Policy directives for service agencies under the authority of the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008

These policy directives outline the requirements for service agencies to develop policies and procedures for complaints and feedback. The directives apply to all service agencies that provide developmental services to adults with a developmental disabilities and are funded by the Ministry of Children, Community and Social Services.

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1. Complaints/feedback process

Applicable to: All service agencies that receive funding under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008 from the Ministry of Children, Community and Social Services to provide adult developmental services and supports.

This policy directive does not apply to Developmental Services Ontario organizations. Requirements for a feedback process are outlined in the Policy Directives for Application Entities.

Legislative Authority: Section 7(1) 1
Effective Date: January 1, 2021

Introduction

These policy directives are written to complement Ontario Regulation 299/10 regarding quality assurance measures, made under the authority of the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008. The directives apply to all service agencies funded by the Ministry of Children, Community and Social Services under the Act, to provide developmental services to adults with a developmental disability.

This document sets out the terms of these directives.
The Ministry of Children, Community and Social Services may amend the directives as needed and where appropriate, with reasonable notice provided to service agencies.

A complaints/feedback process is an important part of providing quality support that is responsive to people’s needs and that supports continuous improvement in service delivery. The information received through a complaints/feedback process can assist an organization to take steps to better support individuals and/or improve administrative practices.

Definitions

“Feedback” may be positive or negative (including complaints) and is related to the services and/or supports that are provided by a service agency. Feedback may be solicited (such as information and comments collected through a satisfaction survey or a comment box) or unsolicited (such as a letter from a person or family member about the services and supports that the agency provides).

Feedback may be formal (like the survey or letter noted above) or informal (such as a verbal complaint expressed to a staff person).

“Complaint” is an expression of dissatisfaction related to the services and/or supports that are provided by a service agency. A complaint may be expressed by a person with a developmental disability who is receiving services and supports from the service agency, or a person acting on their behalf, or by the general public, regarding the services and supports that are provided by the service agency. A complaint may be made formally (such as a letter written to the agency) or informally (such as a verbal complaint expressed to a staff person). A complaint does not include feedback on matters unrelated to the agency and the services and supports that it provides.

Purpose

The purpose of the policy directive is to set out the requirements for service agencies to develop written policies and procedures for a process to receive and address complaints and other feedback about the services and supports that they provide.

The ministry recognizes that service agencies may already have a complaints and/or feedback process in place. An agency’s complaints/feedback process is separate and apart from other means to express concern, either at the local level, or more broadly, such as to the Ombudsman of Ontario or the Human Rights Commission.

The policies and procedures developed by service agencies must include a process to elicit feedback and to resolve and respond to complaints regarding the agency and the services and supports it provides, from individuals with a developmental disability, persons acting on their behalf, and the general public.

Policy

A complaints/feedback process should be readily available and easily understandable to those who wish to submit a complaint or provide feedback and set out the way in which the service agency will provide a response to the complaint/feedback in a timely manner.

A review of the complaints/feedback received in a complaints/feedback process can assist an agency in identifying issues and mitigating a risk to the organization where it may fail to meet expectations of the public, other clients, ministries or other stakeholders.

Note that service agencies must also comply with the requirements for a feedback process that are set out in the Accessibility Standards for Customer Services, Ontario Regulation 429/07, made under the Accessibility for Ontarians with Disabilities Act, 2005.

Directive

A service agency shall have written policies and procedures regarding the process for receiving and addressing feedback and complaints about the services and supports that it provides that may be received from:

an individual with a developmental disability who receives services and supports from the service agency
a person acting on behalf of the individual with a developmental disability who receives services and supports from the service agency
the general public

A service agency must provide information in plain language on the complaints/ feedback process to all people with a developmental disability who come into service with the agency, and/or a person acting on their behalf (where applicable).

A service agency must provide a copy of its written policies and procedures to any person who requests it.

The policies and procedures shall account for differing ways that complaints/feedback may be received (e.g., complaints/feedback submitted in writing, or provided verbally to an agency representative).

The policies and procedures shall identify:

how the service agency receives and documents complaints/feedback
the process for investigating the matter (if applicable) that must be free of conflict of interest
expected time period for the complaints/feedback processes (i.e., for each step of the process)
the process for responding to complaints/feedback
the roles and responsibilities of persons who may be involved in receiving complaints/feedback, documenting, investigating, resolving and providing notification or confirmation with the individual who submitted the complaint/feedback
consideration for the role and any responsibilities of persons who receive support from the service agency, in the complaints/feedback processes
the role and responsibilities of the Board of Directors in the complaints/feedback processes
how to avoid conflict of interest that may arise between the person who makes the complaint or provides feedback, and those who may be involved in the review, documentation, investigation, resolution and notification/confirmation
how to ensure that the review process is free of any coercion or intimidation or bias, either before, during, or after the review.

