Title Page

  • Conducted on

  • Prepared by

  • Location

Green Criteria

  • Physical distancing maintained during break times

  • Satellite break rooms are established

  • Time clock is sanitized after each use with appropriate signage to encourage physical distancing (Visibly verified and account for a best practice)

  • Leadership and team meetings are coordinated with physical distancing practices

  • Shift exchange and cross over with proper physical distancing in place (can articulate the location of discussion)

  • Physical distancing in common spaces, activities, and dining room observed

Screening and Declaration

  • Proper use of PPE at all times

  • Screener asks visitors role (ex. ECP, designated caregiver, other) and has an updated list of designated caregivers/ visitors

  • Screener is verbally asking the questions

  • Temperature checks are completed (entry and exit)

  • One primary entry point with a dedicated screener during peak hours

Resident Temperature and Symptoms Checks

  • Teams can provide evidence that ALL residents temperature and symptoms checks done according to provincial directives (ON - min 2X daily; AB - with care - min 1x daily done by TM, without care - self check for symptoms at least daily, isolation - min 1x daily; BC - min 1x daily unless suspected COVID then 2x daily)

Amica Directives PPE Universal Protocols

  • Teams are able to articulate their practice

  • Daily education to LL and TMs

  • Leaders are monitoring proper use and informing where gaps exist, progressive discipline measures are documented

  • Proper PPE use is maintained outside the residence (on breaks, carpooling, waiting for screener, etc) following Amica PPE guide by role

  • Proper use of PPE has been communicated and signed off by all TMs (can produce evidence of such)

  • PPE signage throughout building; all TM break rooms, time clock, washrooms, etc.

  • Through contact mapping exercises, no impact to Team or residents identified due to inappropriate PPE use

  • PPE education and audits provided to ECPs (including private companions, designated caregivers) to support proper PPE usage across all shifts across all neighborhoods

  • TMs list pulled to audit all TMs over time

PPE and Hand Hygiene

  • PPE and HH audits submitted monthly via outbreak preparedness form in collaboration with DOW

  • Evidence at a minimum of 1 audit/ week per shift of days, evenings, nights in each dept completed with outcomes identified; including weekends

  • TM list pulled to audit all TMs over time. Team able to demonstrate audits on different TMs.

  • ECPs, visiting health professionals, LE vendors, salon operators, designated caregivers, etc included in hand hygiene and PPE audits

Hand Hygiene

  • Hand sanitizers available at all entry points to common spaces and care areas including but not limited to - front entry, screening station, concierge, bistro, entry and exit to dining room, entry to care floors, elevators, break areas, time clock, and spaced throughout care areas

  • *MC - if inappropriate for ABHR to be left out, process to ensure ABHR is available to all TMs and residents (ex. Personal ABHR on all TMs)

  • Residents are being cued to complete hand hygiene prior to dining, activities, and on entry/exit

  • Education on proper hang hygiene is completed regularly noting the 4 moments for hand hygiene across all depts and each shift including weekends

  • Hand washing is completed when ABHR is not available or when appropriate

  • Hand washing observed to be completed properly (at least 20 seconds, washing using warm water and soap, using paper towel to dry and turn off taps, etc)

  • Signage noted at all ABHR stations providing visual cues to complete hand hygiene; visible to both TMs and residents

Daily PPE inventory and secure management system

  • PPE tracker submitted by residence every Thursday end of day via connect form. If COM is not submitter, reviews and approves for accuracy and submits

  • Each week, GM/COM reviews submission for accuracy and validity with regional team

  • Minimum inventory level at least = to 3 days (as outlined by dashboard)

  • Usage within 10% of average use

  • Level 1 masks within 5% of expected use

  • Locked storage with no more than 2 people (non-wellness) managing inventory

  • Dedicated wellness TM 24/7 has access and is accounting for inventory with process owner

Contact mapping exercise

  • Each LL has proficiency in contact mapping exercise and demonstrated ability to coordinate and lead contact mapping exercises

  • Contact mapping exercise completed minimum of 2/month; lead by a different leader in each dept.

