Guidelines for Community Health Service Providers Audits and Reviews August 2012

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Table of Contents INTRODUCTION ........................................................................................................................................... 3

1.1- PURPOSE............................................................................................................................................................... 3 1.2 - REQUIREMENT FOR THE GUIDELINES ................................................................................................................... 3 1.3 - CONTEXT AND LEGISLATIVE FRAMEWORK ............................................................................................................ 4

2. THE CONTINUUM OF INTERVENTIONS FRAMEWORK........................................................................ 7

3. PREVENTION STRATEGIES.................................................................................................................... 8

4. LHIN-LEVEL INTERVENTIONS.............................................................................................................. 11

4.1 - STAGE 1 – LHIN-LEVEL INTERVENTIONS ...................................................................................... 12

4.2 - STAGE 2 – LHIN-LEVEL INTERVENTIONS ...................................................................................... 13

5. MINISTRY-LEVEL INTERVENTIONS..................................................................................................... 14

5.1CCACS - APPOINTMENT OF A SUPERVISOR UNDER SECTION 14 OF THE CCAC ACT .......................................... 14 5.2 COMMUNITY MENTAL HEALTH AND ADDICTIONS AGENCIES – MINISTRY PROGRAM/FINANCIAL REVIEW &

DESIGNATING ADVISORY OFFICERS............................................................................................................................ 16 5.3 CCAC’S AND COMMUNITY SUPPORT SERVICE AGENCIES ............................................................................ 16 5.4 COMMUNITY HEALTH CENTRES .............................................................................................................................18 5.5 LONG-TERM CARE HOMES - COMPLIANCE ORDERS AND REVOCATION OF LICENSES UNDER THE LTCH ACT 18

APPENDIX A – COMMON KEY SENTINEL SIGNALS SCORECARD FOR SPECIFIC SECTORS .......... 20

APPENDIX B – USEFUL SECTOR-SPECIFIC INFORMATION TO REVIEW FOR EACH SECTOR ........ 24

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Introduction

1.1- Purpose The Guidelines for Community Health Service Providers Audits and Reviews (Guidelines) are intended to assist Local Health Integration Networks (LHINs) in undertaking a transparent process in identifying and responding effectively and consistently to Health Service Provider (HSPs) issues, such as organizational and financial health or performance. The Guidelines are intended to support responses to issues that are identified in a manner that is:

Appropriate to the nature and scale of the issue/situation; Reflective of the roles of the LHINs, HSPs and the Ministry of Health and Long-Term Care (the

Ministry) in the Ontario health care system; and Within the legislative framework.

Five guiding principles informed the development of these guidelines:

1. To facilitate early identification and analysis of issues and/or support prevention of issue escalation;

2. To foster and develop relationships and partnerships as key to success; 3. To work together to resolve issues and refrain from assigning blame or taking punitive action; 4. To implement credible processes based on transparency and openness; and 5. To resolve issues at the earliest stages and use Ministry-level interventions such as

Investigations and/or Supervisors only as a last resort

These guidelines are to be used to identify, assess, confirm and address issues at the LHIN level to assist the LHIN in determining whether or not an audit and/or review of a HSP is necessary. The Guidelines also provide support in determining the level of intervention necessary (See the Continuum of Interventions Framework, Figure 1). For example, the government can, as a last resort, appoint a supervisor in the case of a Community Care Access Centre (CCAC) when it is in the public’s interest to do so. Before Ministry intervention is considered, the LHIN must demonstrate that it has taken all the necessary steps to resolve the issue. 1.2 - Requirement for the Guidelines

The Ministry LHIN Performance Agreement (MLPA) requires that the Ministry and LHINs “jointly develop guidelines for the LHIN on conducting audits, inspections, and reviews of HSPs, other than inspections under the Long-Term Care Home (LTCH) legislation, to ensure consistency among LHINs, where appropriate, in managing the local health system” (Schedule 1, paragraph 14).