The service agency shall receive, document, and review all feedback, and receive, document, review, and attempt to resolve all complaints. Wherever possible, the service agency shall make reasonable efforts to resolve or address the matter to the mutual satisfaction of both the person who has made the complaint and the service agency.

Where reasonable and necessary, and in accordance with the Regulation on Quality Assurance Measures and agency’s policies and procedures, a service agency shall investigate complaints/ feedback it receives.

A service agency is not, however, expected to attempt to resolve complaints that it may determine to be frivolous or vexatious.

A service agency shall ensure that a person who submits a complaint or provides feedback is not at risk of having their services and supports negatively impacted or withdrawn, as a consequence of submitting the complaint/feedback, and the agency makes the person aware that their services and supports will not be impacted in that way.

The service agency’s policies and procedures on the complaints and feedback process shall comply with all applicable requirements, including reporting and abuse prevention and reporting requirements, set out in the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008 and its regulations.

Where necessary, a service agency shall ensure that a complaint/feedback is:

Reported to the police (i.e., as in the case of alleged, suspected or witnessed abuse that may constitute a criminal offence), as required by Ontario Regulation 299/10 regarding quality assurance measures made under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008
Reported to the ministry as a serious occurrence through the ministry’s serious occurrence reporting process (based on the nature of the complaint/feedback)

In order to promote continuous quality improvement, a service agency shall:

Conduct a review and analysis of the complaints and feedback received to evaluate the effectiveness of its policies and procedures, on an annual basis
Conduct a review and analysis of the complaints and feedback received to consider the need to revise any other policies and procedures that the agency may have in place.

A service agency shall share information about its complaints/feedback process, and/or about complaints/feedback, as part of the ministry’s risk assessment process, upon request by the ministry.

2. Supporting people with challenging behaviour

supported group living residences
intensive support residences
community participation services and supports
caregiver respite services and supports
activities of daily living services and supports

This policy directive does not apply to Developmental Services Ontario organizations

Legislative Authority: Section 7(1) 1
Effective Date: January 1, 2021

Introduction

The Ministry of Children, Community and Social Services (MCCSS) wants people with a developmental disability to participate fully as citizens of Ontario. Its goal is to create a system of services and supports to help adults with a developmental disability to be more independent, to have more choice, and to be included in the community.

The ministry recognizes that most adults with a developmental disability do not have and/or display challenging behaviour. The behaviour interventions outlined in this policy directive are not meant for, nor are they appropriate for use with, people who do not have and/or display challenging behaviour.

Sometimes, a person may display behaviour as a means of expressing themself. Other times, a person may exhibit behaviour as a means of signalling that something is wrong, such as a physical health problem, or when a person’s environment is not meeting their needs^{footnote 1[1]}. In some cases, behaviour can relate to a person’s mental health, past abuse and/or trauma. Problematic behaviour can increase the risk of social isolation and decrease the quality of life of the person^{footnote 2[2]}. The Primary Care of Adults with Intellectual and Developmental Disabilities: Canadian Consensus Guidelines^{footnote 3[3]}, written by Dr. William F. Sullivan et al., and the associated Tools for Primary Care Providers and Tools for Caregivers^{footnote 4[4]}, by the Developmental Disabilities Primary Care Initiative, are valuable resources in assisting physicians, primary care providers, service agencies, and families or caregivers in assessing the behaviour of a person with a developmental disability. Copies are available at Surry Place.

In instances where an adult with a developmental disability has challenging behaviour, it is important that the support the person receives to address their behaviour is well-informed, appropriate to the person’s needs, and safe, so that the person may take part in the community and live as independently as possible. The ministry also requires that service agencies take steps to ensure that agency staff has the knowledge and skills to react quickly and effectively in the event of a crisis situation, and to keep everyone as safe as possible in the area of the crisis situation.

Definitions

“Challenging behavior” is defined in Ontario Regulation 299/10 as “behavior that is aggressive or injurious to self or to others or that causes property damage or both and that limits the ability of the person with a developmental disability to participate in daily life activities and in the community or to learn new skills or that is any combination of them.”

A “crisis situation” is defined in the regulation as “a circumstance where:

A person with a developmental disability is displaying challenging behaviour that is new or more intense than that which was displayed in the past and the person lacks a behaviour support plan or the strategies outlined in the person’s behaviour support plan do not effectively address the challenging behaviour
The challenging behaviour places the person at immediate risk of harming themselves or others or causing property damage
Attempts to de-escalate the situation have been ineffective.”

