Accountability Supports for Addiction and Mental Health Providers

In December, 2003 the Ministry of Health and Long-Term Care (MOHLTC) released its Operating Manual for Mental Health and Addiction Treatment Services. That manual was written to help Transfer Payment Agencies deliver effective services, and to serve as a resource for managers and Boards in the day to day operation of their programs. At the same time, it specified ninety “Mandatory Requirements” for MOHLTC transfer payment agencies.

In 2004, the Federation determined that a companion document was required – one designed to help community mental health and addiction programs meet the standards and accountability requirements detailed in the Operating Manual. To that end, the Federation applied for funding from the MOHLTC to develop a comprehensive policy and procedures manual for addiction and mental health providers. Johnston Consulting was hired to develop that document.

To order a printed copy or a CD of the "Accountability Supports for Addiction and Mental Health Providers" document, please complete the order form and return it with payment to the Federation office.  Thank you.


Note: Mandatory Requirements (MRs) have been summarized here in the interest of brevity.  See MOHLTC's Operating Manual for exact wording.

Chapter 1: Organizational Components

MR1. All sponsored mental health and/or addiction agencies (i.e. programs sponsored by a larger multi-service provider, such as a hospital) are required to have an advisory committee, made up of people in the community with expertise in mental health or addiction services.

MR2. The Advisory Committee is accountable and reports directly to the Board of Directors.

MR3. If the Board of a sponsored agency decides not to follow the Advisory Committee’s advice when developing its operating plan, it must include a written explanation of its decision.

MR4. Mental health agencies must have former clients and family members on the Board of Directors.

MR5. Board members of non-profit organizations are volunteers, and must not be paid for their services.

MR6. All agencies must comply with relevant employment and human rights legislation. All agencies that are unionized must also comply any requirements in their collective agreements.

MR7. All policies must be consistent with the Ontario Human Rights Code and existing collective agreements.

MR8. Agencies must make every effort to avoid conflict of interest.

MR9. Agencies must have a dispute resolution mechanism and a grievances/complaint reporting process for staff and clients.

Chapter 2: Program and Administrative Components

Agencies must develop and maintain an up-to-date policies and procedures manual.

MR11. All mental health and addiction agencies funded by the MOHLTC must sign a Transfer Payment Agreement.

MR12. Agencies cannot make changes to their programs, operating plans or budgets without written permission from the Ministry.

MR13. All mental health or addiction agencies funded by the MOHLTC must submit an operating plan annually, or as requested by the Ministry.

MR14. Agencies must use the MOHLTC package, Operating Plan Guidelines and Other Reporting Requirements.

MR15. If the agency’s Operating Plan is proposing any significant changes to the agency’s operation, the agency must also submit a rationale for the change as well as evidence of support from relevant local agencies.

MR16. Agencies must use MOHLTC funds to provide service only to people who are residents of Ontario.

MR17. As part of the Operating Plan process, agencies will identify their target population(s), the rationale for serving that population and the services provided.

MR18. Substance abuse agencies must use MOHTC service definitions.

MR19. Agencies must develop and use admission, discharge and referral policies which reflect provincial criteria.

MR20. Substance abuse agencies must use the common assessment tools. Problem Gambling agencies must use SOGS. Child and adolescent services must use BCFPI and CAFAS. Other mental health agencies should establish their own assessments.

MR21. When an agency cannot meet a client’s needs, the client must be redirected to another appropriate community agency or service.

MR22. Problem gambling agencies must have a plan in place to ensure appropriate client services are available during holidays/sick time.

MR23. Mental health and addiction agencies are expected to have a waiting list policy.

MR24. Addiction agencies must keep DART informed about the status of their waiting lists.

MR25. Agencies must have a code of ethics.

MR26. Agencies must have a client complaint/dispute resolution process.

MR27. Agencies must maintain up-to-date client files.

MR28. Sponsored agencies must comply with the sponsoring agency’s legal requirements for record keeping.

MR29. Agencies that keep client information on audio or video tape must have procedures for handling those tapes.

MR30. Agencies must develop policies and procedures to ensure client information is kept confidential.

MR31. Board members, staff, volunteers and clients/substitute decision makers are required to sign a confidentiality agreement or consent-to-counseling form.

MR32. Agencies must have policies to guide staff when they are required to disclose information.

MR33. Agencies must have release of info form for clients/substitute decision makers.

MR34. Agencies must gather and maintain statistics on service availability, capacity and utilization.

MR35. Any change to services agreed to in the OP must be approved in writing by MOH before being implemented.

MR36. Substance abuse and problem gambling agencies must also report any service changes to DART or OPGH.

MR37. Mental health services funded under the ACTT program are required to sign specific TPA which outlines provincial standards for service delivery and reporting requirements.

MR38. Mental health agencies that provide employment supports must complete EAPD report.

MR39. All addiction services must participate in the Drug and Alcohol Registry of Treatment (DART) or the Ontario Problem Gambling Helpline (OPGH).

MR40. All addiction agencies must participate in the Drug and Alcohol Treatment information Systems (DATIS).

MR41. Agencies may not deny service to clients who refuse consent to provide personal info for DATIS.

MR42. Agencies that receive MOH funding to support public communications, promotion or education must develop a communications plan as part of their operating plan submission.

MR43. Agencies developing communications products and services costing more than $25,000 or public info or education campaigns targeting more than 20,000 must submit a communication plan section with their Operating Plan.

MR44. Agencies must acknowledge support of the Government of Ontario in all publicly distributed reports, materials, advertising and publicity. Use of the Trillium logo is subject to approval of the Ministry’s communication director. MOHLTC funding cannot be used to support lobbying activities. The Ministry’s name should not appear on communications materials intended to support lobbying activities.

