Quick facts
- Ontario's long-term care infection prevention and control duties sit in section 23 of the Fixing Long-Term Care Act, 2021 and section 102 of O. Reg. 246/22 (General).
- Section 23 of the Act creates the program and names a lead. Section 102 of the regulation does the harder work: it sets the qualifications of that lead, the hours the role must be given, the monitoring cadence and the written records that prove the program ran.
- The old statute is gone. The Long-Term Care Homes Act, 2007 was repealed on 11 April 2022; any policy manual still citing LTCHA section numbers is citing a repealed instrument.
- The regulation fixes hours by bed count: 17.5 hours a week at 69 beds or fewer, 26.25 hours above 69 and under 200, and 35 hours at 200 beds or more.
- Monitoring is not a monthly exercise. Section 102(9) requires symptom monitoring on every shift, section 102(10) requires the results to be analyzed daily and reviewed at least monthly for trends.
- Neither the Act nor the regulation sets a sterilization monitoring frequency. The daily spore test most Ontario readers associate with "the Ontario rule" is a dental college requirement, not a care-home statutory one — a distinction this article keeps separate throughout.
Ontario long-term care has one of the more tightly written infection prevention regimes in Canadian health care, and it is unusually easy to get wrong — not because the duties are hidden, but because they are split across a statute and a regulation that reference each other by subsection. A home can read the Act, conclude it has a program, and still fail a Ministry inspection on the qualifications of its lead, the hours that role received, or the absence of a written annual evaluation.
This article walks the duties in the order they appear, quotes the operative subsections, and then converts them into the evidence an inspector or an internal auditor will ask to see. Section numbers below are from the current consolidated text published on Ontario's e-Laws service.
Which instruments apply to an Ontario long-term care home
Retirement homes are the most common source of confusion, because they sit under a different statute and a different regulator. Before the clause detail, the map:
| Instrument | What it governs | Where it applies |
|---|---|---|
| Fixing Long-Term Care Act, 2021 (S.O. 2021, c. 39, Sched. 1) | The licensing framework and the duty to have an infection prevention and control program and a lead | Licensed long-term care homes in Ontario |
| O. Reg. 246/22: General, under the 2021 Act | The content, cadence, staffing hours and record-keeping requirements of that program | Licensed long-term care homes in Ontario |
| Retirement Homes Act, 2010 and O. Reg. 166/11 | A separate licensing regime for retirement homes, including its own infection prevention expectations | Retirement homes licensed by the Retirement Homes Regulatory Authority |
| Health Protection and Promotion Act | Outbreak reporting duties to the local medical officer of health | All health care settings |
| Long-Term Care Homes Act, 2007 (LTCHA) | Repealed 11 April 2022. Superseded by the 2021 Act | Historical reference only |
The practical consequence is that a retirement home is not a small long-term care home. It is a different licensee under a different Act, and the section 102 duties described below do not apply to it. Where a supplier, a consultant or an internal policy document uses "LTC" to cover both, the audit trail is wrong at the first line.
What does section 23 of the Fixing Long-Term Care Act require?
Section 23 is short and directional. It creates the obligation and leaves the operational detail to the regulation:
- 23(1): every licensee of a long-term care home shall ensure that there is an infection prevention and control program for the home.
- 23(2): the program must include six things, set out below.
- 23(3): the licensee shall ensure that the program complies with the standards and requirements provided for in the regulations.
- 23(4): except as provided for in the regulations, the home must have an infection prevention and control lead whose primary responsibility is the program.
- 23(5): the lead must possess the qualifications provided for in the regulations.