Purpose

This directive recognizes that, in some instances and perhaps by exception, intrusive measures are used with adults with a developmental disability who have and/or display challenging behaviour.

The purpose of the policy directive is to set out the ministry’s requirements regarding the use of intrusive behaviour intervention strategies by service agencies for adults with a developmental disability who have and/or display challenging behaviour. This policy directive provides additional direction to Part III of Ontario Regulation 299/10, the regulation on quality assurance measures, made under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008.

This policy directive is intended to protect the safety, rights and well-being of adults with a developmental disability who have and/or may exhibit challenging behaviour, as well as the safety of others who may be in the environment and the agency staff who provide support. This directive is also intended to clarify expectations for staff training and promote consistency among service agencies regarding intrusive behaviour intervention with a view to assisting individuals to develop more positive behaviour, communication and adaptive skills, and to reduce, change or eliminate their challenging behaviour, in order to support their inclusion in the community.

Policy

Service agencies funded by the ministry are responsible for delivering services that promote the health, safety and well-being of people who are being supported.

The ministry supports an approach to behaviour intervention that uses the least intrusive and most effective evidence-based practices possible to address the challenging behaviour of a person with a developmental disability. Further, wherever possible, the ministry supports the use of non-intrusive measures in order to prevent and avoid crisis situations.

The ministry’s position is that physical restraint should be used solely as a last resort in crisis situations, or as identified in an individual’s behaviour support plan.

Definition

A “physical restraint”, as an example of a type of intrusive behaviour intervention in Ontario Regulation 299/1, includes “a holding technique to restrict the ability of the person with a developmental disability to move freely, but does not include the restriction of movement, physical redirection or physical prompting if the restriction of movement, physical redirection or physical prompting is brief, gentle and part of a behaviour teaching program.”

A service agency is responsible for the safe use of behaviour intervention strategies. Behaviour intervention strategies should be used as outlined in the behaviour support plan for the person with a developmental disability who has challenging behaviour and in accordance with all legal requirements.

Directive

Review committee

Reviewing and monitoring the behaviour support plan are important steps in making sure that the plan is suitable for the person and their changing needs.

In addition to the requirements set out in section 18, “Behaviour support plan”, in Ontario Regulation 299/10, a service agency shall have access to a third-party committee that reviews the behaviour support plans of person(s) with a developmental disability who have and/or may display challenging behaviour and who are receiving support from the agency, and provides advice as to whether the use of intrusive behavioural supports are:

Ethical and appropriate to the person’s needs and assessment results, based on professional guidelines and best practices
In compliance with the ministry’s requirements outlined in Ontario Regulation 299/10 of the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008 and this policy directive.

A service agency shall have policies and procedures regarding the review committee, its membership, and its roles and responsibilities.

A service agency shall ensure that the review committee includes the involvement of a clinician with expertise in supporting adults with a developmental disability who have and/or may display challenging behaviour.

A service agency shall ensure that the review committee’s findings and any recommendations are documented and provided back to the clinician that oversees the behaviour support plan.

A service agency shall review the committee’s findings and recommendations and determine how the findings and recommendations may be implemented.

Support provided by more than one agency

A service agency shall develop a procedure (which may be formalized, as in a memorandum of understanding) to address situations where a person with a developmental disability who has challenging behaviour receives support from more than one agency, in order to ensure that the strategies outlined in the behaviour support plan are carried out in a consistent manner.

Behaviour support plan

The ministry recognizes that a clinician may recommend multiple strategies to address a person’s challenging behaviour, so that he/she may live as independently as possible and be included in the community. It is expected that a behaviour support plan focuses on the least intrusive and most effective evidence-based practices (which would include positive behaviour intervention strategies). A behaviour support plan may also include intrusive behaviour intervention strategies. This policy directive sets requirements for the use of different types of intrusive behaviour intervention strategies. It is not suggested that a behaviour support plan needs to include intrusive strategies.

In addition to the requirements for a behaviour support plan and approval of a behaviour support plan containing intrusive behaviour interventions strategies, as listed in section 18, “Behaviour support plan”, of Ontario Regulation 299/10, a service agency shall ensure the following:

The behaviour support plan is developed with the involvement of the person with a developmental disability who has challenging behaviour and/or, where applicable, persons acting on behalf of the person with a developmental disability, and the plan documents their involvement
The person with a developmental disability who has challenging behaviour and/or, where applicable, persons acting on behalf of the person with a developmental disability, provides consent to the behaviour support plan and the strategies that it outlines
The clinician(s) who approved the plan includes provision for the eventual fading or elimination of intrusive behaviour intervention strategies, which may be outlined in the behaviour support plan
The agency has access to a review committee for all behaviour support plans that are developed for the person(s) with a developmental disability who have and/or may display challenging behaviour who are supported by the agency, and ensures that the behaviour support plans for the person(s) are reviewed by the committee.

