Policies and Procedures

INTRODUCTION

POLICY

The Policies and Procedures Manual contains general statements of Agency Policy and should not be read as including the fine details of each policy, nor as forming an expressed or implied contract, nor as promising that the policies discussed in it will be applied in all cases.

The Agency reserves the right to add to the policies, revoke or modify them from time to time.

PROCEDURE

As used in this Manual the word "will" is to be construed as mandatory and the word "may" as permissive and the masculine gender will be construed to include the feminine gender and vice versa.

Staff having questions about the Policies and Procedures Manual should consult their immediate Supervisor.

Mission Statement, Vision Statement and Values and Beliefs

Glossary of Terms 

Acronyms

Governance Policies
                       
Table of Contents

Definitions

1. Board Governance

1.1 Governing Style
1.2 Board Schedule
1.3 Board Role Description
1.4 Board Composition
1.5 Individual Responsibilities of Board Members
1.6 Board of Director’s Code of Conduct
1.7 Executive Officer Roles
1.8 Committee Principles
1.9 Role of Committee Chairs
1.10 Board of Director’s Organizational Chart

2.0 Executive Director’s Role
2.1 Executive Director Limitations
2.2 Executive Director’s Communication to the Board
2.3 Executive Director’s Responsibilities to Clients and Community
2.4 Executive Director’s Responsibilities for Staff and Volunteers
2.5 Financial Planning and Budgeting
2.6 Financial Condition
2.7 Asset Management
2.8 Coverage for Absence or Loss of Executive Director

3.0 Board and Executive Director Relationship
3.1 Delegation to the Executive Director
3.2 Executive Director Job Description
3.3 Monitoring of Executive Director Performance

4.0 General
4.1 Staff Access to Board of Directors
4.2 Board Linkages
4.3 Board Monitoring of the Agency
4.4 Board Retention and Disposal of Documents

Appendices

1. Program Committee – Terms of Reference
2. Resources Committee – Terms of Reference
3. Board Member Orientation Manual

Planning 1
                                               
1-10 Quality Improvement

Appendices

            Addendums:
            1A  Planning and Evaluation, Program Plan
            1B  Planning and Evaluation, Treatment/Action Plan
            2    SWOT Analysis
            3    Program Evaluation Measurement Methods
            4    Activity Evaluation Questions
            5    Outcome Evaluation Questions
            6    Qualitative Interview Questions   
            7    Final Evaluation Report Template

2.Client File Audit Checklist

Documenting 2
                                               
2-10      Policies and Procedures Manual
2-20      Filing System
2-30      Minutes
2-40      Client Files
2-50      Case Notes
2-60      Retention/Disposal of Client Files
2-70      Client Access to Client File
2-80      Client Statistical Data
2-90      Log Book
2-100    Incident Reports
2-110    Serious Occurrences
2-110.1 Serious Occurrences - Children’s Residential and Mental Health
2-110.2 Serious Occurrences – Youth Justice Programs

Appendices

1. Order of Assembly – Client Files
2. Client File Audit Checklist
3. Client Incident Report
4. Non-Client Related Incident Report
5. Serious Occurrence Report Tracking and Quality Assurance Sheet - Children’s Residential/Children’s Mental Health
6. Serious Occurrence Report Tracking and Quality Assurance Sheet - Youth Justice

Regulations 3

3-10      Legal Entity/Charter
3-20      Government Codes
3-30      Staff Handbook
3-40      Personal Information Protection
3-50      Risk Management
3-60      Fire and Emergency Evacuation Procedures
3-70      Health and Safety Compliance
3-80      Human Resources Policy
3-90      Contracts
3-100    Insurance         
 
Appendices

1. Notice to Clients – Personal Health Information Protection Act  (PHIPA)
2. Emergency Response Policy
   2a. Contact Telephone List
   2b. Pandemic Plan

3. Staff Handbook – Residential, Generic Section
4. Staff Handbook --Addendum Youth Resource Centre (YRC)
5. Staff Handbook-- Addendum Varency Home (VH)
6. Staff Handbook – Addendum Buffalo Street Residence (BSR)
7. Staff Handbook – Addendum Chatham Street Residence (CSR)
8. Non Residential Staff Handbook

