carrying small loads;

(3.3)  an indication of whether an assessment of the user’s social functioning was conducted using the OEMC and, if so, the date of that assessment;

(4)  concerning any individualized service plan or intervention plan established for the user and any new version of those plans:

(a)  the type of plan;

(b)  the care and service program and the centre or sub-centre of activities to which the plan is associated;

(c)  the dates of beginning and end of the association of the plan with the centre or sub-centre of activities;

(d)  the date of beginning and end of the user’s participation in the care and service program;

(e)  the sequential number assigned to the plan;

(f)  the version number;

(g)  the goal of the plan;

(h)  the date of creation of the plan version and the date on which it was completed;

(i)  the date on which the plan was developed;

(j)  upon any provision of information, the history of the statements of conduct of the plan and the dates on which those statements of conduct have changed;

(k)  the means to be used and the interventions to be performed, identified on the plan, and the category to which they are related, their frequency, the day fixed for their implementation, their dates of beginning and end, the time allocated to them, the place where they are implemented or performed, the type of provider assigned to them, the centre and sub-centre of activities to which they are associated at the time of planning, the identity of their provider, and the link between the provider and the user, where applicable;

(l)  the date of any revision of the plan;

(l.1)  the date of any improvement of the plan;

(m)  the degree of achievement of the objectives per type of act;

(n)  the degree of acceptance of the plan by the user;

(o)  the employment title of the provider in charge of the plan;

(p)  a mention that the case was assigned to a case manager or a pivotal provider and the dates of beginning and end of the assignment of the case to any case manager or pivotal provider;

(q)  the permit number of the institution where the plan was carried out;

(r)  the number, on the institution’s permit, of the facility where the plan was carried out;

(s)  an indication that a case management worker participated in the development of the plan, where applicable;

(5)  concerning any transmission of information to the Minister:

(a)  the permit number of the institution from which the data is provided;

(b)  the code of the health region from which the information originates;

(c)  the date of transmission;

(d)  the number assigned to the transmission;

(e)  the dates on which the period concerned begins and ends;

(6)  concerning the therapeutic nursing plan established for the user:

(a)  the date of preparation of the plan;

(b)  the sector of activities to which the user is associated at the time the plan is established;

(c)  the date of any modification of the plan;

(d)  respecting any statement on the general state of the user entered in the plan by a nurse:

i.  a description of the statement;

ii.  specifications associated to it, where applicable;

iii.  the date and time the statement was established;

iv.  the title and duties of the nurse who established the statement and the service program to which the nurse is assigned;

v.  the sector of activities to which the user is associated at the time the statement is established;

vi.  the type of professionals or the service identified by the nurse to remedy the problem;

vii.  the title and duties of the nurse who established the plan if it is not the person referred to in subparagraph iv;

viii.  its state of realization and the date of any modification to that state of realization;

ix.  the title and duties of the nurse who modified the state of realization, where applicable, and the service program to which the nurse is assigned;

x.  the category, element and theme associated with it;

xi.  the reason for correcting the statement, where applicable;

(e)  respecting any directive associated with the statement:

i.  a description of the directive;

ii.  specifications associated with it, where applicable;

iii.  the date and time the directive is established;

iv.  the title, duties and service program to which the nurse who established it is assigned;

v.  the state of its realization and the date of any modification to that state of realization;

vi.  the title and duties of the nurse who modified the state of realization, where applicable, and the service program to which the nurse is assigned;

vii.  the category, element and theme associated with it;

viii.  the reason for correcting the directive, where applicable;

(f)  the name and number, on the institution’s permit, of the first facility where the user was received.

O.C. 753-2014, s. 4; O.C. 859-2018, s. 6; O.C. 317-2022, s. 9.

2018-07-19

SCHEDULE VII

(s. 5.3)

1. The institution referred to in section 5.3 provides the following information:

(1)  concerning the user:

(a)  the name of the user’s mother;

(b)  the reason for which the user’s health insurance number cannot be provided, where applicable;

(c)  the date of death, where applicable;

(d)  the address of the user’s permanent place of residence;

(e)  the address and code of the municipality of the place where the user is staying, where applicable;

(2)  concerning any identification of the user’s loss of autonomy using the tool Prisma-7:

(a)  the care and service program and the centre or sub-centre of activities to which the identification is associated;

(b)  the dates of beginning and end of the association of the identification with the centre or sub-centre of activities;