See also the requirements in the Review committee section noted above and Crisis situations section.

Debriefing following restraint or secure isolation/confinement time-out

A debriefing is a time to learn from, and reflect on, the events that led up to the use of a restraint or secure isolation/confinement time-out.

In addition to the requirements set out in section 20, “Use of intrusive behaviour intervention”, in Ontario Regulation 299/10, a service agency shall adopt the following standards for debriefing after a physical restraint (including physical restraint in a crisis situation), mechanical restraint, or secure isolation/confinement time-out:

A debriefing process is conducted among all staff who were involved in the restraint or secure isolation/confinement time-out
Staff inquire of others who were in the vicinity and witnessed the restraint or secure isolation/confinement time-out (e.g., other persons with a developmental disability who are supported in the same area, visitors) as to their well-being from having witnessed the restraint
The supervisor or manager who oversees the behaviour support plan of the person with challenging behaviour who was restrained or in secure isolation/confinement time-out is made aware of the restraint or secure isolation/confinement time-out
Other staff who support the person are made aware of the restraint or secure isolation/confinement time-out (e.g., in the event of a shift change shortly after the restraint or secure isolation/confinement time-out has taken place)
A debriefing process is conducted with the individual who was restrained or in secure isolation/confinement time-out (including individuals involved in a crisis situation), as soon as he/she is able to participate, and to the extent that he/she is willing to participate. The debriefing must be structured to accommodate the person with a developmental disability’s psychological and emotional needs and cognitive capacity
Debriefings are documented
The debriefing process is conducted within a reasonable time period (i.e., within two business days) after the restraint or secure isolation/confinement time-out is carried out (including crisis situations). If circumstances do not permit a debriefing process to be conducted within a reasonable time period, the debriefing process should be conducted as soon as possible after the reasonable time period, and a record must be kept of the circumstances that prevented the debriefing process from being conducted within the reasonable time period
A serious occurrence report is filed with the Ministry of Children, Community and Social Services, as may be appropriate and as per the serious occurrence reporting procedure

Crisis situations

In addition to the requirements set out in section 21, “Crisis intervention, use of physical restraint”, of Ontario Regulation 299/10, if a person with a developmental disability experiences three crisis situations within a 12 month period, the service agency shall investigate the potential causes of the behaviour and factors that may have led to the crisis situations. This investigation may lead to a functional assessment of the individual and the development of a behaviour support plan for him/her.

Definition

“Functional assessment” is referenced in the definition of a “behaviour support plan”, which is defined in Ontario Regulation 299/10 as “a document that is based on a written functional assessment of the person that considers historical and current; biological and medical, psychological, social and environmental factors (a bio-psycho-social model) of the person with a developmental disability that outlines intervention strategies designed to focus on the development of positive behaviour, communication and adaptive skills.”

Contacting the police

A service agency may wish to contact their local police department to discuss how the agency and the police can work together to best respond to situations that may engage law enforcement in a safe and effective manner. For example:

To have preliminary discussions to plan and develop protocols that may be used to respond to adults with a developmental disability in certain situations. Agencies may be able to provide information on strategies to engage with the individual, how best to communicate, and how police can keep persons with a developmental disability and themselves safe
To request police assistance during a crisis where the physical safety of agency staff and/or others in the vicinity is at immediate risk and attempts at de-escalation and other means to address the person with challenging behaviour and/or the situation have been ineffective.

The ministry would expect that a service agency’s policies, procedures and practices concerning how to respond to people with a developmental disability who have and/or may display challenging behaviour in a crisis situation would not rely exclusively on involving the police.

The ministry understands that the police may, in some cases, be called upon to respond to complex situations that may be non-criminal in nature. It is important that a service agency explore efficient and effective ways of supporting adults with a developmental disability who have and/or display challenging behaviour, including front-line incident response, to ensure that individuals who are in crisis are receiving support and assistance from the most appropriate parties and the service provider(s). A service agency should also be mindful of the potential impact of involving the police in a crisis situation (e.g., possibly criminalizing the behaviour of an adult with a developmental disability who has/is displaying challenging behaviour).

Training for staff

Seeking to ensure that staff are properly trained and enhancing the safety of all people who receive support from the agency, regardless of whether they have and/or display challenging behaviour (either currently or in the past), is important to the security that any person would want to feel in their home, recreational space, or workspace.

