Ontario was not ready for a pandemic and had no comprehensive plans to protect long-term care homes that have been neglected for years, leaving residents and staff "easy targets" for COVID-19, an independent commission has found.

A 322-page report from Ontario's Long-Term Care Commission, whose mandate was to investigate how and why the coronavirus spread in nursing homes, was released Friday evening.

The report stated that the long-term care sector was insufficiently prepared for a pandemic, and it was made worse by the province's slow and reactive response when the virus arrived.

"Critical decisions came too late and the government's emergency response system proved inadequate to protect staff and residents from COVID-19," the report found.

"Staff, long-term care residents suffered terribly during this pandemic. Residents and long-term care staff who lost their lives to COVID-19 paid the ultimate price."

Long-term care homes in the province have been hit hard by the COVID-19 pandemic, with more than 3,700 resident deaths. Of those, 1,937 occurred during the first wave.

READ IN FULL: Ontario's long-term commission final report

The report looked into the state of long-term care before COVID-19, the deficiencies in Ontario's pandemic response, the devastating impacts of the COVID-19 crisis in long-term care, and best practices and promising ideas that can be adopted and expanded to improve long-term care.

The province's pandemic plan had not been updated since 2014, the commission found.

"The province's lack of pandemic preparedness and the poor state of the long-term care sector were apparent for many years to policymakers, advocates and anyone else who wished to see. Ontario's policymakers and leaders failed during those years to take sufficient action, despite repeated calls for reform," the report stated.

"Rather, the commitment and resources needed to prepare for a pandemic and address long-neglected problems with long-term care were shunted in favour of more pressing policies and fiscal priorities."

The commission found that the government failed to follow through with the recommendations that came out of reports after the SARS outbreak in 2003. While Ontario paid attention to them for a time, it "lost the will to make pandemic preparedness a priority." This resulted in the stockpile of emergency supplies acquired following SARS expiring and later ordered to be destroyed.

"The Ministry of Health did not do enough to meet its legislative obligation to plan for a pandemic, and the Ministry of Long-Term Care did not take sufficient steps to ready the vulnerable long-term care community."

Although the arrival of COVID-19 was unexpected, the commission believed it was predictable that a deadly virus would spread and disproportionately impact the vulnerable long-term care sector.

Many of the issues highlighted by the report are not new, but previous governments all failed to address them.

The report stated that long-term care experts and advocates have repeatedly been calling for an overhaul of the sector even before the pandemic struck. Many homes had outdated and not up to standards infrastructure. Staffing issues have also been a problem prior to the pandemic.

"Containing a virus in such a setting would prove to be difficult," the report said.

The commission also looked into the government's second wave response. The report stated that despite the preparations by the province during the summer when "there was a lull in the storm," it did not protect residents from a deadlier second wave.

"It is clear, though, that problems such as insufficient staff, lack of training, and aging home infrastructure were too deeply ingrained to overcome in the period between the first and second wave," the report stated.

"It is plain and obvious that Ontario must develop, implement, and sustain long-term solutions for taking care of its elderly and preparing for a future pandemic."

85 recommendations

The commission laid out 85 recommendations, which build on the two interim guidance released last year. They include preparing for future pandemics and developing plans to deal with infectious disease outbreaks. The province should maintain a pandemic stockpile, including personal protective equipment.

“Pandemic preparedness must be a constant priority. The lives of those most at risk depend on it. When COVID-19 slammed into an already vulnerable long-term care sector, the cost of that lack of preparedness was on full display.”

“As it should have done following the SARS outbreak in 2003, the province must now accept that there will be another pandemic; it is not a matter of it but when. Ontario must resolve to

Counselling services should be offered to residents and staff whose emotional and psychological well-being were affected by COVID-19.

The commission is also recommending standardizing and prioritizing infection protection and control practices in long-term care homes. Health care system integration should also be strengthened. The commission found that the long-term care sector did not have established relationships with the health care system, particularly hospitals.

Resident-focused care and quality of life must improve. “When COVID-19 entered the homes, many residents were subject to isolation and decreasing levels of care in an environment charged with fear and uncertainty. This situation should never be forgotten and never be replaced,” the commission stated.

The government should also address human resources challenges by accelerating the staffing plan, increasing the number of skilled staff, supporting enhanced education and development and improving working conditions and compensation. The commission also recommended regulating personal support workers.

To meet the care demands of long-term care residents, the province must increase and reorient long-term care funding.

The commission is also recommending an increase in accountability and transparency. “When leadership at any level falters, those who work in and depend on the system pay the price,” the report stated.

“Leadership, accountability and oversight were, to a significant degree, lacking in the system, and in many homes before COVID-19 hit. These shortfalls contributed to the fear, uncertainty and deteriorating levels of resident care and quality of life visited upon residents, their loved ones, and front-line staff during the pandemic.”

The province must also improve its compliance enforcement efforts to protect the residents’ safety and well-being and strengthen investigations under the Health Protection and Promotion Act. That includes enhancing whistleblower protections.

“The devastation that was visited upon long-term care residents and those who care for them must never be repeated. Immediate and sustained action to resolve and improve the issues the pandemic uncovered must be taken,” the commission concluded.

“The Ministry of Long-term Care should on the first and third anniversaries of the release of this report table in the legislature a report describing for the benefit of the stakeholders and the public the extent to which it has implemented this commission’s recommendation.”