Surveyor-Ready Evidence Checklist

Surveyors and reviewers look for evidence that practice matches policy. Keep these on file and current. This aligns with Accreditation Canada / HSO Long-Term Care standards and HQO equity themes.

Policy and procedure

• A current inclusion policy with procedure attached.
• Evidence the policy was communicated to all staff (sign-off records).
• Documentation of how the Residents’ Bill of Rights is applied to 2SLGBTQI+ residents.

Training

• Training records showing all staff (including casual and night) completed foundations training.
• Onboarding module for new hires with completion records.
• Refresher schedule and most recent session date.

Care and documentation

• Sample care-plan language for identity, personal care, and chosen family.
• Evidence of chosen-name and pronoun use in charts and signage (audit results).
• Privacy rule for identity information, documented and communicated.

Incidents and feedback

• Incident records with documented response and follow-up.
• Resident feedback survey results and actions taken.
• Team debrief notes from recent incidents.