Further to the requirements to train direct care staff on the use of physical restraint, as set out in section 17(2), “General behaviour intervention strategies, training”, of Ontario Regulation 299/10, a service agency shall ensure that it selects a training package from the identified list of training packages and providers which were reviewed by the Community Networks of Specialized Care Ontario. During this review, it was determined that the curriculum of these training packages, in their entirety, allow for compliance with requirements outlined in Ontario Regulation 299/10 and could enable direct care staff to respond appropriately to emergency situations involving adults with a developmental disability who are displaying challenging behaviour. A service agency shall therefore ensure that all components of the curriculum within a selected training package (both theory and practice of all physical restraint holds outlined in the curriculum) are taught to and successfully completed by all direct care staff at the agency.

Section 19 of Ontario Regulation 299/10 concerns “Behaviour intervention, strategies, policies and procedures” and requires that a service agency have policies and procedures regarding the use of behaviour intervention strategies for persons with developmental disabilities who have challenging behaviour. As part of these policies and procedures, a service agency must identify strategies and means for direct care staff to respond in a crisis situation. These policies and procedures could include a section that sets out the physical restraint holds covered in the training with staff which may be used by direct care staff during a crisis situation. These policies and procedures may be based on the profile of the individuals supported and the agency’s own philosophy of support. Regardless of a service agency’s policies and procedures, however, a service agency must ensure that all components of the training package curriculum (both theory and practice of all physical restraint holds outlined in the curriculum) are taught to and successfully completed by all direct care staff.

The training packages identified through the review process led by the Community Networks of Specialized Care Ontario^{footnote 5[5]} include information on understanding human behaviour, how to effectively support a person in a manner that allows the individual to feel safe, engaged and respected, as well as early warning signs of, and means to prevent, a crisis situation. Training packages also include information on early intervention techniques, strategies to assist a person to calm him/herself and de- escalate a situation, ways to promote personal safety (for staff and for the individual), should a crisis situation arise, as well as post care, follow-up and debriefing, subsequent to experiencing a crisis situation. The topics covered in these training modules may provide insight and important information that may be relevant to all direct care staff in various aspects of their work.

A service agency shall ensure that staff who work directly with persons with developmental disabilities receive and successfully complete all components of the refresher training, including theory and practice of all physical restraint holds, according to a retraining or recertification schedule developed by the training provider or as recommended by the training provider (e.g., a schedule identified as a best practice).

Note that the requirements above are separate from those outlined in sections 17(3), 17(4), 17(5) and 17(6) of Ontario Regulation 299/10. These sections identify requirements for a service agency concerning training for staff members and volunteers on the behaviour support plan(s) of the people whom the staff and volunteers will be supporting.

Feedback to staff on behaviour intervention

In order to ensure that the strategies contained in a behaviour support plan are effective, it is important that the supporting staff person(s) carry out the strategies as they have been outlined in the plan.

In addition to the requirements set out in section 17, “General behaviour intervention strategies, training”, of Ontario Regulation 299/10, a service agency shall ensure that:

Supervisors monitor the application and use of behaviour intervention strategies (both positive and intrusive strategies), to see that the strategies are carried out as outlined in the behaviour support plan and in accordance with best practices in the field
Supervisors ensure that feedback is provided on a regular basis to their staff on the application of behaviour intervention techniques with people who have a developmental disability with challenging behaviour, and as part of the staff person’s performance plan (e.g., the discussion about the staff person’s overall performance, held on an annual basis)

Use of restraint or secure isolation/confinement time-out – general

The ministry recognizes that restraint, secure isolation/confinement time-out, and prescribed medications are used in some situations with adults with a developmental disability who have challenging behaviour, as part of their behaviour support plan. The remaining sections of this directive focus on the ministry’s expectations for the use of intrusive behaviour strategies, which are aimed at ensuring a person’s safety and well-being during the use of restraint, secure isolation/confinement time-out, or with prescribed medication.

Definitions

“Mechanical restraint”, as an example of a type of intrusive behaviour intervention in Ontario Regulation 299/10 is “a means of controlling behaviour that involves the use of devices and equipment to restrict movement, but does not include any restraint or device:

That is worn most of the tie to prevent personal injury, such as a helmet ro prevent head injury resulting from seizures or a device to safely transport a person in a motor vehicle
That helps to position balance, such as straps to hold a person upright in a wheelchair, or
That is prescribed by a physician to aid in medical treatment, such as straps used to prevent a person from removing and intravenous tube.”

Further to the above definition, a mechanical restraint is not a device that is worn or used at points in time for protective purposes, such as mittens.