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1.3 - Context and Legislative Framework

Prior to the introduction of the Local Health System Integration Act, 2006 (LHSIA) and the establishment of the LHINs, the Ministry had responsibility for monitoring, investigating and ensuring HSP compliance of legislative, policy and contractual obligations. Under LHSIA, other legislation, regulations and service accountability agreements with HSPs and Ministry policy the LHINs are responsible for conducting HSP audits and reviews. Service accountability agreements between LHINs and their local HSPs set out how the LHINs may conduct an operational or financial audit of the HSPs. For example, the Multi-Sectoral Accountability Agreement (M-SAA) with the community sector HSPs provides LHINs with the authority to enter the premises of the health service provider to review the provider’s fulfillment of its obligations under the M-SAA. While the LHINs are responsible for conducting audits and reviews of HSPs, the Ministry retains its compliance powers under legislation. Schedule 1, paragraph 12(a) of the MLPA states the “MOHLTC will retain its compliance, inspection and enforcement authorities under legislation.” However, the structure for the Ministry-level and LHIN-level interventions is different in the legislation and service/performance agreements below. 1. General: All Sectors Local Health System Integration Act, 2006 Sections 21 and 22 of the LHSIA provide the LHINs with the authority and flexibility to undertake audits and request information from the HSPs where needed. Under Section 21 of the LHSIA, a LHIN has the authority, at any time, to direct a HSP to engage or allow a third party audit of its accounts or financial transactions by licensed auditors. Additionally, under Section 22(1) of the LHSIA, LHINs may require that any HSP to which the network provides funding or proposes to provide funding under subsection 19(1) provide to the network the plans, reports, financial statements and other information, other than personal health information as defined in the Commitment to the Future of Medicare Act, 2004, that the network requires for the purposes of exercising its powers and duties under LHSIA. Ministry-LHIN Performance Agreement The MLPA 2010-2012 further strengthens the authority of the LHINs to conduct audits and reviews of local health service providers, as defined in the LHSIA. Pursuant to Schedule 1, paragraph 13 of the MLPA, the LHIN will “exercise its legislative and contractual authority as necessary or as required under law, including conducting or commissioning audits and reviews of HSPs, other than inspections of LTCHs as performed by the MOHLTC.” In terms of the Long-Term Care Homes (LTCHs) Schedule 1, paragraph 13 of the MLPA specifies that the LHINs have the power to “conduct as necessary or as required under law, audits and reviews of LTCH HSPs related to financial matters and performance.” Commitment to the Future of Medicare Act, 2004 The authority of the LHINs to require an audit or a review of a HSP or for the HSP to provide information to the LHIN is strengthened by the Commitment to the Future of Medicare Act, 1994 (CFMA). Section 25 of the CFMA gives both the LHINs and the Ministry power to issue compliance directives in various circumstances, including instances of non-compliance by the HSPs of terms of a service accountability agreement or a performance agreement.

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Excellent Care for All Act, 2010 The Excellent Care for All Act, 2010 (ECFAA), provides LHINs with the authority to require health care organizations (currently defined to include public hospitals only) to provide them with a draft of their annual quality improvement plans for review before it is made available to the public. The ECFAA also provides the Minister with the authority to develop regulations requiring health care organizations to submit reports concerning compliance with the ECFAA, and governing when and how those reports are to be submitted. 2. Long-Tem Care Homes Long-Term Care Homes Act, 2007 The Ministry maintains its compliance and enforcement role for LTCHs under the Long-Term Care Homes Act, 2007 (LTCHA). The LTCHA provides for the appointment of inspectors to inspect to ensure compliance with requirements under the LTCHA. This means compliance with a requirement under the LTCHA, O.Reg 79/10 under the LTCHA, and in an order or agreement made under the LTCHA (e.g. direct funding agreement). This also means compliance with a condition of a license under Part VII or approval under Part VIII (which includes compliance with the requirements in the service accountability agreement between the LHINs and the long-term care home operators) and a condition to which funding is subject under section 90 of the LTCHA. The powers of the inspector are set out in Part IX of the LTCHA. In addition, section 143 provides that each LTCH must be inspected at least once a year. The Ministry determines compliance with requirements under the LTCHA through the Ministry’s compliance and enforcement program. The Ministry currently employs inspectors who conduct critical incident inspections, follow-up and other inspections. Long-Term Care Homes Service Accountability Agreements The LHINs successfully negotiated and signed Long-Term Care Homes Service Accountability Agreements (L-SAAs) with all LTCHs effective July 1, 2010. Under article 8, a LHIN or its’ authorized representatives may conduct a financial or operational audit or other form of review of the LTCH to confirm the LTCH licensee’s fulfillment of its obligations under the L-SAA. The cost of any financial or operational audit or review will be borne by the HSP if the audit or review (i) is made necessary because the HSP did not comply with a requirement under the LHSIA or the L-SAA or (ii) determines that the HSP has not fulfilled its obligations under the L-SAA or the LTCHA.