  • Effective contact mapping tool is followed which outlines all of the tools one can pull and interview techniques

  • Regional teams review finalized contact mapping, probing deep for commonalities and fulsome contact mapping and confirms they are using most up to date version of the effective contact mapping tool

  • Teams can articulated learnings, impact, and opportunities and have seminar action items on opportunities

  • Contact mapping results show no impact to TM and Residents due to weakness in 5 lines of defence (inappropriate PPE, lack of physical distancing, inadequate screening)

Enhanced Cleaning

  • Documentation of infection control cleaning (can provide evidence of)

  • 7 days a week schedule in place

  • Can articulate ‘outbreak’ cleaning procedures and are executing for line listed residents

  • Common area 3x minimum per day

  • LE, bus, dining room, and bistro enhanced cleaning completed prior to/after programs and/or dining services

  • Shared equipment disinfected between individual use

  • Proper use of chemical (disinfecting solution for all surface cleaning, exception being food prep areas)


  • Attendance being tracked and logged for 100% of activities/ outings in provided template

  • Evidence of enhanced cleaning prior to programs and between programs

  • LE outing checklist completed including evidence of enhanced cleaning

  • Limit of 5 participants per outing OR as directed by bus capacity to ensure proper physical distancing guidelines

  • Program limits do not exceed space limits or government guidelines and ensure proper physical distancing

  • Process in place to disinfect equipment that may be shared outside of programming times (ex. Cards, games, library books, etc)

  • Resident cohort plan completed in the event we move to a high risk scenario

Common Spaces

  • Each common space capacity is identified and signage posted at the door

  • Physical distancing reminders/ signage visible for residents

  • Furniture is arranged to promote physical distancing

  • Enhanced cleaning evident 3x/day or after common space has been used (schedule for use of common areas)

  • Signage at elevators indicating max capacity

Dining Room/Bistro

  • Residents dine with the same dining partner selected. Only 2 people per table

  • Tables set up to support physical distancing

  • No communal items in dining rooms and on tables

  • Proper use of PPE by entire team

  • Enhanced cleaning of all surfaces occurring prior and after each services

  • Bistro staffed by TM while open

  • No Self Serve items available in Bistro

  • All bistro items individually wrapped

  • Physical distancing is observed in bistro with signage/reminders or decals for residents with only 1 chair per table

  • Evidence of enhanced sanitization

  • All kitchen deliveries are 'tailgate drops'. No delivery person permitted inside the building

Resident Coming and Going

  • Education provided to residents for coming and going - at minimum, monthly ongoing education provided to residents on physical distancing and actions to take to keep themselves safe

  • Mask provided to residents at frequency directed by Amica. Any additional are made available at cost

  • Resident Interaction Journal provided to Residents


  • Visitor education provided to all visitors on onsite protocols, PPE, and hand hygiene

  • Visitors wear PPE, physical distancing, and follow onsite protocol

  • Screener provides visitor education toolkit, if visit indicates. If visitor does not understand protocols at point of declaration, able to articulate the protocols

  • Screener able to instruct visitor on proper use of PPE

  • TM instructs visitors on proper donning/doffing of PPE as necessary

TM Case Management & Testing

  • LL contacts any isolated TMs every other day to see if their condition has changed and how they are doing

  • Updates TM Case Mgmt Form within shift

  • TMs returning to work on anticipated RTW dates

  • Regional Team always consulted on RTW protocol discussions and decisions

  • 100% of symptomatic TMs immediately tested and placed in isolation

  • Hard copies of ALL positive TM test results are collected and place in TM medical files

  • Interval testing completed per regional guidelines

Saliva and Panbio Study consent for TMs

  • Panbio pilot and saliva based study are voluntary alternatives to the PH NP swab for routine asymptomatic surveillance testing. Consent forms are available at residence (Saliva based study)