“Secure isolation or confinement time-out”, as an example of a type or intrusive behaviour intervention in Ontario Regulation 299/10, is a “designated, secure space that is used to separate or isolate the person from others and which the person is not voluntarily able to leave.” Secure isolation or confinement time-out does not refer to a space that a person may use to “cool down” when he/she feels anxious or angry, and where the person may leave freely, or an apartment where a person may live on their own.

“Prescribed medication”, as an example of an intrusive procedure or action in Ontario Regulation 299/10, is medication prescribed to “assist a person in calming themselves, with a clearly defined protocol developed by a physician as to when to administer the medication and how it is to be monitored and reviewed.”

In addition to the requirements set out in section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that the use of physical restraint, mechanical restraint, and secure isolation or confinement time-out is stopped when there may be a risk that the intervention itself will endanger the health or safety of the individual; or the supporting staff person(s) have assessed the individual and situation and have determined that there is no longer a clear and imminent risk that the individual will injure him/herself or others.

Use of secure isolation or confinement time-out rooms

In addition to the requirements set out in section 19, “Behaviour intervention, strategies and policies and procedures”, and section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that, where secure isolation/confinement time out is recommended to be used to address a person’s challenging behaviour as part of their behaviour support plan, the following performance standards and measures are adopted:

A service agency shall ensure that its written policies and procedures on the use of a secure isolation or time-out room address the following:
- Stages of interval monitoring
- Duration of time that a person may spend in secure isolation or confinement time-out, any extension periods, and the total/maximum amount of time that a person may spend in secure isolation or confinement time-out
- Protocols regarding continuous observation and monitoring of a person who is in the secure isolation or confinement time-out room
- Regular record keeping (e.g., every fifteen minutes) of secure isolation or confinement time-out room use for each person with a developmental disability who has challenging behaviour, and trend analysis for each person
- Notification of key agency staff that the secure isolation or confinement time-out room has been used, and regular report-backs to key clinicians overseeing the person’s behaviour support plan
A service agency will ensure that the physical space of the secure isolation/confinement time-out room:
- Is not used as a bedroom for a person with a developmental disability who has challenging behaviour
- Is of an adequate size for the person with a developmental disability who has challenging behaviour
- Does not contain any objects that could be used by the person to cause injury or damage to him/herself or others (i.e., staff who may enter the room)
- Is a safe area, with modifications (as appropriate) that would protect the person from self-injury
- Has means to allow for constant observation and monitoring of the person by service agency staff (e.g., a window, a video-camera)
- Is adequately illuminated so that the person inside the room may be seen
- Is adequately ventilated and heated/cooled
A service agency shall ensure that its fire escape plan includes provisions for escape from the secure isolation/confinement time-out room, in the event of an emergency.
If the secure isolation/confinement time-out room has a lock on the door to prevent the person from leaving the room, the service agency will ensure that the lock can be easily released from the outside in an emergency.

Use of mechanical restraint

In addition to the requirements set out in section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that where a mechanical restraint is recommended to be used to address a person’s challenging behaviour as part of their behaviour support plan, any apparatus or device used as part of a mechanical restraint meets all of the following standards:

It is designed and manufactured for use as a mechanical restraint
It is appropriate for use with the individual (e.g., the size of the device or apparatus is appropriate to the size and weight of the person)
It is purchased from a company that is dedicated to manufacturing such devices
It is checked by agency staff to ensure that it is in good working order at all times
It is maintained in good repair by the manufacturer or by a person or organization recommended by the manufacturer.

Use of prescribed medication

As previously noted, the Primary Care of Adults with Developmental Disabilities: Canadian Consensus Guidelines^{footnote 6[6]} and the Tools for Primary Care Providers and Tools for Caregivers^{footnote 7[7]}, are valuable resources that may be of assistance to service agencies and clinicians who support adults with a developmental disability, as well as their families or caregivers. Both documents contain specific sections on the use of prescribed medication to address challenging behaviour.

In addition to the requirements set out in section 19, “Behaviour intervention, strategies and policies and procedures”, and section 20, “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that where prescribed medication is recommended to be used to address a person’s challenging behaviour, as part of their behaviour support plan, a one-time visit to a physician, or a visit to a hospital emergency room, there is a protocol for the use of prescribed medication administered on a pro re nata (PRN) (as needed) basis only, on advice of the prescribing clinician. PRNs are not to be administered:

excessively, beyond the recommended dosage
as a punishment for the person’s behaviour, a mistake or wrongdoing
for convenience, to make it easier for staff to support the person
as a substitute for meaningful supports

A service agency shall ensure that all medication prescribed to the person with a developmental disability who has challenging behaviour is reviewed by the prescribing physician and is included in the regular review of the individual’s behaviour support plan.