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3. Community Care Access Centres, Community Support Service Agencies, Community Health Centres and Mental Health and Addictions Agencies. Community Care Access Corporations Act, 2001 Under the Community Care Access Corporations Act, 2001 (CCAC Act), the Minister may issue directions to CCACs on matters relating to a CCAC’s rights and powers and the performance of its duties under the CCAC Act. The Minister could issue directions to a CCAC requiring an audit or review of the CCAC to be undertaken and results reported to the Minister. The Minister also has the power to appoint a person as a supervisor of a CCAC if the Minister considers it to be in the public interest to do so and may request information and reports from the supervisor. Home Care and Community Services Act, 1994 The Home Care and Community Services Act, 1994 (HCCSA), which covers both CCACs and other approved agencies, such as Community Support Service Agencies allows for the appointment of a program supervisor who may enter and inspect the business premises of a service provider, any premises where a community service is provided and the community services provided on the premises and the records relevant to the inspection. The powers of a program supervisor are set out in Section 62 of the HCCSA. Mental Health Act, 1990 The Mental Health Act, 1990, allows the Minister to designate officers of the Ministry or appoint persons to advise and assist medical officers of health, local boards of health, hospitals and other bodies and persons in all matters pertaining to mental health and who may have other duties assigned by the Act or regulations. An advisory officer appointed by the Minister may visit and inspect any psychiatric facility and in doing so may interview patients, examine books, records and other documents relating to the patients, the range of services provided and any other matters deemed relevant to the maintenance of standards of patient care. Multi-Sectoral Service Accountability Agreements The LHINs are in the process of finalizing the 2011-2014 M-SAA draft. Under Article 8 of the 2011-2014 M-SAA, a LHIN or its authorized representatives may conduct a financial or operational audit, investigation or other form of review of the HSP to confirm the HSP’s fulfillment of its obligations under the M-SAA. The cost of a financial audit, review or investigation will be borne by the HSP. The cost of any other form of audit, review or inspection will be borne by the HSP if it is determined that the HSP did not fulfill its obligations under the M-SAA.

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2. The Continuum of Interventions Framework The foundation for these Guidelines is a Continuum of Interventions Framework that was first developed for the Hospital Sector Audits and Reviews Guidelines in 2009 and have been adopted across LHINs. It is intended to provide guidance and support in selecting mitigating strategies and in supporting decisions with respect to resolving issues of concern. The Continuum of Interventions Framework contains three major components and they are listed below in the order that it is recommended they be used in most occasions: Prevention Strategies LHIN-Level Interventions Ministry-Level Interventions

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Note: Depending on the nature and severity of the problem/risk, the LHIN may choose the highest level of intervention up to and including Ministry involvement. LHINs may also choose one or more interventions.

3. Prevention Strategies Prevention Strategies are activities or processes that are in place to facilitate the sharing of information, provide support, advice and assistance between LHINs and the HSP as part of regular on-going relations. These prevention strategies can be applied across all sectors. Prevention strategies activities might include regular meetings between the LHIN and the HSP’s executive director or senior management to discuss a range of issues. These type of discussions could for example, include a review of the root causes of quarterly performance indicator results or exploratory or investigative discussions on how the LHIN and HSP work together to make any necessary improvements. Alleviating the need for serious intervention by preventing problems from occurring is the preferred best practice. As local health system managers, LHINs have the opportunity to develop creative prevention strategies that work best for them and their HSPs. The following have been identified as potential prevention approaches and are explained in further detail below:

Capacity Building; Contracts for Performance; Detailed Funding Allocation Letters; Quarterly Performance Reviews; Increased Frequency and Content of Reporting and Review; On-going Engagement; and The Sentinel Signals Scorecard.

Capacity Building Capacity building is defined as enhancing and strengthening the capabilities and competencies that facilitate effective organizational leadership and operations. A LHIN can assist a HSP to improve its capacity by providing them with assistance and support through initiatives such as:

Encouraging the building and improvement of HSP relationships with stakeholders. Key stakeholders for the HSP are the LHIN, local and regional partners and the community the HSP serves;

Building and improving Board governance and leadership capacity and clarifying roles and responsibilities, including accountability (i.e. to whom HSP boards are accountable and for what); and

Developing and nurturing HSP leadership through an emphasis on mentoring, coaching and peer reviews and mediation.