The six required elements of the program are specific, and each one generates a different piece of evidence:
| Section | What the program must include | Typical evidence |
|---|---|---|
| 23(2)(a) | Evidence-based policies and procedures | Version-controlled policies with a review date and an author |
| 23(2)(b) | An educational component for staff, residents, volunteers and caregivers | Attendance records covering all four groups, not staff alone |
| 23(2)(c) | Daily monitoring to detect the presence of infection in residents | Daily monitoring records, reconciled with the shift-level records required by the regulation |
| 23(2)(d) | Measures to prevent transmission of infections | Isolation, cohorting and additional precautions procedures with the decision criteria written down |
| 23(2)(e) | A hand hygiene program | Point-of-care access evidence plus compliance observation |
| 23(2)(f) | Any additional matters provided for in the regulations | The section 102 requirements below |
Two of these are quietly demanding. Clause 23(2)(b) names caregivers and volunteers alongside staff, which means a home whose education records stop at paid employees is incomplete on the face of the Act. Clause 23(2)(c) says daily, and the regulation then requires monitoring on every shift as the method of achieving it — so a home that monitors once a day to satisfy 23(2)(c) will still fail section 102(9).
How does O. Reg. 246/22 turn section 23 into checkable duties?
Section 102 is where an audit becomes possible. It opens by tying itself back to the Act: the program required under subsection 23(1) of the Act must comply with the requirements of the section.
The program's structural duties
| Subsection | The duty |
|---|---|
| 102(1) | The program required under section 23(1) of the Act must comply with this section |
| 102(2) | The licensee must implement any surveillance protocols issued by the Director for a particular communicable disease or disease of public health significance, and any standard or protocol issued by the Director on infection prevention and control |
| 102(3) | The Director must update those standards and protocols regularly to reflect relevant evidence and practice |
| 102(4)(a) | An interdisciplinary team approach in coordinating and implementing the program |
| 102(4)(b) | An interdisciplinary team that includes the infection prevention and control lead, the Medical Director, the Director of Nursing and Personal Care, and the Administrator |
| 102(4)(c) | That team meets at least quarterly, and more frequently during an infectious disease outbreak in the home |
| 102(4)(d) | The local medical officer of health, or their designate, is invited to the meetings |
| 102(4)(e) | The program is evaluated and updated at least annually against the Director's standards and protocols |
| 102(4)(f) | A written record of each evaluation: its date, who participated, a summary of changes made, and the date those changes were implemented |
| 102(4)(g) | The program is implemented consistently with the precautionary principle and the most current medical evidence |
| 102(8) | All staff participate in implementation, expressly including the Administrator, Medical Director, Director of Nursing and Personal Care, and the lead |
| 102(18) | A quality management program to assess and improve infection prevention and control, as set out in a Director's standard or protocol |
Subsection 102(4)(b) and (c) are the two clauses most often under-documented in practice. The team is defined by named roles, and the meeting frequency has a floor of four a year — with an escalation trigger during an outbreak. A home that holds a quarterly "quality" meeting without the Medical Director present has not met 102(4)(b), however good the minutes are.
Subsection 102(4)(f) is the clause that converts the annual evaluation into evidence. The written record must carry four data points: the evaluation date, the participants, a summary of the changes, and the implementation date of those changes. An evaluation file with a date and a note that "no changes required" is a partial record; the regulation assumes changes will be identified.
Who is the infection prevention and control lead, and how many hours must the role receive?
The Act requires a lead with the primary responsibility for the program. The regulation supplies both the qualification list and the time commitment.
The qualifications in section 102(5)
The licensee must designate a staff member as the infection prevention and control lead who has education and experience in infection prevention and control practices, including all of the following:
| Clause | Area of education and experience |
|---|---|
| 102(5)(a) | Infectious diseases |
| 102(5)(b) | Cleaning and disinfection |
| 102(5)(c) | Data collection and trend analysis |
| 102(5)(d) | Reporting protocols |
| 102(5)(e) | Outbreak management |
| 102(5)(f) | Asepsis |
| 102(5)(g) | Microbiology |
| 102(5)(h) | Adult education |
| 102(5)(i) | Epidemiology |
| 102(5)(j) | Program management |
| 102(5)(k) | Current certification in infection control from the Certification Board of Infection Control and Epidemiology |
Clause 102(5)(k) carries a transition in subsection 102(6): a licensee was not required to comply with the certification qualification until three years after the section came into force. That transition window has closed, which matters for any policy manual written in 2022 and never revised. The remaining ten clauses are not optional alternatives to certification; the section reads as a list of areas in which the lead must have education and experience, with certification required in addition.
