As per the February 27, 2017 memo from the Director of the Licensing Policy Branch, the ministryhas become aware of monetary payments and payments in kind, including non-monetary benefits,that some LTC homes across the province have received or are receiving from their pharmacyservice provider.

In order to gain a better understanding of the prevalence of these payment arrangements, as wellas how these payments are being used by LTC homes, the ministry is requesting that all licenseesprovide this information for the calendar years 2014, 2015, and 2016, as well as any one-timepayments made prior to those years. Homes that do not receive or have not received payments orpayments in kind from their pharmacy service provider are still required to complete and submit thetemplate.

The ministry is also requesting information on co-payments charged to Ontario Drug Benefit (ODB)recipients in LTC homes.

This request is being made under Section 88(2) of the Long-Term Care Homes Act, 2007, whichstates that the Director may at any time request a licensee to submit a report to the Director on anymatter, in a form acceptable to the Director, and the licensee shall comply with such a request.

All LTC home Administrators will receive an email from Survey Monkey with a unique link tocomplete the pharmacy payments report. LTC homes will be able to view and edit their reportinformation until March 31, 2017, via their individual links. Even after the report has beensubmitted, LTC homes may continue to make necessary revisions until the survey is closed. LTChomes are required to submit completed reports by March 31, 2017, as the survey link will beclosed after this date.

The report will include an attestation to confirm that the individual(s) completing the survey is (are)authorized to provide the response on behalf of the Licensee and has (have) made all necessaryinquiries to ensure that the response, on behalf of the Licensee, is accurate and complete. Thereport will also include a question to confirm that the Chief Financial Officer has reviewed theinformation being submitted.

Should you require further information or clarification, please send an email tospecialprojectreporting@ontario.ca.

1. Reporting of Payments to Long-Term Care homes from Pharmacy Service Providers

Pharmacy Reporting Template

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Kindly note, questions marked with an asterisk are mandatory for completion throughout thereporting template. Please ensure questions marked with an asterisk are completed in order toadvance to the next section of the report.

2. Long-Term Care Home Information

Pharmacy Reporting Template

LTC Home Name:*

Facility ID:*

LTC ID:*

LHIN*

Total Number of Licensed/Approved Beds*

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3. Pharmacy Information

Pharmacy Reporting Template

2014

2015

2016

If "other" pharmacy service provider was selected in 2014, 2015 and/or 2016, please specify the name of the pharmacy or pharmacies:

Please use the drop down filters below to specify the pharmacy service provider for your home for therespective calendar year (note: if you had two pharmacy service providers in a calendar year, indicate thepharmacy service provider in place at the end of the year)

*

What is the length of the current contract with your pharmacy service provider?*

1 Year

2 Years

3 Years

4 Years

5 Years

Other (please specify):

Year (YYYY)

Month (MM)

Day (DD)

When does the current contract with your pharmacy service provider expire? Note: if the current contractdoes not have an expiry date, please enter 0000/00/00 in the date fields below.*

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From this point forward, homes will be asked to disclose whether any payments or "payments inkind" were received from pharmacy service provider(s) since January 1, 2009. If non-monetarybenefits (i.e. goods and/or services) were received from a pharmacy service provider, then theseshould be disclosed as "payments in kind" in this report.

4. Disclosure of Pharmacy Payments and/or Payments in Kind

Pharmacy Reporting Template

If the answer is yes, please provide a brief explanation of the arrangement and/or agreement:

At anytime after January 1, 2009 and before January 1, 2014, did any pharmacy make a payment orpayment in kind in order to be selected as the pharmacy service provider for your home?*

No

Yes

Please confirm whether any per bed fee ($/bed), annual/lump sum fees and/or payments in kindwere received from pharmacy service provider(s) in 2014, 2015 and/or 2016:*

Yes

No

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Did a pharmacy service provider make any payments or payments in kind to a charity, foundation or thirdparty owned by the licensee or an associate of the licensee (as per section 2(4) in the LTCHA) in 2014,2015 and/or 2016?

*

No

Yes

If the answer is yes, please provide a brief explanation of the arrangement and/or agreement, and include details of paymentsand payments in kind:

As required Daily Weekly Biweekly Monthly Other

2014

2015

2016

If Other (please specify)

How frequently were chronic-use drugs typically dispensed by the pharmacy service provider to yourhome? This is in regards to medications that are used on a long term basis and not those dispensed as aresult of events such as new admissions, mid-cycle changes in therapy or acute illnesses.