(c)  the dates of beginning and end of the user’s participation in the care and service program;

(d)  the sequential number assigned to the identification;

(e)  the date on which identification began and the date on which it is completed;

(f)  the result of the identification;

(g)  the permit number of the institution where the identification was conducted;

(h)  the number, on the institution’s permit, of the facility where the identification was conducted;

(3)  concerning any assessment of the user’s loss of autonomy using the multi-clientele assessment tool (OEMC) or the functional autonomy measurement system (SMAF) exclusively;

(a)  the assessment model used;

(b)  the care and service program and the centre or sub-centre of activities to which the assessment is associated;

(c)  the dates of beginning and end of the association of the assessment with the centre or sub-centre of activities;

(d)  the dates of beginning and end of the user’s participation in the care and service program;

(e)  the sequential number assigned to the assessment;

(f)  the date on which assessment began and the date on which it is completed;

(g)  upon any provision of information, the history of the statements of realization of the assessment and the dates on which those statements of realization have changed;

(h)  the result of the computation of the SMAF;

(i)  the results of the computation of incapacity and handicap for each element of the SMAF;

(j)  the type of resource-person who renders services to the user with respect to each element of the SMAF and an indication of the resource’s stability for each of those elements;

(k)  the Iso-SMAF profile;

(l)  the Euclidean distance;

(m)  the employment title of the provider who conducted the assessment;

(n)  the permit number of the institution where the assessment was conducted;

(o)   the number, on the institution’s permit, of the facility where the assessment was carried out;

(4)  concerning any individualized service plan or intervention plan established for the user and any new version of those plans:

(a)  the type of plan;

(b)  the care and service program and the centre or sub-centre of activities to which the plan is associated;

(c)  the dates of beginning and end of the association of the plan with the centre or sub-centre of activities;

(d)  the date of beginning and end of the user’s participation in the care and service program;

(e)  the sequential number assigned to the plan;

(f)  the version number;

(g)  the goal of the plan;

(h)  the date of creation of the plan version and the date on which it was completed;

(i)  the date on which the plan was developed;

(j)  upon any provision of information, the history of the statements of conduct of the plan and the dates on which those statements of conduct have changed;

(k)  the means to be used and the interventions to be performed, identified on the plan, and the category to which they are related, their frequency, the day fixed for their implementation, their dates of beginning and end, the time allocated to them, the place where they are implemented or performed, the type of provider assigned to them, the centre and sub-centre of activities to which they are associated at the time of planning, the identity of their provider, and the link between the provider and the user, where applicable;

(l)  the date of any revision of the plan;

(m)  the degree of achievement of the objectives per type of act;

(n)  the degree of acceptance of the plan by the user;

(o)  the employment title of the provider in charge of the plan;

(p)  a mention that the case was assigned to a case manager or a pivotal provider and the dates of beginning and end of the assignment of the case to any case manager or pivotal provider;

(q)  the permit number of the institution where the plan was carried out;

(r)  the number, on the institution’s permit, of the facility where the plan was carried out;

(5)  concerning any transmission of information to the Minister:

(a)  the permit number of the institution from which the data is provided;

(b)  the code of the health region from which the information originates;

(c)  the date of transmission;

(d)  the number assigned to the transmission;

(e)  the dates on which the period concerned begins and ends;

(6)  concerning the therapeutic nursing plan established for the user:

(a)  the date of preparation of the plan;

(b)  the sector of activities to which the user is associated at the time the plan is established;

(c)  the date of any modification of the plan;

(d)  respecting any statement on the general state of the user entered in the plan by a nurse:

i.  a description of the statement;

ii.  specifications associated to it, where applicable;

iii.  the date and time the statement was established;

iv.  the title and duties of the nurse who established the statement and the service program to which the nurse is assigned;

v.  the sector of activities to which the user is associated at the time the statement is established;

vi.  the type of professionals or the service identified by the nurse to remedy the problem;

vii.  the title and duties of the nurse who established the plan if it is not the person referred to in subparagraph iv;

viii.  its state of realization and the date of any modification to that state of realization;

ix.  the title and duties of the nurse who modified the state of realization, where applicable, and the service program to which the nurse is assigned;

x.  the category, element and theme associated with it;

xi.  the reason for correcting the statement, where applicable;

(e)  respecting any directive associated with the statement:

i.  a description of the directive;

ii.  specifications associated with it, where applicable;

iii.  the date and time the directive is established;

iv.  the title, duties and service program to which the nurse who established it is assigned;

v.  the state of its realization and the date of any modification to that state of realization;

vi.  the title and duties of the nurse who modified the state of realization, where applicable, and the service program to which the nurse is assigned;

vii.  the category, element and theme associated with it;

viii.  the reason for correcting the directive, where applicable;

(f)  the name and number, on the institution’s permit, of the first facility where the user was received.

