Infection Prevention and Control (IPC) is one of our Accreditation Themes. It covers hand hygiene education & training, compliance with accepted practices, and infection rate tracking and analyzing.

You can download the full version by clicking here: Accreditation 2026 #3: Resident Safety4: Infection Prevention & Control

Surveyor Question:  How do we evaluate compliance with accepted hand hygiene practices?

Answer: We evaluate hand hygiene compliance by directly observing (audit) the practice using the Speedy Audit tool conducted by trained peer team member auditors.

ROP 2  Hand Hygiene Education and Training

Surveyor Question:  What education and training have you received on hand hygiene?

Answer: We receive regular education assigned to us in Surge Learning, we have visual signs posted throughout our site, we receive hands on education at unit team meetings as required, and get direct feedback by hand hygiene peer auditors.

ROP 3  Infection Rates are Tracked and Analyzed

Surveyor Question: How do we track infection information, analyze it, and communicate this information throughout the organization?

Answer: We track infection rates, analyze the information to identify clusters, outbreaks and trends; this is shared throughout the organization following our policy AP 5.05 IPC Program.

                        Visit our website for more information on each of these ROP’s

Menno Place has a Resident Safety Plan to ensure our delivery of care and services are provided safely to the residents and for the team members. Here is the summary of our Menno Place Resident Safety Plan.

You can download the full version by clicking here: Accreditation 2026 #3: Resident Safety

ROP: Resident Safety Plan

Surveyor Question:  Does Menno Place have a developed and implemented Resident Safety Plan?

Answer: Yes, Menno Place has a Resident Safety Plan that identifies, monitors, and addresses resident safety risks to ensure safe, high-quality care.

Evidence:

• Regularly reviews resident care and potential safety risks.
• Monitors quality indicators such as falls, pain, medications, and restraints.
• Uses incident reviews and quality improvement initiatives to enhance safety.
• Investigates resident and family concerns to improve care and services.

ROP: Residents’ Rights and Responsibilities

Surveyor Question: How are residents informed of their rights and responsibilities?

Answer:
Residents and/or their Substitute Decision Maker/Power of Attorney are informed of their rights during admission.

Evidence:

• Rights are reviewed through the Move-In Agreement.
• The Resident Bill of Rights is included in the Resident Handbook.
• The Bill of Rights is posted at Menno Home and Menno Hospital entrances.

ROP: Addressing Resident Rights Concerns

Surveyor Question: What should you do if a resident or family member reports that a resident’s rights have been violated?

Answer:
Listen respectfully, document the concern, and follow Menno Place’s feedback process.

• Menno Place Compliments, Concerns, and Ideas Process available on the family website.

Visit our website for more information on each of these ROP’s

ACCREDITATION 2026 – SAFETY CULTURE

Safety is one of our Accreditation Quality Dimensions. It focuses on creating a culture of safety at Menno Place. The following are our ROPs (Required Organizational Practices) that form the foundation of our safety culture.

If you would like a copy of this information for your review you can download it by clicking here: Accreditation 2026 #2 – Safety Culture. You will also find practice questions at the end of this post. All past Accreditation Bulletins are linked here: Accreditation 2026

ROP 1: Resident Identifiers

Surveyor Question: Are at least two resident identifiers used to confirm the resident is receiving the correct care, service, or procedure?

Answer: Resident photos are available on medication carts/outside resident rooms. Second verification is facial recognition through other staff members, families (if they are present), or by resident stating their full name, DOB (if resident is capable).

ROP 2: Workplace Violence Prevention Program

Surveyor Question: Does Menno Place have a documented and coordinated approach to prevent workplace violence?

Answer: Yes, Menno Place has workplace violence and harassment policies, conducts regular risk assessments, and provides mandatory staff training.

ROP 3: Resident Safety Incident Management System

Surveyor Question: Are there processes in place to review resident safety incidents, recommend actions, and monitor improvements?

Answer: Yes, incidents are reviewed through team huddles & meetings, trend analysis, and quality improvement processes guided by established policies.

ROP 4: Safety Incident Management System

Surveyor Question: What is the process to report safety incidents such as near miss, workplace hazards, and employer incident investigation reports?

Answer: Staff can report safety incidents on Quality and Risk Management (QRM) on Surge. All resident related incidents are reported on Point Click Care- Risk Management.

ROP 5: Resident Safety Incident Disclosure

Surveyor Question: Does Menno Place have a documented and coordinated approach for disclosing resident safety incidents to residents and families?

Answer: Yes, resident safety incidents are disclosed and documented according to the Disclosure of Harm or Near Miss policy (AP 2.28) in Surge.

ROP 6: Preventing Falls and Reducing Injuries from Falls

Surveyor Question: How does the team identify residents at risk for falls and implement strategies to prevent falls and reduce injuries?

Answer: Fall risk is assessed on admission and every 3 months, with individualized prevention strategies and care plan reviews for residents with recurrent falls.

ROP 7: Optimizing Skin Integrity

Surveyor Question: How does the team identify residents at risk for impaired skin integrity and implement interventions to prevent skin breakdown?

Answer: Residents are assessed using the Braden Scale, with individualized interventions, treatment plans, and interdisciplinary supports implemented as needed.

Safety Culture: Sample Surveyor Questions

Question: Do you feel Menno Place promotes a just and no-blame culture?
Answer: Yes, staff are encouraged to report concerns and incidents openly to support learning and improvement.

Question: How are resident safety concerns discussed within your neighbourhood or team?
Answer: Safety concerns are discussed during huddles, meetings, and quality improvement reviews.

Question: What can you tell us about the incident reporting process at Menno Place?
Answer: Staff report incidents promptly on QRM on Surge. We can fill out Near Miss, Incident Report, Employer Incident Investigation, and Workplace Hazard Report.

Question: Can you describe an improvement initiative that has been implemented in your area during the past year?
Answer: A few of the initiatives that took place in the past year are new call bell system, new full lifts, and safety huddles.

Question: Why do you think Near Miss Reporting is important?
Answer: Near misses are reported so potential risks can be addressed before harm occurs.

Question: How would you define a harmful event?
Answer: A harmful event is an incident that results in physical, emotional, or psychological harm to a resident.

Question: How does your team learn from incidents and use that information to improve care?
Answer: We review incidents, identify contributing factors, share lessons learned, and implement actions to prevent recurrence.

 Visit our website for more information on each of these ROP’s