APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER:
20260007
OBJECTING PARTY:
WORKER
REPRESENTED by:
WORKER REPRESENTATIVE
RESPONDENT PARTY:
EMPLOYER (NOT PARTICIPATING)
HEARING:
HEARING IN WRITING
HEARD by:
KEVIN MACMILLAN, APPEALS RESOLUTION OFFICER
OCTOBER 3, 2025
ISSUE
The worker representative, on behalf of the worker, is objecting to the Occupational Therapist’s (OT) decision of August 31, 2023 with respect to the quantum of the personal care allowance (PCA).
BACKGROUND
On June 24, 2010 the worker reported gradually developing pain and numbness in both lower arms, as well as symptoms with their neck. The worker underwent five surgeries in 2011 and 2012 for the
work-related injuries. A 47% non-economic loss (NEL) benefit was awarded for the bilateral wrists, elbows, neck, and Raynaud’s syndrome. Workplace Safety and Insurance Tribunal (WSIAT) decision number 657/22 dated September 15, 2022 provides a thorough file summary that will not be repeated. WSIAT authorized entitlement to a permanent psychological condition, as well as full loss of earnings (LOE) benefits from September 11, 2014. WSIAT further authorized full LOE benefits from June 6, 2016, the date of the final LOE benefit review. The total NEL benefit increased to 60% in December 2022 to include the permanent work-related psychological impairment. An independent living allowance was authorized by a Case Manager within a decision dated January 31, 2023.
A personal care needs in-home assessment was performed on May 12, 2023 by a Registered Nurse whose recommendations were documented in a report dated May 22, 2023. A WSIB OT reviewed the report and adjusted some of the recommended time allotments on July 4, 2023. The resulting decision letter of August 31, 2023 confirmed a monthly PCA amount of $859.76 effective September 1, 2023, and a retroactive amount of $83,996.89 for the period of April 8, 2021 (date of eligibility) to August 31, 2023.
A Case Manager denied entitlement to sleep apnea on November 17, 2023. The OT’s reconsideration letter of January 31, 2024 upheld the decision dated August 31, 2023. The reconsideration letter explained that the PCA allowance decision was based on a review of the file documentation, medical literature related to the work injury such as recovery from carpal tunnel syndrome (CTS) surgery, the PCA reports of 2016 and 2023, as well as corroborating the information verbally with the worker and their spouse. A queen split-bed with adjustment bed frame and mattress were subsequently authorized in
January 2025. A Case Manager’s decision letter dated April 24, 2025 denied the request for entitlement to a deterioration of the bilateral upper extremity condition as well as entitlement to the lower back and bilateral lower extremity symptoms. The Case Manager authorized extended entitlement to include the C3-4 and C4-5 levels.
The administrative decision of May 1, 2025 determined that the worker’s objection would be addressed as a hearing in writing. The issue of the quantum of the PCA is now before me.
AUTHORITY
Operational Policy Manual
Published
17-01-02 Entitlement to Health Care 17-06-05 Personal Care Allowance
January 3, 2023
August 1, 2007
ANALYSIS
I find that two aspects of the PCA are to be increased for their respective daily minute allotment. I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision, including both PCA assessments performed in 2016 and 2023.
Worker representative’s position and remedy sought
The worker representative argues that the worker is facing significant challenges due to various medical conditions, including bilateral CTS, cubital tunnel syndrome, Raynaud’s syndrome, and spondylitis changes with cord compression at C5-C6 and C6-7.
The worker representative submits that the community in-home assessment performed by a highly experienced clinician (a Chief Nursing Executive) should be given greater weight than the opinion of the WSIB OT who only conducted a file review. The worker representative argues that the in-home assessment involved spending a lot of time directly observing the worker’s care needs in their home setting. The written submission of April 1, 2025 encloses Workplace Safety and Insurance Tribunal (WSIAT) decision number 177/20 (dated April 16, 2020) and 430/20 (dated July 19, 2020) in support of the view that preference should be granted to the recommendations provided by the in-home assessment.