MR45. Agencies must report any planned or unplanned disruption in services to MOHLTC immediately.

MR46. Agencies must provide the MOH with a list of emergency contact ##, and to keep the list up to date.

MR47. Agencies must have an internal process of quality improvement, including program evaluation.

MR48. MH and Add agencies must establish and maintain effective, efficient administrative policies and procedures that comply with all legal requirements and reflect accepted standards.

MR49. Agencies must maintain appropriate filing systems and demonstrate due diligence in keeping files secure and confidential.

MR50. Agencies must have appropriate commercial general liability and counselors’ errors and omissions insurance at the minimum amounts specified in the Transfer Payment Agreement.

MR51. Agencies must comply with all relevant workplace legislation –WSIB or Employers Liability and Voluntary Compensation, WHMIS.

MR52. Agencies must have emergency plans in place.

MR53. Agencies wishing to merge, amalgamate or transfer a program must make a formal joint proposal to the MOH.

MR54. The merger/amalgamation of MH agencies must support the strategic directions in Making it Happen, and recommendations from the Task Forces and/or the Rationalization Project

MR55. The merger/amalgamation of add agencies must reflect strategic direction in Setting the Course, and provide information summarized in Appendix 7.

MR56. Agencies involved in merger/amalgamation must provide the MOHLTC with copies of updated agency documentation (e.g. letters patent).

MR57. Agencies must have MOHLTC approval to close and must provide at least 60 days notice.

MR58. Agencies must inform MOHLTC about any planned program move or relocation within their catchment area, and demonstrate that it can manage the rental costs within its existing budget.

MR59. If the relocation will move the agency out of the catchment area and affect existing clients and services, agencies must submit a request for MOH approval.

Chapter 3: Financial Record Keeping and Reporting Requirements

MR60. Agencies must prepare an annual operating budget as part of the operating plan.

MR61. Agencies may not use MOHLTC funds or fixed assets purchased with MOH funds as collateral without the prior written consent of the MOHLTC.

MR62. Sessional fees can only be used for the seven types of indirect services listed on the Semi-Annual and Annual Psychiatric Sessional Fee Report.

MR63. If agencies are generating income from assets or services already funded 100% by the Ministry, they are either required to use the funds to support MOHLTC funded programs or to repay the MOHLTC.

MR64. Agencies must keep all funds in interest bearing accounts as long as that doesn’t cause any financial loss. Interest earned on MOHLTC funds must be reported.

MR65. Agencies may use interest income earned on MOHLTC funds to support ministry-funded activities within the same fiscal year, but must first obtain MOHLTC approval in writing.

MR66. MOHLTC funds cannot be used to support fundraising activities. Any fundraised $$ must be accounted for separately on the agency’s audited financial statement.

MR67. Agencies should establish a policy for gifts to staff or board.

MR68. Agencies may not charge fees for any client services funded by the MOHLTC.

MR69. Agencies must obtain written approval from the MOH LTC before charging clients any fees for unfunded service.

MR70. Agencies must report any income generated from renting space paid for by the MOHLTC on the “rental fees” line in the Comparative Statement of Revenue and Expenditure Settlement Form.

MR71. Agencies that receive funding from other players to run distinct programs out of an MOH LTC funded program must report all income from these sources.

MR72. All unspent funds are the property of the government and are returned to government at the end of the fiscal year.

MR73. Requests to use unspent/surplus funds must be made in writing to the MOH LTC and submitted no later than January 31 of the current fiscal year.

MR74. Unspent funds cannot be carried forward from one year to the next.

MR75. MOHLTC operating funds cannot be used for specified purposes.

MR76. Agencies must have internal financial controls designed to ensure financial integrity.

MR77. Boards have a fiduciary responsibility to ensure the agency’s financial integrity and will adopt specified procedures.

MR78. Agencies are expected to use a competitive purchasing process and document it.

MR79. Agencies must seek MOHLTC approval in writing for capital purchases over $5,000, to request at least 3 quotes and keep quotes on file. If the agency doesn’t use competitive process, it must include in its request the justification for purchasing from the supplier

MR80. Agencies must maintain an up to date inventory of all furniture, fixtures and equipment purchased with MOHLTC funds, which are valued at more than $1,000.

MR81. Employees or Board members claiming expenses must use the agency’s standard claim form and attach original receipts. Travel forms should include the date of travel, the destination, purpose and distance/cost of travel. Agencies will not reimburse expenses without approval.

MR82. Agencies must have a policy/procedure for managing petty cash.

MR83. Agencies must keep accurate employment/H.R. records which will form the basis for compensating employees and identifying HR issues. Agencies will use an attendance reporting system to maintain records.

MR84. Agencies that want to change the number of FTEs in the operating plan must have approval.

MR85. All property purchased with MOH funds are the property of the agency and must be used only for the benefit of program participants. Agencies must seek MOHLTC approval in writing before selling, changing the use of, or disposing of any property or asset purchased with MOHLTC funds, with a purchase price of $1,000 or more.

MR86. Agencies that receive funding from more than one source must allocate expenses appropriately to each funding source, keep separate records for MOHLTC funding, and report separately on their use of MOHLTC funds

MR87. Agencies must provide mid-year operating reports that explain any significant variances.

MR88. All independent agencies will provide an agency non-consolidated audited financial statement, and a management letter, signed by the Auditor, by Aug 1 of the next fiscal year.

MR89. Agencies delivering program gambling programs must file separate settlements forms using the unique program number assigned for problem gambling

MR90. The agency agrees to co-operate fully with any ministry-initiated financial review

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