Contracts for Performance The M-SAA and L-SAA consist of a standard provincial template and schedules which detail the responsibilities for performance by the HSP for funding received. Specific expectations are discussed between the HSP and LHIN and are set in the schedules with respect to volumes of service and other

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standard, desired indicators of performance. A LHIN may set additional performance indicators or obligations to reflect a particular locally desired circumstance. These may include obligations with respect to advancing local health system plans or integration initiatives and/or additional performance targets that the LHIN and HSP have agreed are critical to the local health environment or for indicating the ongoing satisfactory performance of the HSP. In addition, the M-SAA and L-SAA require the LHINs and HSPs to work together to achieve on-going performance improvement. The LHIN and HSP will address performance improvement in a proactive, collaborative and responsive manner.

Ongoing Engagement Conversations and regular dialogue between LHINs and HSPs can occur for a variety of reasons and in a variety of ways. The key will be to engage in open, transparent conversations that enable potential issues to be identified at their earliest stages. LHINs may wish to develop or adopt tools and processes to assist Community agencies conduct their own self-assessment of governance and business practices, identification of gaps and/or opportunities for improvements. Some potential strategies for engaging in early and/or ongoing dialogue could include regular formal meetings between the LHINs and HSPs in order to facilitate a pattern of communication that can help to identify and mitigate issues at the earliest stage. For instance, HSPs are required to submit quarterly reports. Regular meetings and conversations between the HSPs and the LHINs could facilitate mutual understanding of trends or potential issues arising from these reports. Board engagement opportunities can enhance mutual learning of the responsibilities and challenges facing the HSPs and the LHINs and enable consensus building with respect to overall strategic direction. These efforts are supported by ensuring there are clear expectations for performance and multiple opportunities for discussion. Attention to detail in funding allocations will help ensure that an agency is very clear on what constitutes acceptable performance and will reduce the risk of inadvertently being identified as failing to perform. It is important to identify the difference between base, restricted base, on-going one-time and one-time/project funds. It is also recommended that specific deliverables, including additional performance metrics, and reporting requirements be included in the service accountability agreement. Quarterly Performance Review At a minimum, HSPs must report their performance on a quarterly basis beginning with the second quarter report. The performance report is standard across the province and includes historical financial and service information as well as a fiscal year end forecast. It is important that each HSP’s report be reviewed to ensure accuracy/validity, achievement of targets as per the M-SAA/L-SAA indicators and any additional performance deliverables contained in funding letters. In addition, the forecast should be reviewed for achievability and reasonableness. It is also beneficial to include opportunities for dialogue with the HSP as part of the quarterly performance review process. This may be in the form of telephone or video conference meetings and/or in person meetings where the budget is sizeable or an issue requires resolution. Face-to-face meetings allow for the building of positive relationships.

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It is important that the findings from the quarterly reviews and notes from any discussions be documented and retained for future reference. This information may be required to confirm that the LHINs took the necessary and appropriate steps to identify, assess, confirm and address the issues to the extent possible prior to requesting ministry-level intervention (e.g. supervisor or investigator). Frequency and content of reporting and review LHINs may wish to move from quarterly reporting on M-SAA/L-SAA indicators to monthly reporting with an extended list of key operational indicators and more in depth requirements with respect to forecasting assumptions and methodology. This heightened attention is a very good signal to the HSP that the performance issue is considered to be serious and worthy of the attention of senior HSP staff. 3.1 - Sentinel Signals Scorecard Good communication practices by the LHINs and HSPs are important to building and sustaining strong relationships. LHINs and HSPs are then able to have discussions about potentially sensitive or difficult topics from a problem resolution versus blame assignment perspective. Specifically, this involves first seeking clarification on information/issues and then offering support in developing solutions. Each situation is unique with some HSPs welcoming support and some finding that to be intrusive. A tool has been developed to assist in identifying questions for clarification or discussion when the goal or focus is on prevention. This tool is an adaptation of the Balanced Scorecard that was developed by Robert Kaplan and David Norton, as a strategic planning and management system to align business activities to the vision and strategy of the organization, improve internal and external communications, and monitor organization performance against strategic goals. The Balanced Scorecard (BSC) approach provides a basis on which to identify and assess issues of concern. The BSC approach suggests that four perspectives – Financial, Customer, Internal-Business-Processes and Learning and Growth need to be considered together in a balanced manner in order to achieve and sustain high organizational performance. This framework has been modified for the purposes of these guidelines in identifying sentinel signals for HSPs. Similar to the traditional BSC, the Sentinel Signals Scorecard (Scorecard) uses four quadrants:

Organizational Health – Quadrant focuses on a HSP’s board and leadership’s functioning within commonly accepted best practices.