The minimum hours in section 102(15)
This is the most concrete number in the entire regime, and it scales with licensed bed capacity:
| Licensed bed capacity | Minimum hours per week on site in the role |
|---|---|
| 69 beds or fewer | At least 17.5 hours per week |
| More than 69 beds but less than 200 beds | At least 26.25 hours per week |
| 200 beds or more | At least 35 hours per week |
The requirement is not merely that the home has someone qualified. Subsection 102(15) requires that the lead "works regularly in that position on site at the home" for the stated weekly time. Subsection 102(16) then requires the licensee to consider the complexity and vulnerability of the resident population and decide whether the lead must work more than the minimum, or whether additional leads should be designated. Subsection 102(17) closes the obvious loophole: designating an additional lead does not relieve the licensee of the minimum hours owed by the lead designated under subsection (15).
For a home with 80 beds, that means a documented 26.25 hours a week in the role, plus a recorded consideration of whether the resident population requires more. A staffing schedule that shows the lead working three clinical shifts produces neither.
What must the lead do, and what must be monitored?
Subsection 102(7) lists eleven responsibilities of the designated lead. They are day-to-day duties, not a job description preamble.
| Item | Responsibility under section 102(7) |
|---|---|
| 1 | Working with the interdisciplinary team to implement the program |
| 2 | Managing and overseeing the program |
| 3 | Overseeing infection prevention and control education for all staff, caregivers, volunteers, visitors and residents |
| 4 | Auditing infection prevention and control practices in the home |
| 5 | Conducting regular infectious disease surveillance |
| 6 | Convening the Outbreak Management Team at the outset of an outbreak and regularly throughout it |
| 7 | Convening the interdisciplinary team at least quarterly, and more frequently during an outbreak |
| 8 | Reviewing the information gathered under subsection (9) |
| 9 | Reviewing daily and monthly screening results to determine whether action is required |
| 10 | Implementing improvements required by audits under paragraph 4 or by the licensee |
| 11 | Ensuring a hand hygiene program is in place per the Director's standard, including at a minimum access to hand hygiene agents at point-of-care |
Item 4 is where the lead's own audit becomes evidence, and item 10 is where that evidence has to change something. An audit programme that produces findings but no implemented improvements is not compliant with the pair.
The monitoring cadence
The cadence below is the part of the regime most often misstated in supplier guidance, so it is worth laying out plainly. Every row is a subsection of the regulation, not an interpretation.
| Frequency | Requirement | Subsection |
|---|---|---|
| Every shift | Symptoms indicating infection in residents are monitored in accordance with the Director's standard or protocol | 102(9)(a) |
| Every shift | Those symptoms are recorded, and immediate action is taken to reduce transmission and to isolate and cohort residents as required | 102(9)(b) |
| Daily | The information gathered under subsection (9) is analyzed to detect the presence of infection | 102(10) |
| At least monthly | The same information is reviewed to detect trends, for the purpose of reducing the incidence of infection and outbreaks | 102(10) |
| At least quarterly | The interdisciplinary infection prevention and control team meets | 102(4)(c) |
| At least annually | The program is evaluated and updated against the Director's standards, with a written record | 102(4)(e), (f) |
The daily analysis requirement sits on the licensee, not on the lead alone, and it depends on shift-level data being recorded in a form that can be analysed at all. This is the quiet argument for a structured monitoring record: a stack of loose notes satisfies neither 102(9)(b) nor 102(10).
Outbreak management, screening and immunization duties
The outbreak system
Subsection 102(11) requires two outputs:
- an outbreak management system for detecting, managing and controlling infectious disease outbreaks, which must include defined staff responsibilities, reporting protocols based on the requirements under the Health Protection and Promotion Act, communication plans, and protocols for receiving and responding to health alerts;
- a written plan for responding to infectious disease outbreaks.
The reporting protocols point outward, to the statutory framework that governs reporting to public health. The written plan points inward, and it is the document an outbreak review will ask for first.