Procedures not permitted

In addition to the definitions and examples of behaviour interventions set out in section 15, “Application and definitions”, of Ontario Regulation 299/10 (the quality assurance measures regulation), the following practices are never to be used by a service agency in addressing the challenging behaviour of a person with a developmental disability:

Mistreatment of the person – mistreatment could include but is not necessarily limited to physical or corporal punishment, such as punching, slapping, or pulling hair; abandonment or segregation, rough handling, ridicule, humiliation, or name-calling
Noxious stimulus – people shall not be subjected to harmful or offensive odours or liquids as a form of punishment or discipline, such as a spray of lemon juice, drops of Tabasco sauce, or pepper
Deprivation of basic human needs – people shall not be deprived of basic human needs, including food, adequate clothing, and adequate heat and cooling; access to health care, suitable shelter and safety; or reasonable access to family members (if desired by the individual), as part of a behaviour intervention strategy.

Definition

“Segregation” is the act of setting a person apart from others in the general vicinity, in the scenario considered above, for the purposes of punishing the person. It is not considered part of the definition of “secure isolation or confinement time-out”. As with the definition of “secure isolation or confinement time-out, segregation does not refer to a space that a person may use to “cool down” when he/she feels anxious or angry, and where the person may leave freely, or an apartment where the person may live on their own.

Monitoring

This standard is further to section 20(3), “Use of intrusive behaviour intervention”, of Ontario Regulation 299/10, a service agency shall ensure that there are protocols in place that must be followed in monitoring and assessing the condition of the person with a developmental disability during the use of intrusive behaviour intervention. These protocols may differ, depending on the type of intrusive intervention, and on the individual and their needs.

A service agency or the clinician who oversees the behaviour support plan must ensure that there are safeguards to prevent misuse of intrusive behaviour intervention.

A service agency shall have a means to record and track intrusive behaviour intervention procedures for the purpose of review and analysis.

When applicable, a service agency shall file a serious occurrence report with the Ministry of Children, Community and Social Services (e.g., in an instance where a person becomes seriously injured, or an instance where allegations of mistreatment emerge).

Notification of the use of behaviour intervention

In addition to the requirements set out in section 19, “Behaviour intervention, strategies and policies and procedures”, of Ontario Regulation 299/10, a service agency shall have policies and procedures regarding the notification of persons (a “contact person”) acting on behalf of the individual with a developmental disability who has challenging behaviour. The policies and procedures shall consider an individual’s ability to provide consent regarding notification, and shall address:

Whether and/or under what circumstances the agency would notify the contact person of the use of intrusive behaviour intervention with the individual, where the intrusive behaviour intervention is outlined in the individual’s behaviour support plan
Regular updates on the use of intrusive behaviour intervention with the individual to the contact person, when the behaviour support plan does not specify that each use of intrusive behaviour intervention be communicated to the contact person; and
Notifying the contact person of the use of a physical restraint with the individual, in a crisis situation

3.0 Posting letter of compliance or letter of non-compliance

Applicable to: All service agencies that receive funding under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008 from the Ministry of Community and Social Services to provide adult developmental services and supports.

Legislative authority: Section 7(1)1

Effective date: January 25, 2016

Introduction

The Ministry of Community and Social Services’ (MCSS) Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008 (SIPDDA) provides the legislative framework for ministry-funded adult developmental services in Ontario. The regulation on quality assurance measures (Ontario Regulation 299/10), made under the Act, and the Policy Directives for Service Agencies and Policy Directives for Application Entities set out further requirements for agencies and application entities (operating as Developmental Services Ontario (DSO).

The ministry conducts compliance inspections of MCSS-funded service agencies and DSOs, to assess whether they meet the requirements outlined in the regulation on quality assurance measures and the policy directives. During a compliance inspection, the ministry typically reviews records and documentation, policies and procedures, and conducts a site inspection, to evaluate and determine whether service agencies and DSOs are adhering to the requirements that are set out in the regulation on quality assurance measures (Ontario Regulation 299/10), made under SIPDDA, and the policy directives. At the end of the inspection, ministry staff issue a letter to the agency/DSO that outlines the agency’s/DSO’s compliance status.

The ministry recognizes that people who access developmental services and supports, their families and others who may act on their behalf, and the general public, likely expect that MCSS-funded services and supports are provided in a sufficiently safe environment that seeks to meet the needs of the individual. There is also an expectation that the agency/DSO is meeting the requirements set out by the ministry. The ministry acknowledges the need for openness and transparency of information. Requiring that developmental services agencies and DSO offices provide information on the outcome of a compliance inspection of an agency or DSO is one such way to promote openness and transparency.