If the worker’s appeal is successful, the worker representative requests that the worker be provided with the original time allotments for person care activities as recommended within the May 22, 2023 report (based on the assessment of May 12, 2023). The worker representative is requesting that the worker’s monthly PCA amount be based on the hours identified by the community OT who performed the
in-person assessment.
Employer’s position
The Participant Form issued to the employer on January 22, 2024 has not been returned. The employer has not provided any submissions or arguments with respect to the PCA quantum decision of
August 31, 2023.
Personal care allowance
It is my view that an increase is in order for daily bathing/drying time and lower body dressing.
A letter from the worker dated July 22, 2014 requests reimbursement for the spouse at a minimum of 4 hours per day, if not more, from February 8, 2012 to May 19, 2012 during which they were wearing a cervical collar 24 hours a day for three months. The worker’s verbal statement of August 8, 2023 states that they required continuous assistance with personal care activities since the first surgery in 2011. The worker’s verbal statement of October 23, 2023 suggests that the correct monthly PCA amount from September 1, 2023 should be approximately $1,300 per month, not $859.76.
On December 6, 2023, the worker verbally expresses that they required help throughout all the years from 2011. The worker’s letter of December 18, 2023 asks why the WSIB authorized an in-home assessment if the recommendations were not going to be followed. Similar to the worker representative’s written submission, the worker raises concern that the WSIB OT had never seen them personally but still adjusts the PCA minutes listed within the May 22, 2023 report.
Policy 17-01-02, Entitlement to Health Care, outlines that a worker is entitled to benefits for health care as may be necessary, appropriate, and sufficient as a result of the injury. Policy 17-01-02 confirms that health care includes the services of an attendant.
Policy 17-06-05, Personal Care Allowance, provides the authority to pay severely impaired workers a personal care allowance to hire attendants. Policy defines the term severely impaired as a permanent impairment resulting in a NEL benefit totalling at least 60%. Policy 17-06-05 explains that the three categories of attendant care include skilled attendant care to handle complex health care and hygiene, and personal attendant care to handle routine personal care. Policy confirms that the WSIB can either pay agency attendants directly or pay a PCA directly to the worker to hire one or more non-agency attendants to provide assistance.
Below is a summary of the most recent in-home assessment performed on May 12, 2023:
Personal care activity
In-Home Assessment Report of May 22, 2023
Skin Care
2 minutes, 5 times a day (10 minutes a day, or 70 minutes weekly)
Medication
2 minutes, 2 times a day (4 minutes a day, or 28 minutes weekly)
Bathing
Daily 2 minutes transfers, 10 minutes bathing/drying, 2 minutes lotion
Other Therapy (TENS)
10 minutes daily (including preparation), 2 minutes maintaining
Maintenance of Supplies/Equipment
5 minutes per day, or 35 minutes weekly
Dressing and Undressing
2 minutes per day upper, 5 minutes per day lower dressing 2 minutes per day upper and lower body undressing
Orthotics
2 minutes, 10 times per day
Personal Hygiene
5 minutes per month shaving, 15 minutes per month hair, 5 minutes twice per month for fingernail care (equivalent to 8 minutes weekly)
Mealtimes
2 minutes, 2 times per day (or 28 minutes weekly)
Mobility
0 minutes weekly
Extra Laundry
5 minutes daily (or 35 minutes weekly)
Hygiene (for bathroom, bedroom and clothing)
5 minutes daily bathroom, 5 minutes daily bedroom, 2 minutes daily for preparing clothes, 5 minutes weekly for hanging/sorting clothes, 5
minutes 3 times per day to ensure comfort, safety and security.
Attendant Care on an Intermittent Basis
Listed as not applicable.