Screening and immunization in section 102(12)
| Item | Requirement |
|---|---|
| 1 | Each resident admitted must be screened for tuberculosis within 14 days of admission, unless screened in the 90 days before admission with documented results available to the licensee |
| 2 | Residents must be offered immunization against influenza at the appropriate time each year |
| 3 | Residents must be offered immunization against pneumococcus, tetanus and diphtheria per the publicly funded schedules posted by the Ministry of Health |
| 4 | Staff are screened for tuberculosis and other infectious diseases in accordance with the Director's standard or protocol |
| 5 | There must be a staff immunization program in accordance with the Director's standard or protocol |
Subsection 102(13) exempts a licensee from item 1 for residents being relocated to another home operated by the same licensee, or transferring to a related temporary, re-opened or replacement home. Subsection 102(14) requires that pets living in or visiting the home have up-to-date immunizations.
Item 1 is the one that fails silently, because the 90-day rule has a documentation condition attached: prior screening only displaces the admission screening if the documented results are available to the licensee. A record that exists at the transferring hospital but not in the home's file does not satisfy the clause.
Records, contacts and the duties that reach outside the home
Three provisions determine how the program connects to the wider system:
- 102(19) requires the direct contact information of all infection prevention and control leads — a telephone number and an email address that are monitored regularly — to be provided to the local medical officer of health or their designate, and, where an entity is designated as the relevant IPAC hub for the home under a funding agreement with the Ministry of Health, to that hub.
- 102(11)(a) ties the home's outbreak reporting protocols to the Health Protection and Promotion Act, which is the statute under which the local medical officer of health acts.
- 102(18) requires a quality management program to assess and improve infection prevention and control, as set out in a Director's standard or protocol.
Subsection 102(19) is a useful test of whether a program is maintained or merely documented. Contact details that were sent once at licensing and never updated fail the "monitored regularly" condition, and a stale contact in an outbreak is a practical failure, not a paperwork one.
Does Ontario law set a sterilization monitoring frequency for care homes?
No — and this is worth stating precisely, because the misattribution is common in supply-side content.
Neither section 23 of the Act nor section 102 of the regulation sets a frequency for biological indicator testing, chemical indicator use or sterilizer log review. What the regulation requires is the program: surveillance, monitoring, education, audit, records. Where a long-term care home operates a sterilizer or a washer-disinfector for reusable medical devices, the reprocessing duties arrive through other instruments — the manufacturer's instructions for use, the applicable CSA medical device reprocessing standard, and, where the home is part of a hospital or a shared service, that organization's medical device reprocessing programme.
Three specific frequencies circulate in the Canadian market and should be kept apart:
| Claim | Where it actually comes from | Does it bind an Ontario long-term care home? |
|---|---|---|
| A biological indicator every day the sterilizer is used, for each type of cycle | The Royal College of Dental Surgeons of Ontario's infection prevention and control standard, which applies to dental practices in Ontario | Not as a statutory duty. It is a dental college requirement |
| A biological indicator at least weekly | The CDC and ANSI/AAMI ST79 baseline used widely in the United States | Not an Ontario or Canadian legal requirement; it is a comparison baseline |
| A sterility assurance programme with monitoring, records and recall procedures | Canadian medical device reprocessing standards, which require the programme and its records but do not themselves set the testing frequency | Yes, as a professional and standards baseline — but the frequency remains a policy decision for the home |
The distinction matters at inspection. Ontario does not require weekly biological indicator testing. The daily test that Ontario readers associate with the phrase "the Ontario rule" is a dental college requirement that applies to dental practices, and the weekly cadence is a United States comparison baseline, not a requirement in Ontario. A long-term care home that cites a dental college rule as its own authority has misattributed the source. Where the frequency is not set by a binding instrument, the home's own written policy becomes the standard against which its records are read — which makes the policy itself the document to get right.