Finances 4

4-10     Overview
4-20     Signing Officers/Authority
4-30     Finance Department Staff Coverage
4-40     Annual Audit
4-50     Charity Returns
4-60     General Ledger System
4-70     Internal Financial Statements
4-80     Allocated Central Administration
4-90     Budgets
                        Operating Budgets
                        Capital and Training Budgets
4-100   Electronic Banking
4-110   Records Retention
4-120   Computer Network Security and Backup
                        Security
                        Additional Server/Data Security
4-130   Bank Reconciliation
4-140   Food Inventory
4-150   Capital Assets Inventory
4-160   Agency Vehicle – Licensing, Insurance
4-170   Investments
4-180   Insurance
4-190   Income/Receivables/Receipts
4-200   Donations and Fundraising
4-210   Purchases/Payables/Payments
                        Purchase Orders
                        Receipt of Goods and Services
                        Processing Accounts Payable
                        Cheque Requisitions
                        Advances
                        Petty Cash                  
4-220   Agency Credit Cards
4-230   Staff Travel Expenses
4-240  Goods and Services Tax (GST)
4-250  Payroll and Benefits
                        Mandatory Reporting and Filing Requirements
                        Registered Pension Plan (RRP)
                        Registered Retirement Savings Plan (RRSP)
                        Benefit Plan
                        Vision Care
                        Fitness Membership   
           
Appendices

1. Bank Reconciliation
2. Food Inventory Reconciliation
3. Invoice – Sample
4. Charitable Donation Receipt
5. Purchase Order
6. Cheque Requisition
7. Petty Cash Summary
8. Petty Cash Voucher
9. Visa Summary
10. Staff Expense Report

Facilities 5

5-10     Physical Facilities
5-20     Building and Property
5-21     Electronic Surveillance
5-30     Keys
5-40     Fire Alarms, Smoke/Heat Detectors and Carbon Monoxide Detectors
5-50     First Aid Kits
5-60     Smoking Areas
5-70     Storage
5-80     Proper Transportation, Refilling and Storage of Propane Tanks and Cylinders
5-90   Waste Reduction

Appendix

1. Alvio Property Award Terms of Reference

Human Resources 6

6-10       Philosophy
6-20       Introduction
6-30       Organizational Chart
6-40       Employment of Staff
6-50       Staff Transfer Policy
6-60       Service Contracts
6-70       Hiring (Nepotism)
6-80       Hiring –Clients and Ex-Clients
6-90       Categories of Employment
6-100     Permanent Full-time
6-110     Permanent Part –time
6-120     Temporary Full-time
6-130     Temporary Part-time
6-140     Part time Pool
6-150     Professional Qualifications
6-160     Licences, Certification or Registration
6-170     Professional Associations
6-180     Fees for Professional Registrations or Memberships
6-190     Medical Examinations
6-200     Staff Identification Cards
6-210     Probationary Period
6-220     Staff Orientation
6-230     Student Recruitment, Selection and Orientation
6-240     Volunteer Recruitment, Selection and Orientation
6-250     Staff Supervision
6-260     Inservice Training
6-270     Professional Development
6-280     Performance Evaluations
6-290     Annual Staff Declaration
6-300     Human Resources Files
6-310     Staff Access to Human Resources Files
6-320     Job Descriptions
6-330     Job Values
6-340     Bands
6-350     Job Rate Levels
6-360     Job Rates
6-370     Hours of Work
6-380     Location of Work
6-390     Benefits
6-400     Holidays
6-410     Vacation Leave
6-420     Vacation Pay – Part time Staff
6-430     Payment of Salaries
6-440     Compulsory Deductions
6-450     Staff Fund
6-460     Travel Expense
6-470     Pregnancy/Parental Leave
6-480     Sick Leave
6-490     Personal Day
6-500     Compassionate Leave
6-501     Jury Duty Leave
6-510     Unpaid Leaves
6-520     Unpaid Compassionate Leave
6-530     Unpaid Emergency Leave
6-540     Unpaid Leave of Absence
6-550     Grievance Procedures
6-560     Code Of Conduct (Word format) Code Of Conduct (pdf format)
6-570     Productive Work Environment (Harassment)
6-580     Productive Work Environment (Bullying)
6-590     Productive Work Environment (Workplace Violence Prevention)
6-600     Staff Meetings
6-610     Cross Functional Teams
6-620     Role of the Chair
6-630     Years of Service Awards
6-631     Years of Service Payment
6-640     Staff Use of Electronic Technology
6-650     Disciplinary Procedures
6-660     Investigation of Complaints About Staff
6-670     Suspensions
6-680     Smoking
6-690     Staff Legal Counsel
6-700     Alcohol Policy
6-710     Staff Security
6-720     Health and Safety
6-730     Early and Safe Return to Work
6-740     Safe Driving
6-750     HIV/AIDS
6-760     Treatment of Human Bite or Needle Stick
6-770     Hepatitis B
6-771     Universal Precautions
6-772     N-95 Respirator Fit-Testing
6-780     Resignations
6-790     Layoffs
6-800     Termination
6-810     Retirement
6-820     Exit Interview
6-830     Employment Reference