In response, the WSIB OT authorized the following:
Personal care activity
April 8, 2011 to August 12, 2011
February 8, 2012 to
May 19, 2012
February 3, 2014 and onwards
Skin Care
14 minutes weekly
14 minutes weekly
14 minutes weekly
Medication
14 minutes weekly
0 minutes weekly
14 minutes weekly
Bathing
63 minutes weekly (based on 2 minutes daily for transfer, 5 minutes bathing/drying, 2
minutes lotion)
63 minutes weekly
63 minutes weekly
Other Therapy
84 minutes weekly
84 minutes weekly
84 minutes weekly
Maintenance of Supplies/Equipment
0 minutes weekly
0 minutes weekly
14 minutes weekly
Dressing and Undressing
56 minutes weekly (based on 2 minutes per day for both upper/lower body dressing and
undressing)
56 minutes weekly
56 minutes weekly
Orthotics
35 minutes weekly
35 minutes weekly
70 minutes weekly (based on 10 minutes daily)
Personal Hygiene
119 minutes weekly
119 minutes weekly
8 minutes weekly
Mealtimes
28 minutes weekly
210 minutes weekly
28 minutes weekly
Mobility
0 minutes weekly
70 minutes weekly
0 minutes weekly
Extra Laundry
35 minutes weekly
35 minutes weekly
35 minutes weekly
Hygiene (for bathroom, bedroom and clothing)
89 minutes weekly
89 minutes weekly
124 minutes weekly
Attendant Care on an Intermittent Basis
140 minutes weekly
140 minutes weekly
0 minutes weekly
Briefly, I accept that the WSIB OT is in agreement with the recommended PCA minutes for the following:
Bathing with respect to transfers and application of lotion;
Other therapy (for all three periods);
Dressing of 2 minutes daily for upper body dressing, 2 minutes daily for upper body undressing;
Dressing of 2 minutes daily for upper body undressing;
Personal hygiene from February 3, 2014;
Mealtimes from February 3, 2014;
Mobility from February 3, 2014 onwards;
Extra Laundry (although for orthotic supplies not for incontinence);
Hygiene for 5 minutes daily bathroom, 2 minutes daily for preparing clothes, 5 minutes weekly for hanging/sorting clothes, 5 minutes daily bedroom (for both periods prior to February 3, 2014); and,
No minutes for Attendant Care on an Intermittent Basis from February 3, 2014 onwards.
I will not review any category for any of the three time periods where the WSIB OT awarded more weekly minutes than recommended by the in-home assessment report of May 22, 2023.
April 8, 2011 to August 12, 2011
I acknowledge that the PCA amount paid for this period does not necessarily reflect the actual period dates. For example, the period of April 8, 2011 to August 12, 2011 represents a distinct period prior to
the worker’s cervical spine surgery of February 8, 2012 which required them to wear a cervical collar
24-hours a day for three months. I also appreciate the worker’s arguments that they received assistance from their spouse back to 2011.
That being said, there is general agreement that the worker had CTS release surgery on April 8, 2011, left ulnar transposition surgery on August 17, 2011, followed by right ulnar nerve transposition on
August 22, 2012. Given the medical literature referenced by the WSIB OT, I accept that there would be a temporary period of recovery after each surgery in which the worker would require PCA. However, I find that this period would reasonably be over by the time of either PCA report in 2016 or 2023. Hence, it is my view that the medical literature referenced within the case record is the most appropriate method of determining the period of care required from April 8, 2011.
For example, the referenced literature suggests that after four weeks from CTS release surgery a person would be expected to be able to perform heavier tasks. The three referenced sources indicate that modifications would be required for approximately one month or more. Hence, I find that the WSIB OT’s use of six weeks is reasonable. Similarly, the two medical literature articles regarding ulnar nerve transposition suggest limited lifting for the first three weeks with varying recovery time. Based on this evidence, I accept that a total of 18 weeks (six weeks for each of the three surgeries) is reasonable as of the date of the first surgery. Consequently, I find that a PCA for the 18-week period from April 8, 2011 is appropriate.
Again, I am not persuaded that the PCA report of 2023 provides applicable information with respect to the acute recovery periods after the three upper extremity surgeries of April 8, 2011, August 17, 2011 or August 22, 2012. The worker representative has not provided any specific arguments to the period of April 8, 2011 to August 12, 2011 or referenced any arguments with respect to the period between August 12, 2021 and the next PCA period beginning on February 8, 2012.
When reviewing the medical reporting within the case record, I find it material that the neurosurgery consultation notes of April 18, 2011 document that the worker is independent with self-care other than the pain and symptoms interfering with sleep, driving, exercise, and pushing. The report confirms that the worker denies any difficulty with gait and indicates that the worker can walk unlimited distances. A psychological assessment report dated November 17, 2011 describes the worker’s ability on a typical day to dress and drive themselves to physiotherapy and prepare lunch. I also note that the psychiatric assessment report of November 18, 2011 outlines that the worker can bathe, groom, and dress independently.