A tick-box self-audit for the section 102 duties
The table below converts the clauses above into evidence items. Each row can be checked against a live file rather than against a policy statement.
| # | Evidence item | Clause | Present |
|---|---|---|---|
| 1 | Current infection prevention and control policies, with review dates and named authors | 23(2)(a), 102(1) | ☐ |
| 2 | Education records covering staff, residents, volunteers and caregivers | 23(2)(b), 102(7)3 | ☐ |
| 3 | Shift-level monitoring records showing symptoms recorded on every shift | 102(9) | ☐ |
| 4 | Daily analysis record, plus a monthly trend review with the date it was completed | 102(10) | ☐ |
| 5 | Interdisciplinary team terms of reference naming the lead, Medical Director, Director of Nursing and Personal Care, and Administrator | 102(4)(b) | ☐ |
| 6 | Minutes showing at least four meetings a year, with the medical officer of health invited | 102(4)(c), (d) | ☐ |
| 7 | Annual program evaluation with its date, participants, change summary and implementation dates | 102(4)(e), (f) | ☐ |
| 8 | Dated documentation of the lead's qualifications against all eleven areas in 102(5) | 102(5) | ☐ |
| 9 | Schedule evidence that the lead worked the required minimum weekly hours on site | 102(15) | ☐ |
| 10 | Written consideration of resident complexity and vulnerability, and of whether more hours or additional leads are needed | 102(16) | ☐ |
| 11 | Outbreak management system document and the written outbreak response plan | 102(11) | ☐ |
| 12 | Current contact details for the lead held by the medical officer of health and the IPAC hub | 102(19) | ☐ |
| 13 | Hand hygiene programme with point-of-care access evidence and observation results | 102(7)11 | ☐ |
| 14 | Integrated reprocessing policy for any sterilizer or washer-disinfector, with logs and recall procedures | Programme-level duty, supported by the applicable standard | ☐ |
Rows 8 to 10 are the ones a licensing review can test in a single afternoon: a certificate, a schedule and a written rationale. Rows 3 and 4 are the ones a records review tends to find incomplete, because shift-level recording requires a form that works at 3 a.m. as well as at 3 p.m.
What changes in practice
Four patterns account for most of the gap between a compliant-looking programme and a compliant one.
A lead in name only. Section 102(15) sets hours on site in the position, and section 102(16) requires a documented judgement about complexity and vulnerability. A home where the lead also carries a full clinical assignment rarely has either.
Monitoring that produces data but not analysis. Subsection 102(9) requires the record; subsection 102(10) requires daily analysis and a monthly trend review. Forms designed for filing rather than for reading fail the second half.
An annual evaluation with no changes in it. Subsection 102(4)(f) asks for a summary of the changes made and the dates they were implemented. An evaluation cycle that never records a change is either perfect or not being performed as written.
A programme that stops at staff. Clause 23(2)(b) names caregivers and volunteers, and subsection 102(7)3 extends education oversight to visitors and residents as well. Infection control education that covers only employees leaves the statutory list unfinished.
Related reading
- Long-term care PPE requirements in Canada: what regulators expect
- Long-term care infection control audit preparation: what surveyors ask to see
- Biological indicator testing frequency by facility type: dental clinics, long-term care and laboratories
- Spaulding classification versus Canadian reprocessing rules
- free sterilization log tool
Frequently Asked Questions
Which law sets infection prevention duties for Ontario long-term care homes?
Section 23 of the Fixing Long-Term Care Act, 2021, S.O. 2021, c. 39, Sched. 1, requires every licensee of a long-term care home to ensure there is an infection prevention and control program, and requires an infection prevention and control lead whose primary responsibility is that program. O. Reg. 246/22: General, under the same Act, sets the operational content in section 102. The earlier Long-Term Care Homes Act, 2007 was repealed on 11 April 2022.
How many hours a week must an infection prevention and control lead work?
Subsection 102(15) of O. Reg. 246/22 sets minimum weekly hours on site in the role by licensed bed capacity: at least 17.5 hours per week in a home with 69 beds or fewer; at least 26.25 hours per week in a home with more than 69 beds but fewer than 200; and at least 35 hours per week in a home with 200 beds or more. Subsection 102(16) requires the licensee to consider resident complexity and vulnerability and decide whether the lead must work more than the minimum, or whether additional leads should be designated.