O.C. 753-2014, s. 4; O.C. 859-2018, s. 6.

2014-09-18

SCHEDULE VII

(s. 5.3)

1. The institution referred to in section 5.3 provides the following information:

(1) concerning the user:

(a) the name of the user’s mother;

(b) the reason for which the user’s health insurance number cannot be provided, where applicable;

(c) the date of death, where applicable;

(d) the address of the user’s permanent place of residence;

(e) the address and code of the municipality of the place where the user is staying, where applicable;

(2) concerning any identification of the user’s loss of autonomy using the tool Prisma-7:

(a) the care and service program and the centre or sub-centre of activities to which the identification is associated;

(b) the dates of beginning and end of the association of the identification with the centre or sub-centre of activities;

(c) the dates of beginning and end of the user’s participation in the care and service program;

(d) the sequential number assigned to the identification;

(e) the date on which identification began and the date on which it is completed;

(f) the result of the identification;

(g) the permit number of the institution where the identification was conducted;

(h) the number, on the institution’s permit, of the facility where the identification was conducted;

(3) concerning any assessment of the user’s loss of autonomy using the multi-clientele assessment tool (OEMC) or the functional autonomy measurement system (SMAF) exclusively;

(a) the assessment model used;

(b) the care and service program and the centre or sub-centre of activities to which the assessment is associated;

(c) the dates of beginning and end of the association of the assessment with the centre or sub-centre of activities;

(d) the dates of beginning and end of the user’s participation in the care and service program;

(e) the sequential number assigned to the assessment;

(f) the date on which assessment began and the date on which it is completed;

(g) upon any provision of information, the history of the statements of realization of the assessment and the dates on which those statements of realization have changed;

(h) the result of the computation of the SMAF;

(i) the results of the computation of incapacity and handicap for each element of the SMAF;

(j) the type of resource-person who renders services to the user with respect to each element of the SMAF and an indication of the resource’s stability for each of those elements;

(k) the Iso-SMAF profile;

(l) the Euclidean distance;

(m) the employment title of the provider who conducted the assessment;

(n) the permit number of the institution where the assessment was conducted;

(o) the number, on the institution’s permit, of the facility where the assessment was carried out;

(4) concerning any individualized service plan or intervention plan established for the user and any new version of those plans:

(a) the type of plan;

(b) the care and service program and the centre or sub-centre of activities to which the plan is associated;

(c) the dates of beginning and end of the association of the plan with the centre or sub-centre of activities;

(d) the date of beginning and end of the user’s participation in the care and service program;

(e) the sequential number assigned to the plan;

(f) the version number;

(g) the goal of the plan;

(h) the date of creation of the plan version and the date on which it was completed;

(i) the date on which the plan was developed;

(j) upon any provision of information, the history of the statements of conduct of the plan and the dates on which those statements of conduct have changed;

(k) the means to be used and the interventions to be performed, identified on the plan, and the category to which they are related, their frequency, the day fixed for their implementation, their dates of beginning and end, the time allocated to them, the place where they are implemented or performed, the type of provider assigned to them, the centre and sub-centre of activities to which they are associated at the time of planning, the identity of their provider, and the link between the provider and the user, where applicable;

(l) the date of any revision of the plan;

(m) the degree of achievement of the objectives per type of act;

(n) the degree of acceptance of the plan by the user;

(o) the employment title of the provider in charge of the plan;

(p) a mention that the case was assigned to a case manager or a pivotal provider and the dates of beginning and end of the assignment of the case to any case manager or pivotal provider;

(q) the permit number of the institution where the plan was carried out;

(r) the number, on the institution’s permit, of the facility where the plan was carried out;

(5) concerning any transmission of information to the Minister:

(a) the permit number of the institution from which the data is provided;

(b) the code of the health region from which the information originates;

(c) the date of transmission;

(d) the number assigned to the transmission;

(e) the dates on which the period concerned begins and ends.

O.C. 753-2014, s. 4.