Appendices

1. Recruitment and Selection Manual and 1a) Application Form
2. Minimum Qualifications
3. Police Check Request Form            
4. Medical Examination Form 
5. Immunization Waiver
6. Written Acceptance Form
7. Staff Confidentiality Agreement
8. Staff Fund Deduction Acknowledgment Form
9. Staff Orientation Checklist
10. Staff  Supervision Model
11. Group Insurance Benefits Authorization
12. Health and Safety Policy Statement
13. Vehicle Inspection Log
14. Staff Training Log
15. Early and Safe Return to Work Communication Log
16. .....
17. Agreement to Work Excess Hours
18. Vacation Request Form
19. a) Flextime Sheet, b) Overtime Sheet, c) Overtime Agreement
20. Transfer Request Form
21. Request for Leave
22. Continuation of Pension Benefits During ESA (2000) Leaves
23. Tuition and Books – Promissory Note
24. Contractor’s Agreement
25. Service Confidentiality Agreement
26. Accreditation Team – Terms of Reference
27. Client Service Team – Terms of Reference
28. Health and Wellness Team- Terms of Reference
29. Internal Communications Team – Terms of Reference
30. James Roxburgh Award for Employee of the Year - Terms of Reference
31. Job Valuation Team – Terms of Reference
32. Management Team - Terms of Reference
33. Marketing Team – Terms of Reference
34. Multi-Workplace Joint Health and Safety Committee – Terms of Reference
35. PMAB Trainers Committee – Terms of Reference
36. Supervision Training Committee – Terms of Reference
37. Staff Resignation/Termination Checklist
38. Exit Interview
39. Facilitator Feedback Form
40. Annual Professional Development Proposal
    40.1 Annual Professional Development Proposal Assessment
    
41. Health Screening Tool (Non-Disclosure) for Disposable Particulate Respirators
    
42. Report of Health Assessment for Respirator Use
    
    

Internal Communications 7

7-10     Management Meetings
7-20     Staff Meetings         
7-30     Internal Reports
7-40     Staff Supervision Model

Community Relations 8

8-10     Community Relations Philosophy
8-20     Meetings, Conferences, Associations
8-30     Co-operation with Government and Outside Agencies
8-40     Neighbours      
8-50     Client Community Resources

Marketing  9

9-10     Mission/Vision/Values and Beliefs//Programs        
9-20     Annual General Meeting
9-30     Annual Report
9-40     Public Awareness       
9-50     Public Enquiries      
9-60     Media Relations

            Appendices

1. Client Media Consent/ Release Form
2. Media Acknowledgement Form
3. YCJA Media Release Form
4. Graphics Standards Manual

Client Service 10

10-10   Services and Programs 
10-20   Accessibility
10-30   Diversity 
10-40   Client Service Model

Addendum

1a) Client File
1b) Downloadable Interview Guides
2 Client Strengths List
3 Strength Based Interview Guide
4 Rights and Responsibilities for Standardized Assessment
5 Accessing Psychological Services
6 Accessing Agency Child Psychiatric Services
7 Accessing Child Psychiatric Services Without a Physician Referral for Youth Aged 16 to 18
8 Access to Emergency Psychiatric Consultation/Assessment for Clients Aged 16 and up.
9 Community Protocol
           
             Forms:

A Consent to the Provision of Psychiatric Consultation via Interactive Video Link
B Consent to Disclose Personal Health Information Pursuant to the Personal Health  Information Protection Act 2004 (PHIPA)
C Information about your Telepsychiatry Consultation
D Referral Sheet
E Additional Consultation Form

10 Indirect Consultation

10-50   Client Handbook
10-60   Staff Awareness of Client Needs and Rights
10-70   Wait List
10-80   Consent to Service
10-90   Client Consent to Release/Obtain Information
10-100 Intra-Agency Protocol – Mental Health Crisis Support
10-110 First Aid and CPR              
10-120 Child Abuse
10-130 Behaviour Management and Discipline
10-140 Prevention and Management of Aggressive Behaviour PMAB
10-150 Suicidal Behaviour
10-160 Client Complaints
10-170 Third Party Disclosure
10-180 Group Programs
10-190 Respite
10-200 Community Consultation
10-210 Research and Distribution of Research Material and Journals
10-220 General Water Activity Recreation
10-230 Wilderness Camping
10-240 Ex-Clients
10-250 Agency Program Directory

            Appendices

1. Client Handbook
2. Consent to Service and Statement of Confidentiality and Limits of Confidentiality
3. Consent To Release Information
4. Consent To Obtain Information
5. Service Confidentiality Agreement
6. Client Notification of Wait List Status   
7. Wait List Letter - Youth
8. Wait List Letter – Parent
9. Youth Information Update    
10. Child Information Update
11. Client Complaint Form
12. Client Swim Test Results
13. Suicide Watch Information Exchange