How often must residents be monitored for infection?
Subsection 102(9) requires monitoring on every shift: symptoms indicating the presence of infection in residents must be monitored in accordance with the Director's standard or protocol, and those symptoms must be recorded, with immediate action taken to reduce transmission and to isolate and cohort residents as required. Subsection 102(10) then requires that information to be analyzed daily to detect the presence of infection and reviewed at least once a month to detect trends.
Does O. Reg. 246/22 require a daily biological indicator test?
No. Section 102 of the regulation does not set a sterilization monitoring frequency. The daily biological indicator requirement — a test each day the sterilizer is used and for each type of cycle used — is a requirement of the Royal College of Dental Surgeons of Ontario's infection prevention and control standard for dental practices. The weekly testing baseline associated with the CDC and ANSI/AAMI ST79 is not the Ontario requirement; it is the United States comparison baseline.
What qualifications must the infection prevention and control lead have?
Subsection 102(5) requires education and experience in eleven areas, including infectious diseases, cleaning and disinfection, data collection and trend analysis, reporting protocols, outbreak management, asepsis, microbiology, adult education, epidemiology, program management, and current certification in infection control from the Certification Board of Infection Control and Epidemiology. Subsection 102(6) provided a three-year transition for the certification clause, which has since expired.
What records must a licensee keep for the program?
Three record families are named directly. Subsection 102(4)(f) requires a written record of each annual program evaluation containing the date, the participants, a summary of changes and the date those changes were implemented. Subsection 102(9)(b) requires shift-level symptom monitoring to be recorded. Subsection 102(19) requires the lead's direct contact information, including a monitored telephone number and email address, to be provided to the local medical officer of health and, where one exists, the designated IPAC hub for the home.
How does this differ for a retirement home?
A retirement home is licensed under the Retirement Homes Act, 2010 and O. Reg. 166/11 and regulated by the Retirement Homes Regulatory Authority. It is a different licensee under a different statute, and the section 102 requirements described here are long-term care requirements. Treating the two as one category is one of the more common attribution errors in Ontario infection control documentation.
CliniEco Medical supplies infection-control and sterilization consumables to Canadian long-term care homes, clinics and laboratories — MDEL #35334. Homes building out the monitoring side of a section 102 programme typically review 24-hour self-contained biological indicators and a 24-well dry-block incubator for spore testing records, with isolation gowns and nitrile examination gloves covering the additional-precautions side of the program. A 25-pack of 24-hour rapid-readout biological indicators supports sites evaluating readout times before standardising, and institutional purchasing runs through the wholesale account, with the wider long-term care supply range supporting day-to-day program consumables. A five-pack biological indicator trial pack is available for homes that want to verify readout timing on their own sterilizer before standardising on a full case.
Sources
- Fixing Long-Term Care Act, 2021, S.O. 2021, c. 39, Sched. 1 — current consolidated text
- O. Reg. 246/22: General, under the Fixing Long-Term Care Act, 2021 — section 102
- Retirement Homes Act, 2010, S.O. 2010, c. 11
- O. Reg. 166/11: General, under the Retirement Homes Act, 2010
- Health Protection and Promotion Act, R.S.O. 1990, c. H.7
- Public Health Ontario — infection prevention and control guidance for long-term care (PIDAC, April 2026)
- Public Health Ontario — infection prevention and control checklist for long-term care and retirement homes
- Public Health Ontario — reprocessing of medical equipment and devices in all health care settings
- Public Health Ontario — infection prevention and control for clinical office practice
- Royal College of Dental Surgeons of Ontario — infection prevention and control standard
- ANSI/AAMI ST79, comprehensive guide to steam sterilization and sterility assurance in health care facilities
- CAN/CSA-Z314:23, Canadian medical device reprocessing in all health care settings
- ISO 17665:2024, sterilization of health care products — moist heat
- Medical Devices Regulations, SOR/98-282
- CliniEco Medical — long-term care supply programme
- CliniEco Medical — sterilization monitoring collection
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