*

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5. Pharmacy Payments and Use of Funds in 2014

Pharmacy Reporting Template

A. Per Bed Fee ($/bed)

B. Total From Bed Fees

C. Annual Fee / Lump Sum

Total Amount Received (B+C)

Please enter the per bed fee and/or annual fee/lump sum received from the pharmacy service providerin 2014 (if not applicable, enter "0" in each of the fields):*

Other (mandatory to specify):

Were payments in kind received from the pharmacy service provider in 2014? Please select all that apply:*

N/A (Payments in kind were not provided)

Training/Education

Sponsorship to conferences

Equipment

Supplies

Services

Gift Card

Discount

Other

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Training/Education

Sponsorship toConferences

Equipment

Supplies

Services

Gift Card

Discount

Other

If payments in kind were received from the pharmacy service provider in 2014, please describe thegood(s) and/or service(s) received:

Were payments received from the pharmacy service provider reported as a type of revenue in the 2014 annual report?*

Yes

No (pharmacy payments received but not reported in AR)

N/A (did not receive pharmacy payments in 2014)

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Nursing and Personal Care (NPC) Direct Care

Nursing and Personal Care (NPC) - Administration

Program and Support Services

Raw Food

Housekeeping Services

Building and Property - Operations and Maintenance

Dietary Services

Laundry and Linen Services

General and Administrative

Facility Costs

Other

Please enter the amount of pharmacy payments that were used for the types of expenditures listed belowin 2014. The list of expenditures aligns with the annual report. If required, please refer to the AR reportingguidelines and/or eligible expenditures policies for additional information. If pharmacy payments were notreceived in 2014 enter "0" in each of the following fields. If pharmacy payments were not used for a specifictype of expenditure enter "0" in the respective field(s). All fields must be completed in order to advance tothe next section of the report.

*

If pharmacy payments were used for "Other" types of expenditures in 2014, please specify:

Were any of the expenditures related to the pharmacy payments reported in the 2014 annual report?*

Yes

No (pharmacy payments received were spent but not reported in the AR)

N/A (pharmacy payments were not received/spent in 2014)

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6. Pharmacy Payments and Use of Funds in 2015

Pharmacy Reporting Template

A. Per Bed Fee ($/bed)

B. Total From Bed Fees

C. Annual Fee / LumpSum

Total Amount Received(B+C)

Please enter the per bed fee and/or annual fee/lump sum received from the pharmacy service provider in2015 (if not applicable, enter "0" in each of the fields):*

Other (please specify):

Were payments in kind received from the pharmacy service provider in 2015? Please select all that apply:*

N/A (Payments in kind were not provided)

Training/Education

Sponsorship to conferences

Equipment

Supplies

Services

Gift Card

Discount

Other

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Training/Education

Sponsorship toConferences

Equipment

Supplies

Services

Gift Card

Discount

Other

If payments in kind were received from the pharmacy service provider in 2015, please describe thegood(s) and/or service(s) received:

Were payments received from the pharmacy service provider reported as revenue in the 2015 annualreport?*

Yes

No (pharmacy payments received but not reported in AR)

N/A (did not receive pharmacy payments in 2015)

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Nursing and Personal Care (NPC) Direct Care

Nursing and Personal Care (NPC) - Administration

Program and Support Services

Raw Food

Housekeeping Services

Building and Property - Operations and Maintenance

Dietary Services

Laundry and Linen Services

General and Administrative

Facility Costs

Other

Please enter the amount of pharmacy payments that were used for the types of expenditures listed belowin 2015. The list of expenditures aligns with the annual report. If required, please refer to the AR reportingguidelines and/or eligible expenditures policies for additional information. If pharmacy payments were notreceived in 2015 enter "0" in each of the following fields. If pharmacy payments were not used for a specifictype of expenditure enter "0" in the respective field(s). All fields must be completed in order to advance tothe next section of the report.

*

If pharmacy payments were used for "Other" types of expenditures in 2015, please specify:

Were any of the expenditures related to the pharmacy payments reported in the 2015 annual report?*

Yes

No (pharmacy payments received were spent but not reported in the AR)

N/A (pharmacy payments were not received/spent in 2015)

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7. Pharmacy Payments and Use of Funds in 2016

Pharmacy Reporting Template

A. Per Bed Fee ($/bed)

B. Total From Bed Fees

C. Annual Fee / LumpSum

Total Amount Received(B+C)

Please enter the per bed fee and/or annual fee/lump sum received from the pharmacy service provider in 2016 (if not applicable, enter "0" in each of the fields):*

Other (please specify):

Were payments in kind received from the pharmacy service provider in 2016? Please select all that apply:

N/A (Payments in kind were not provided)

Training/Education

Sponsorship of conferences

Equipment

Supplies

Services

Gift Card

Discount

Other

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Training/Education

Sponsorship toConferences

Equipment

Supplies

Services

Gift Card

Discount

Other

If payments in kind were received from the pharmacy service provider in 2016, please describe thegood(s) and/or service(s) received:

Will payments received from the pharmacy service provider be reported as revenue in the 2016 annualreport?*

Yes

No

N/A (did not receive pharmacy payments in 2016)

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Nursing and Personal Care (NPC) Direct Care

Nursing and Personal Care (NPC) - Administration

Program and Support Services

Raw Food

Housekeeping Services

Building and Property - Operations and Maintenance

Dietary Services

Laundry and Linen Services

General and Administrative

Facility Costs

Other

Please enter the amount of pharmacy payments that were used for the types of expenditures listed belowin 2016. The list of expenditures aligns with the annual report. If required, please refer to the AR reportingguidelines and/or eligible expenditures policies for additional information. If pharmacy payments were notreceived in 2016 enter "0" in each of the following fields. If pharmacy payments were not used for a specifictype of expenditure enter "0" in the respective field(s). All fields must be completed in order to advance tothe next section of the report.