Quality of Care, Patient Safety, Service Provision and Community Support – Quadrant focuses on how well a HSP is performing in areas related to quality of care, patient safety, patient satisfaction, provision of services and responsiveness to community concerns.

Financial/Operational Health – Quadrant focuses on how well the HSP is performing in commonly accepted financial elements.

Employee Health and Safety – Quadrant focuses on how well a HSP is performing in areas related to workplace safety, employee satisfaction and health and performance.

Within each of the four quadrants in the Scorecard are a set of sentinel signals that LHINs may wish to consider in identifying and assessing whether or not a HSP is in need of support. The list of sentinel signals is not exhaustive. It is not the intent of these guidelines, nor is it feasible, to provide LHINs with definitive answers as to whether or not an intervention is required. The key is to view the Scorecard as a tool to

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assist in identifying and highlighting issues of concern. LHINs will be required to draw upon their unique local knowledge and analysis of their data to draw appropriate conclusions.

With respect to quantitative information, the easiest information to obtain is Financial/Operational Health and Quality of Care/Patient Safety data. For example:

Quarterly updates on HSP financial information can be obtained through the Web Enabled Reporting System (WERS) or starting in 2011/12 Self-Reporting Initiative (SRI) system.

Information on MLPA indicators, such as wait times, can be obtained through the Local Health System Performance Dashboard at https://www.healthinfo.moh.gov.on.ca/cognos8/dashboard.html.

Information to support the Organizational Health and Employee Health and Safety quadrants will be more challenging to obtain. LHINs will need to explore a variety of options to obtain data and information to support their requirements, including, if necessary the provisions contained in Subsection 22(1) of the LHSIA.

See Appendix A for common key sentinel signals for each specific sector.

4. LHIN-Level Interventions In the event that an issue of concern arises or persists despite preventive discussions and strategies, then the LHIN may wish to consider initiating a series of steps in which they identify, assess and confirm the issue and work with the HSP using a variety of different approaches to address the issue. The type of mitigation approach taken would likely be commensurate with the intensity of the issue in question.

Under section 8.2 of the M-SAA and L-SAA, a LHIN or its authorized representatives has the authority to conduct a financial or operational audit or other form of review of the HSP to confirm the HSP’s fulfillment of its obligations under the M-SAA and L-SAA provided that no less than 24 hours Notice to the HSP is provided and is conducted during normal business hours.

There are two stages within the LHIN-Level interventions:

Stage 1 – LHINs identify, assess, validate and confirm that there is an issue of concern through conversations, research and investigations with stakeholders and/or advisors to understand the issue.

Stage 2 – LHINs investigate and confirm the issue through reviews of various types and they facilitate the resolution of the issue through the assistance of external supports such as coaches or facilitators.

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4.1 - Stage 1 – LHIN-Level Interventions All Sectors:

Dialogue between LHINs and External Advisors (Internal/External Validation of the Issue) If an individual has previously reviewed, audited or supervised a HSP, it may be useful to have a discussion with that individual. That individual would bring their experience with this HSP or similar HSPs, to the table which may lead to the development of strategies that the LHINs could use to work with the HSP. This type of conversation can also provide a chance for the LHIN to have its concerns validated and/or assessed.

 

Root Cause Analysis Root Cause Analysis is a problem-solving technique designed to identify the sources of problems, issues or events. This technique is based on the idea that problems are best solved by attempting to correct or eliminate root causes instead of symptoms. Addressing root causes increases the likelihood that the problem will be mitigated and recurrence minimized. Root Cause Analysis can also be helpful as a tool to support continuous improvement as it facilitates understanding of cause and effect relationships. The Canadian Patient Safety Institute provides a number of helpful tools to support Root Cause Analysis in the Canadian Root Cause Analysis Framework which can be accessed at: http://www.patientsafetyinstitute.ca/English/toolsResources/rca/Pages/default.aspx.