  • Team is able to describe the process of obtaining consent and ensuring the consent forms are submitted with samples

  • Team is able to describe the process for managing testing refusal


  • DS recruitment: postings closed within 20 days; # of new hires in month > or = # of terms in month

  • Maintaining relationship with COVID contract TMs that have left; keeping them warm in case we need to recall them

  • Building plan on how to incrementally reduce surge labour hours, overtime; sensible, logical and able to maintain dedicated staffing within the parameters

  • TMs available to work hrs & hrs being scheduled as per surge labour dashboard results

  • Have all TMs identified in Commitment Tracker and know who can extend shifts if necessary; schedule template prepared in case of need

ECP Management

  • Contingency plan in place to staff for ECP hours if needed

  • Conversations had up front with Agencies, private companions, etc in event of outbreak

  • Meet at minimum monthly with Agency provider to work through staffing, troubleshoot issues, and discuss payment in case of missed care. ECP missed visit incident connect form completed. Contingency planning conversations had with resident/POA

  • A list of ECPs/Private companions are kept at the residence for easy contact mapping

  • ECPs have been trained on all COVID protocols; offered/ encouraged to participate in interval testing when available

  • ECP Dashboard is reviewed with Wellness Team, GM, and LL monthly


  • 100% enrollment - all Dept schedules are published in WAA for 4 weeks upcoming

Cohorting Plans

  • Cohorting plan prepared in the event of outbreak

  • This should include a schedule/TM assignment where primary TMs are assigned to care for ill residents and well residents separately

  • In outbreak scenario, to the best of ability, we reduce movement of TMs between neighborhoods/floors in collaboration with PH

New Hire/LOAs Return to Work

  • 100% of new hires and TMs returning to work have been fully trained on COVID directive and any changes to protocols

50% reduction in staffing plan

  • 3+ agency agreements in place

  • Continually recruiting and receiving referrals from TMs

  • Received commitments from TMs of max availability if we were to suffer reduction in staffing

  • Schedule is prepared in event of Outbreak and/or reduction of staffing occurs

  • Essential tasking duties list prepared in case of non-care related duties need to be stripped away from Wellness positions and given to UTMs

TM Culture and Communication

  • Physically distancing daily stnd up occurring using stand up tool and being disseminated to TMs to review during crossover

  • Communicating updates to FAQs and TM letters, showing videos

  • Weekly acts of recognition/appreciation

Physician/ Medical Director Collaboration

  • Physician and Medical Director proactively communicated with regarding approach and treatment in the event of CV positive residents to ensure up to date treatment given as appropriate

  • Communication regarding our swabbing efforts and expectations around ordering physycian (all swabs must have submitter information completed)

  • Expectations are set up front with our physicians and the availability of emergency calls to support CV positive resident

Line List Review with Wellness/LL and CV scenario form completed

  • 2x daily review and CV scenario connect form completed

PN review/symptom search report review

  • Reviewed 7 days a week by wellness team leaders for aggressive case finding (more often in case of outbreak)

PH Management and CV Testing Readiness

  • 100% of symptomatic residents swabbed (if POA - consent received)

  • Swabs available onsite (max amount of swabs allowed onsite as determined by PH)

  • Administration prepared in advance and includes pertinent information including submitter information

  • Pending swabs reviews (able to articulate resident and date of swab) regularly with PH.

Daily Assessment of Isolated Residents

  • Symptomatic residents assessed at each shift (3x/day)

  • Asymptomatic - Process in place to communicate to Wellness any changes in status noted and 2x symptoms check

  • Health status updated to LL daily 7 days a week

Residents on Droplet Precautions

  • All residents as per Amica scenarios or government directives (contact mapping, exposure risk, return from hospital, move in or any atypical symptoms)

  • PPE signage outlining PPE requirements on the door and caddie prepared and placed in approved area

  • Line list is updated and all TMs made aware (communication, crossover, and daily stand up)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.