*

If pharmacy payments were used for "Other" types of expenditures in 2016, please specify:

Will any of the expenditures related to the pharmacy payments be reported in the 2016 annual report?*

Yes

No (pharmacy payments received were spent but will not be reported in the 2016 AR)

N/A (pharmacy payments were not received/spent in 2016)

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This section of the report applies to resident pharmacy co-payments. Please answer the followingquestions to the best of your knowledge.

8. Collection of Resident Co-Payments in 2014

Pharmacy Reporting Template

How were pharmacy co-payments collected in 2014? *

Home collected payments from residents on behalf of the pharmacy service provider

Pharmacy service provider collected payments directly from residents

Co-payments were not collected from residents

Uncertain whether co-payments were collected from residents

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9. Resident Co-payments Collected in 2014

Pharmacy Reporting Template

Enter the pharmacy co-payment fee in 2014:*

Please specify the frequency of charging the co-payment fee in 2014:*

Once per prescription per day

Once per day

Once per prescription per week

Once per week

Once per prescription per month

Once per month

Other (please specify)

Enter the total amount of pharmacy co-payment fees collected in 2014 (if you are uncertain of theamount of co-payment fees collected by the pharmacy from residents enter "Uncertain")*

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10. Collection of Resident Co-Payments in 2015

Pharmacy Reporting Template

How were pharmacy co-payments collected in 2015?*

Home collected payments from residents on behalf of the pharmacy service provider

Pharmacy service provider collected payments directly from residents

Co-payments were not collected from residents

Uncertain whether co-payments were collected from residents

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11. Resident Co-payments Collected in 2015

Pharmacy Reporting Template

Enter the pharmacy co-payment fee in 2015:*

Please specify the frequency of charging the co-payment fee in 2015:*

Once per prescription per day

Once per day

Once per prescription per week

Once per week

Once per prescription per month

Once per month

Other (please specify)

Enter the total amount of pharmacy co-payment fees collected in 2015 (if you are uncertain of theamount of co-payment fees collected by the pharmacy from residents enter "Uncertain")*

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12. Collection of Resident Co-Payments in 2016

Pharmacy Reporting Template

How were pharmacy co-payments collected in 2016?*

Home collected payments from residents on behalf of the pharmacy service provider

Pharmacy service provider collected payments directly from residents

Co-payments were not collected from residents

Uncertain whether co-payments were collected from residents

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13. Resident Co-payments Collected in 2016

Pharmacy Reporting Template

Enter the pharmacy co-payment fee in 2016:*

Please specify the frequency of charging the co-payment fee in 2016:*

Once per prescription per day

Once per day

Once per prescription per week

Once per week

Once per prescription per month

Once per month

Other (please specify)

Enter the total amount of pharmacy co-payment fees collected in 2016 (if you are uncertain of theamount of co-payment fees collected by the pharmacy from residents enter "Uncertain")*

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14. Attestation and Confirmation

Pharmacy Reporting Template

Were there other arrangements with the pharmacy service provider(s) related to financial payments orpayments in kind in 2014, 2015 and/or 2016 that were not disclosed elsewhere in this report?*

No

Yes

If yes (please explain):

I, as the submitter, am authorized by the Licensee to provide the response on behalf of the Licensee andhave made all necessary inquiries to ensure that the survey response is accurate and complete.*

Yes

No (this report will not be accepted as "complete" if "no" is selected )

Name (First, Last):

Title:

Email address:

Telephone Number and Ext:

Submitter Contact Information*

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I confirm that the Chief Financial Officer (CFO) has also reviewed the information to ensure its completionand accuracy. This person could be the CFO of the LTC home or CFO of the chain organization to whichthe home belongs.

*

Yes

No (this report will not be accepted as "complete" if "no" is selected; please ensure the CFO has reviewed the information enteredin this template)

Name (First, Last):

Title:

Email address:

Telephone Number and Ext:

CFO Contact Information*

I confirm that the Licensee is aware that this information is being submitted to the Ministry.*

Yes

No (this report will not be accepted as "complete" if "no" is selected; please ensure the Licensee is aware that the informationentered in this template is being submitted to the Ministry)

Name (First, Last):

Title:

Email address:

Telephone Number and Ext:

Licensee Contact Information:*

Date(MM/DD/YYYY)

MM

/

DD

/

YYYY

Enter Submission Date:*

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Click the "Done" button to ensure the information you entered is saved and/or submitted. LTChomes will be able to view and edit their report information until March 31, 2017, via their individual

links.

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