In-Depth LHIN analysis Move from simple review of M-SAA/L-SAA indicators and the underlying drivers to a more detailed benchmark analysis of key business indicators, and a “mini” operational review (see Appendix A for useful information to review for each sector). Please note that not every LHIN will have the internal expertise necessary to complete this level of analysis and may need to engage external resources. The purpose of this analysis is to gain an understanding of the key drivers of the issues at the forefront (e.g. access to service, financial sustainability, etc.) in order to assist in problem-solving with a HSP. In many cases, the issue is a lack of sufficient expertise in the HSP management group and/or a lack of local of access to the relevant data sources.

Appointing a Third Party Auditor under Subsection 21 of the LHSIA Under the provisions of Subsection 21 of the LHSIA, LHINs may appoint a third party auditor licensed under the Public Accounting Act, 2004 to audit the accounts and financial transactions of the service provider. The primary focus of this intervention is to investigate, understand and assess the financial issues of concern with a HSP.

 

4.2 - Stage 2 – LHIN-Level Interventions

All Sectors: tivities described in this stage focus on the investigation or review of an issue at a HSP and

n.

eer Review r Review is undertaken by an individual or a team of staff from a peer HSP with the

dations on

perational Review s typically conducted by a third party consultant or an outside CEO-led team

ese

The acthe subsequent identification of recommendations for actions to mitigate the concerns identified and/or confirmed. There are a range of investigative/confirmation initiatives that can be undertakeIn each instance an important first step is to develop a terms of reference that clearly articulates the goals, objectives and deliverables of the investigative intervention. Common approaches thathave been used in the past are as follows: PTypically a Peepurpose of examining a specific issue or concern. In some cases, CEOs and/or senior management of other HSPs review the HSP operations and provide specific recommenhow to improve efficiencies (clinical and/or operational) and a workable plan to address the issues (e.g. balance budgets, etc). In other cases a team of peers review specific aspects of a HSP’s operations (e.g. a financial peer team reviews financial issues, etc). OAn operational review iwith a focus on the operational rather than the leadership/governance aspects. Operational elements of typical concern include financial and/or clinical processes and practices. Often th

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Governance Review

e also generally conducted by a third party (usually an external consultant

he decision to undertake an operational or governance review is generally predicated on an g

ubmission of a Performance Improvement Plan (PIP) t may be necessary for the HSP to

nt

sue Support and Resolution

he activities described in this section focus on the provision of assistance to a HSP in addressing

oach intment of a coach is often a facilitative measure designed to provide time-limited

or

acilitator erve a number of purposes that are generally related to the implementation of a

iew.

5.1 – CCACs - Appointment of a Supervisor under Section 14 of the CCAC Act

he CCAC Act provides the Minister with the authority to appoint a person as a supervisor of a CCAC if the

two elements are intertwined in that inefficient or costly clinical programs/practices create burdenson the HSP’s financial position. However, an operational review can also examine the board/management dynamic.

Governance reviews arwith extensive experience in governance and HSP administration. Governance reviews are detailed reviews that focus on a HSP’s leadership and governance. Tassessment of the possible root causes and the associated magnitude of the situation requirinreview. For example, a HSP in financial difficulties with appropriately functioning board and management leadership may be a candidate for an operational review. SWhile having identified and resolved the underlying issues, ipresent a detailed plan to explain how the HSP will return to a balanced position and how any operating surplus or accumulated working capital deficit will be managed. It is important for the LHIN to provide a template and clear objectives/expectations with respect to the form and conteof the PIP as well as to the process of review and/or approval as is desired for the circumstances. Is Tproblem areas or in implementing the recommendations from a review or investigation. CThe appoassistance that focuses on a specific issue or problem area. In some cases the term advisormentor may also be used to describe this activity. FFacilitators sspecific, often difficult or controversial, initiative. For example, the government may appoint a facilitator to prepare a CHC for the implementation of the recommendations contained in a rev

5. Ministry-Level Interventions

TMinister considers it to be in the public’s interest to do so. The Minister may in the appointment, specify the powers and duties of the supervisor and the terms and conditions governing those powers and duties. The

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Minister may also ask the supervisor to give the Ministry such information and reports as the Minister requests. As well, within this intervention the Minister may allow the CCAC, its board of directors or its Executive Director to continue performing any duties during the term of the supervisor’s appointment, but only with the written approval from the supervisor. In requesting this level of intervention, the LHIN should provide:

1. A detailed description of the situation including a historical accounting of the situation, previous reviews, and the LHIN’s supporting qualitative and quantitative analysis. A timeline and an accounting of the various initiatives that the LHIN has undertaken with the CCAC to identify, validate, address, and resolve the issue. The accounting should include reports detailing audits and/or reviews that the LHIN has supporting their respective findings and outcomes.

