Monitoring compliance with the director's decision

The director's decision

If an abuse report is investigated by Protection for Persons in Care (PPC), the director will review the investigator's report and make a decision, which may set out specific steps or measures (referred to here as directives) that the service provider or individual involved must take to prevent the abuse of clients.

The director also has authority to include how and when a service provider or individual involved* must respond to demonstrate that they are in compliance with the director's decision.

* Individual involved is a person who allegedly abused a client or who allegedly failed to prevent abuse of a client.

How service providers and individuals involved are expected to respond

Where the director's decision requires a response, service providers and individuals involved must reply in writing, by a specific date, to confirm they are in compliance with each directive in the decision. The response should describe the actions they have taken and should include any supporting documentation, if required.

The specific type of supporting documentation will vary depending on the nature of the directive. For example, if the directive requires the service provider to create or revise a specific policy, a copy of the approved policy should be attached.

Other examples of supporting documentation include copies of items such as: memos; meeting minutes; care plan updates; process and procedures; confirmation of attendance at staff education sessions such as sign-in sheets or certificates issued; educational materials; log notes; case conference minutes; behaviour management plans; medication administration records; nursing assessment and care records; staffing schedules; action plans; data sheets; and correspondence.

Why a written response is required

The Protection for Persons in Care Act requires service providers and individuals involved to comply with the director's decision. Failure to comply is an offence.

A written response, including supporting documentation, is important because it provides proof that the service provider or individual involved is in compliance with the director's decision.

Timeline for responding

The director's decision will include a timeline within which the service provider or individual involved is required to respond. The date will vary depending upon the nature of the directives in the decision.

If a service provider or individual involved requires more time to come into compliance, they may make a written request (by mail, fax or e-mail) for an extension, with reasons, to the director. The director will respond, in writing, indicating if the request is granted and, if so, will provide a new timeline.

The director may request an interim progress report prior to the extended due date.

What PPC does with the response after it is received

Once PPC receives a written response from a service provider or individual involved, PPC completes a compliance assessment, examining the timeliness and adequacy of the response.

The assessment involves reviewing and analyzing the entire response to determine if the requirements within the director's decision have been met. The director then reviews the response and assessment, and determines if the service provider or individual involved is compliant.

After the compliance assessment

If the director decides there is compliance, the director notifies the service provider or individual involved, in writing, and the PPC file is then closed.

If the director decides there is non-compliance, the director will determine what action should be taken. In most cases, the director will send an advisory letter notifying the service provider or individual involved that they are non-compliant, identify the areas of non-compliance and request another response within a set timeline. In some circumstances, the director may also decide to bring the file forward at a future date and review the situation again.

Definitions

Compliance occurs when all requirements within the director's decision are met and/or the intent of the director's decision is met. The desired outcome of compliance is a reasonable level of safety or the prevention of abuse.

Non-Compliance occurs when a directive is not met and/or the intent of a directive is not met. Examples of non-compliance include:

  • PPC did not receive a response and the timeline is overdue,
  • No meaningful action has been taken by the service provider or individual involved to implement the directive, or
  • The action taken does not meet the directive's intent.

Directives are specific steps or measures service providers or individuals involved must take to prevent the abuse of clients. While the aim of each directive is to prevent abuse, directives may also help to correct or improve a situation, or help to improve the safety and well-being of clients.

Enforcement refers to measures that are taken to bring about compliance.

How compliance is enforced

The role of PPC is to:

  • Encourage and promote compliance with the director's decisions, thereby promoting client safety and the prevention of abuse; and
  • Address non-compliance in a fair, effective and consistent manner.

In some cases, PPC enforces compliance by issuing a letter of non-compliance (either an advisory letter or a warning letter), referring the matter to the crown prosecutor, or taking other action such as addressing the matter with the funding body.

If non-compliance poses a serious or potentially serious threat to clients, the director may also consider referring the matter to the Minister of Health.

How the director decides what enforcement action to take

When deciding on the type of enforcement action to take, the director considers various factors, including:

  • the nature of the non-compliance or safety concern, including the seriousness of the non-compliance or concern (e.g., the resulting harm or potential harm to life, health, or property of the client or other clients including whether there is a threat to safe delivery of care or support services); 
  • whether the service provider or individual involved attempted to comply with the directives in the director's decision; 
  • whether the abuse, incident or safety concern is likely to recur; 
  • any corrective action already taken; and 
  • the willingness of the service provider or individual involved to co-operate.

The offence for non-compliance

People who do not comply may be guilty of an offence, subject to a fine of up to $10,000 for individuals and up to $100,000 for service providers.