I also appreciate that the in-home assessment of 2023 recommends the equivalent of 70 minutes weekly for skin care while the WSIB OT grants 14 minutes weekly. I find it material that the May 12, 2023 assessment confirms that the worker does not have any skin integrity issues requiring treatment. Rather, the worker’s spouse provides skin checks under their splints and braces 5 times a day, as well as rubbing lotion on the worker’s hands, arms, and elbows twice a day. It is my view that preventative measures such as the multiple daily skin checks do not fall within the PCA as the worker does not have any skin integrity issues. Nevertheless, I am in agreement that 2 minutes per day (or 14 minutes weekly) is reasonable to ensure that there are no developing pressure sores or breakdowns of the skin during the post-surgical recovery periods.
Given these factors, I accept the rationale provided by the WSIB OT within their review of July 4, 2023 and the resulting authorized minutes documented within the decision letter of August 31, 2023 with the exception of bathing and dressing which I will address below.
February 8, 2012 to May 19, 2012
I note that February 8, 2012 represents the date of the cervical spine surgery and that the period from then until May 19, 2012 is the time in which the worker was wearing the cervical collar 24 hours per day. Yet, I must consider that this period also necessarily includes the right CTS release surgery performed on March 2, 2012. For the reasons discussed above, I find that a 6-week period is reasonable for recovery from CTS surgery. Therefore, I find that both surgeries are to be considered in the same timeframe in order to avoid duplication of PCA amounts given that the cervical spine surgery had a much longer recovery time.
I acknowledge the worker’s letter of July 22, 2014 requesting a minimum of 4 hours a day, if not more, for this period. As noted by the WSIB OT, the PCA only recognizes time allotted for each individual task. In addition, I note that the case record documents the verbal statement of the spouse that there were no skin care issues. Still, I find that 14 minutes weekly for skin care are in order for this period given the worker’s use of a collar 24-hours per day.
Turning to medication, I note that the case record documents the clarification from the spouse on
July 31, 2023 that the worker did not require assistance with the administration of medication during this period, nor were there any equipment/devices requiring monitoring or maintenance. However, I do accept that the spouse assisted with changing and donning/doffing the collar and inserts post-surgery, as well as the daily washing of them. I find that there is insufficient evidence that either task would take more than the 5 daily minutes allocated for each by the WSIB OT.
Regarding hygiene (for bathroom, bedroom, and clothing care), I observe that the WSIB OT granted the recommended daily amounts for all but the recommended 5 minutes, 3 times per day to ensure “comfort, safety and security in this environment”. While I appreciate the presented argument and supporting WSIAT case law, I am not persuaded that more weight should be placed on the in-home assessment with respect to this category as there is no supporting clinical opinion, observations, or reported level of function explaining why this is required 3 times per day for 5 minutes each time. Therefore, I am in agreement with the WSIB OT’s recommended time allotments during the period of February 8, 2012 to May 19, 2012 with the exception of bathing/drying and lower body dressing.
February 3, 2014 onward
I appreciate that the Canada Pension Plan Disability questionnaire completed on February 3, 2014 documents that the worker’s spouse assists them with putting on socks, over-the-head clothing, cutting food and washing. The medical report of February 4, 2014 discusses that the worker has intermittent
difficulty with some activities of daily living. Unlike the prior two temporary periods, I find that ongoing skin checks allotted at 2 minutes remain in order for similar reasons discussed above.
I recognize that the 2023 in-home assessment recommends 2 minutes, twice a day for medication. The report states that the worker is independently taking their medication but that their spouse refills the blister pack and monitors the codeine medication which is not in blister backs. Regardless, I find that 1 minute twice daily represents a reasonable time allotment for the spouse to perform these activities given that the worker is independent in taking the medication.