2. An assessment of the CCAC’s situation within the context of the above noted circumstances that may lead to the appointment of a supervisor.

3. A record of various discussions that have taken place between the ministry and the LHIN on matters related to the CCAC in question.

4. Other supporting information the LHIN deems important in facilitating the ministry’s understanding of the situation (e.g. local media reports, stakeholder communication, etc)

As part of ongoing dialogue on issues, the LHINs should first contact the LHIN Liaison Branch about the issue and steps taken to prepare the submission to the Minister recommending the appointment of a Supervisor. Please refer to steps 1-4 above for the information that should be provided when the LHIN is requesting Ministry intervention. When the LHIN makes a direct recommendation to the Minister to appoint a supervisor, the LHIN Liaison Branch in conjunction with the Deputy Minister’s Office will coordinate the information and analysis to inform the Minister’s decision regarding the LHIN’s recommendation.

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5.2- Community Mental Health and Addictions Agencies – Ministry Program/Financial Review & Designating Advisory Officers The Ministry can review agencies that provide mental health and addition services to determine if services need to be improved. The way this level of intervention works is that the Ministry would provide the agency with 24 hours notice before conducting a program or financial review and will make sure that the review is not disruptive to clients or services. Review Process This type of review may be initiated:

At the request of the Board to give the agency feedback on its operations; In response to unresolved complaints from staff or clients; To verify financial information provided by an agency; To investigate a financial complaint or concern; and When the agency does not comply with the Ministry’s reporting requirements.

What happens after the review is completed:

1. Ministry representatives meet with the Board to discuss a draft report. 2. Ministry identifies issues/priorities in writing. 3. Board has the opportunity to respond to the facts of the report. 4. Board submits a work plan, with timelines, to address the priority areas. 5. Ministry follows up with the agency at regular set intervals. 6. If the Board does not begin implementing recommendations or remedies within the set timeline or

in a manner acceptable to the Ministry, the Ministry will inform the Board funding is in jeopardy. 7. If the agency still does not respond appropriately, the Ministry will give notice of its intention to

terminate funding in accordance with sections 18 and 19 of the Transfer Payment Agreement, stating clearly the reasons why the funding will be terminated and when.

* Note: The LHIN will be kept informed throughout the review process by Ministry representatives.

5.3 CCACs and Community Support Service Agencies Under the HCCS Act, the Minister may appoint any person in writing as a program supervisor to inspect CCACs, Community Support Services Agencies and other approved agencies (e.g. March of Dimes). A program supervisor can enter the premises of HSPs and question any person on matters relevant to the inspection, subject to the person’s right to have counsel or another representative present during questioning. Circumstances that would be considered in making a recommendation to appoint a Program Supervisor are:

Chronic deficits or excessive debts Suspected mismanagement of funds

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Pattern of client complaints Ongoing and significant failure to meet service accountability agreement requirements.

In requesting or recommending a program supervisor the LHIN should make a case documenting the issues of concern, supporting evidence, and escalated actions (i.e., peer reviews, operational reviews, audits, coaches, etc.) and their respective outcomes. As part of ongoing dialogue on issues, the LHINs should first contact the LLB about the issue and steps taken to prepare the submission to the Minister recommending the appointment of a Program Supervisor. The case supporting the request should include:

A detailed description of the situation including a historical accounting of the situation, previous reviews and the LHIN’s supporting qualitative and quantitative analysis. A timeline and accounting of the various initiatives that the LHIN has undertaken with the community HSP to identify, validate, address, and resolve the issue. The accounting should include reports detailing audits and/or reviews demonstrating that the LHIN has supported their respective findings and outcomes.

An assessment of the community HSP’s situation within the context of the above noted circumstances that may lead to the appointment of a program supervisor.

A record of various discussions that have taken place between the Ministry and the LHIN on matters related to the community HSP in question.

Other supporting information the LHIN deems important in facilitating the Ministry’s understanding of the situation (e.g., local media reports, stakeholder communications, etc).