Definitions

“Letter of Compliance” is a letter that is issued by the Ministry of Community and Social Services to a service agency or DSO, following the ministry’s review and evaluation of the service agency’s or DSO’s ability to meet requirements that are outlined in the regulation on quality assurance measures (Ontario Regulation 299/10, made under SIPDDA) and the Policy Directives for Service Agencies or Policy Directives for Application Entities. The Letter of Compliance summarizes the results of the compliance inspection and confirms that the agency or DSOs is in compliance with requirements.

“Letter of Non-compliance” is a letter that is issued by the Ministry of Community and Social Services to a service agency or DSOs, following the ministry’s review and evaluation of the service agency’s or DSO’s ability to meet requirements that are outlined in the regulation on quality assurance measures (Ontario Regulation 299/10, made under SIPDDA) and the Policy Directives for Service Agencies or Policy Directives for Application Entities. The Letter of Non-compliance summarizes the results of the compliance inspection, and confirms there are areas of non-compliance and may identify the non-compliances that must be remedied within specified timelines.

Purpose

The purpose of this policy directive is to outline the Ministry of Community and Social Services’ requirements for service agencies regarding the public posting of the results of an agency compliance inspection conducted by the ministry. These requirements aim to promote public access to information about MCSS-funded services and supports and the providers of those services and supports.

The ministry also requires DSOs to publicly post the results of their compliance inspections.

Directive

A service agency shall post a hard/paper copy of the Letter of Compliance that is issued by the ministry following a compliance inspection. The Letter of Compliance shall be posted at or near the main entrance of the head office of the service agency in a prominent location of that office so that the letter is clearly and easily visible to those who enter. The Letter of Compliance shall remain posted until the completion of a subsequent compliance inspection.

A service agency shall post a hard/paper copy of the Letter of Non-compliance that is issued by the ministry if the service agency remains in non-compliance post 10 business days of the compliance inspection. The Letter of Non-compliance shall be posted at or near the main entrance of the head office of the service agency in a prominent location of the office so that the letter is clearly and easily visible to those who enter. The Letter of Non-compliance shall remain posted until the agency receives a Letter of Compliance.

A service agency shall ensure that the most recent Letter of Compliance or Letter of Non-compliance is posted within three business days of receipt from the ministry.

A service agency shall provide information on its current compliance status and the results of its ministry compliance inspection, if requested by any person.

A service agency shall respond to inquiries about the compliance status that may be received (e.g., from an individual with a developmental disability who receives services and supports from the agency, from a person acting on behalf of the individual who receives services and supports from the agency, or from the general public).

For service agencies that are funded by the ministry to provide adult developmental services and supports at multiple sites/locations, the agency shall ensure that a copy of the Letter of Compliance or Letter of Non-compliance related to each residence and/or community participation program location is available upon request from the agency’s head office. A copy of the letter need not be posted at each site/location owned or operated by the agency; however, the agency is expected to respond to any questions about the compliance or non-compliance of any site (e.g., a supported group living residence, a community participation support program).

In addition to posting a hard/paper copy of the Letter of Compliance or Letter of Non-compliance, a service agency is encouraged to post an electronic copy of the Letter on its website, if available, although this is not required.

Updated: May 24, 2023

Published: June 07, 2021

Footnotes

footnote[1] Back to paragraph Bradley, E & Developmental Disabilities Primary Care Initiative Co-editors (2011). Initial Management of Behavioural Crises in Family Medicine (PDF), © 2011 Surrey Place Centre.
footnote[2] Back to paragraph Condillac, Rosemary A. “Behavioural Intervention and Developmental Disabilities” in I. Brown and M. Percy (Eds) Developmental Disabilities in Ontario. 2^nd ed. (407-419). Toronto: Ontario Association on Developmental Disabilities; 2003.
footnote[3] Back to paragraph Intellectual and Developmental Disabilities: Canadian Consensus Guidelines, written by Dr. William F. Sullivan et al., and the associated Tools for Primary Care Providers
footnote[4] Back to paragraph Tools for Caregivers, by the Developmental Disabilities Primary Care Initiative, are valuable resources in assisting physicians, primary care providers, service agencies, and families or caregivers in assessing the behaviour of a person with a developmental disability.
footnote[5] Back to paragraph This list is available on the MCCSS website. Further detail on the training packages is available in the “Final Summary of Findings” document
footnote[6] Back to paragraph Dr. William F. Sullivan et al.: Primary care of adults with intellectual and developmental disabilities, 2018 Canadian consensus guidelines (PDF)
footnote[7] Back to paragraph Developmental Disabilities Primary Care Initiative.