Regarding maintenance of supplies/equipment, I find that the cleaning of orthotics is already captured under the category of Extra Laundry while the maintenance of the TENs unit is captured under Other Therapy. Consequently, I accept that the WSIB OT appropriately adjusted the recommend time allotment. Under Orthotics, I find that the in-home assessment does not provide sufficient explanation on why it takes the worker’s spouse 2 minutes to remove and re-apply the bilateral wrist splints and bilateral
elbow protectors. There is no disagreement with the observation that the spouse does this at a frequency of 10 times per day. Given the lack of details explaining the required duration, I find that 1 minute for each of the 10 times is appropriate.
Finally, the in-home assessment recommends 5 minutes, 3 times per day to ensure comfort, safety and security in the environment. As discussed above, I find that the in-home assessment report does not provide any supporting rationale as to why this is recommended 3 times per day. Therefore, I am in agreement with the WSIB OT to allot 10 minutes daily for bedroom hygiene which would include ensuring comfort and security in the environment.
Bathing/drying
I find that bathing/drying is to be increased to the recommended amount of 10 minutes per day for all three periods of the PCA.
The in-home assessment report of May 22, 2023 recommends 10 minutes for bathing/showering and drying the worker. In contrast, the WSIB OT indicates that the recommended time for bathing exceeds what is reasonable for an able-bodied attendant to assist with the task. The WSIB OT reduces the time to 5 minutes for bathing/drying.
I observe that the in-home assessment report explains that the worker’s spouse assists completely for the entire shower, and notes that the worker struggles with poor hand function and restricted range of motion/strength. Given that the WSIB OT confirms the allowance of 2 minutes to assist with transfers to and from the bath/shower, I accept that 10 minutes for bathing/showering and drying is reasonable based on the confirmation that the spouse assists completely for the entire shower.
Lower body dressing
In my view, there is sufficient rationale to increase lower body dressing to the recommended time allotment for all three periods of the PCA.
When reviewing the case record, I note that the home safety assessment of July 24, 2016 states that due to upper extremity pain and limitations, the worker is unable to bend over to put on socks or tie their
shoes. The report documents the worker’s indication that their spouse assists with most activities involving the upper extremity as well as lower body dressing. The PCA assessment of August 9, 2016 recommends 12 daily minutes for dressing and 11 daily minutes for undressing (or a total of 23 minutes daily). The in-home assessment of May 12, 2023 recommends 2 minutes per day for upper body dressing and undressing, as well as for lower body undressing. The in-home assessment recommends 5 minutes per day for lower body dressing.
I observe that the in-home assessment report documents that the worker’s spouse cannot rush the worker with dressing as they are very particular about how the items fit for comfort and having to work around the limit of the worker’s range of motion and pain. The report indicates that the spouse assists with underwear, pants, and socks. In the opinion of the WSIB OT, the recommended time for lower body dressing exceeds what is reasonable for an able-bodied attendant to assist with this task. The WSIB OT reduces the recommended 5 minutes daily to 2 minutes daily. Even so, I note that NEL rating of the permanent psychological impairment includes consideration of ongoing symptoms of hyperarousal, hypervigilance, and remaining emotionally fragile, irritable with poor self-regulation when distressed.
Policy 17-06-05 states that in most cases, a home visit will be conducted to help determine the level of assistance required by the severely impaired worker with regards to the activities of daily living (such as
eating, maintaining good personal hygiene, grooming, and being mobile). Policy explains that information is also gathered regarding any special medical requirements. On account of these work-related psychological factors and the prior PCA assessment of 2016, I accept the indication from the in-home assessment report of May 22, 2023 that additional time is required for the spouse to assist with lower body dressing given the worker’s concerns with fit and comfort. Accordingly, I find that the time allotment for lower body dressing is to be increased from 2 minutes per day to 5 minutes per day for all three periods of the authorized PCA.
CONCLUSION
I conclude the personal care allowance (PCA) is to be increased as follows:
The daily time allotment for bathing (showering)/drying is to be increased from 5 minutes daily to 10 minutes daily.
Lower body dressing is to be increased from 2 minutes per day to 5 minutes per day.
The worker’s objection is allowed-in-part.
DATED OCTOBER 3, 2025
Kevin MacMillan
Appeals Resolution Officer Appeals Services Division