When the LHIN makes a direct recommendation to the Minister to appoint a program supervisor, the LLB will coordinate the information, analysis and recommendation for the Minister’s consideration.

5.4 Community Health Centres

There is no specific legislative authority that would permit the same kinds of Ministry level interventions for community health centres as exist for other LHIN HSPs. For instance, the Ministry does not have the authority to appoint a supervisor as it can in the case of CCACs.

In the case of CHCs, the Ministry and LHINs can work together to resolve issues that may be beyond the control of just the LHINs. The Ministry has significant moral suasion, which can be used to influence and pressure certain behaviour, if needed.

5.5 - Long-Term Care Homes - Compliance Orders and Revocation of Licenses under the LTCH Act

Under the LTCHA, the Minister may appoint one or more persons as the Director and inspectors. The

here specified grounds have been met, an inspector or the Director may order a licensee: nt under the

authority of the rson

he Ministry may recover the reasonable costs of any work or activity performed under a section 154 order

addition to the orders described above, the Director may issue the following types of orders where the

Director is, by virtue of his or her office, an inspector. W

to do anything, or refrain from doing anything to achieve compliance with a requiremeLTCHA, or to prepare, submit and implement a plan for achieving compliance with a requirement under the LTCHA (a compliance order under section 153 of the LTCHA); or

to allow employees of the Ministry, or agents or contractors acting under the Ministry to perform any work or activity at the LTCH that is necessary, in the opinion of the pemaking the order, to achieve compliance with a requirement under the LTCHA, and to pay the reasonable costs for the work or activity (a work and activity order under section 154 of the LTCHA).

Tby withholding an amount from the funding that would otherwise be provided to the LTCH under the LTCHA or may direct the LHIN that provides funding under LHSIA to the licensee to withhold from such funding an amount equal to the reasonable costs of any work or activity performed under section 154 of the LTCHA. Ingrounds for issuing the order(s) have been met:

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an order that a specified amount of funding proved to a LTCH licensee by the Minister or by the LHIN that provides funding under LHSIA to the licensee be returned by the licensee or withheld from the licensee by the Minister or LHIN, respectively (see section 155 of the LTCHA);

a mandatory management order compelling a LTCH licensee to retain, at the licensee's expense, one or more persons acceptable to the Director to manage or assist in managing the long-term care home (see section 156 of the LTCHA)

an order revoking a licence, which may include an order providing for the LTCH to be occupied and operated by an interim manager until the revocation of the licence becomes effective and the residents of the LTCH are relocated.

For further information regarding this type of ministry—level intervention, please contact the Performance Improvement and Compliance Branch.

Appendix A – Common Key Sentinel Signals Scorecard for Specific Sectors

Figure 1 – Community Care Access Centres Common Key Sentinel Signals Scorecard

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Figure 2 – Community Mental Health and Addictions Agency Common Key Sentinel Signals Scorecard

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Figure 3 – CHC & CSS Common Key Sentinel Signals Scorecard

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Figure 4 – Long-Term Care Homes Common Key Sentinel Signals Scorecard

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Appendix B – Useful sector-specific information to review for each sector

Community Care Access CentresOHRS/MIS Trial Balance Submissions (through OHFS)OHRS/MIS Supplementary Reports – Quarterly Reports (through WERS)Annual Reconciliation ReportsBoard Approved Audited Financial Statements Home Care Reporting System Information French Language Services Implementation and Accountability Reports

Community Mental Health and Addictions Agencies OHRS/MIS Trial Balance Submissions (through OHFS)OHRS/MIS Supplementary Reports – Quarterly Reports (through WERS)Community Annual Planning Submissions (CAPS)Board Approved Audited Financial Statements Common Data for Community Mental Health Service ReportsDATIS Reports ConnexOntarioHealth Services Information Local Demographic Information French Language Services Implementation and

Accountability Reports

Community Health Centres & Community Support Service Agencies

OHRS/MIS Supplementary Reporting – Quarterly Reports (through WERS)Annual Reconciliation Reports Board Approved Audited Financial Statements CHS Program Reporting System French Language Services Implementation and Accountability Reports

Long-Term Care Homes Resident Assessment Instrument-Minimum Data Set Information (through CIHI)In-Year Revenue/Occupancy Reports Long-Term Care Annual ReportsFinancial StatementsPerformance Reports French Language Service Implementation and Accountability Reports

In-Depth LHIN Analysis

Sector-Specific Information