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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 DSO 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 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 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.