This section describes the complaint and appeal processes to be followed by the Community Care Access Centre (CCAC) with respect to decisions regarding the provision of community services and admission to a long-term care (LTC) home.
10.1 Complaint Resolution – Community Services
The Long Term Care Act, 1994 (LTCA) provides that the CCAC must establish a process for reviewing complaints regarding the provision of community services. Section 39 of the LTCA states:
s. 39(1) An approved agency shall establish a process for reviewing complaints made to it by a person about any of the following matters:
1. A decision by the approved agency that the person is not eligible to receive a particular community service.
2. A decision by the approved agency to exclude a particular community service from the person’s plan of service.
3. A decision by the approved agency respecting the amount of any particular community service to be included in the person’s plan of service.
4. A decision by the approved agency to terminate the provision of a community service to the person.
5. The quality of a community service provided to the person or arranged for the person by the approved agency.
6. An alleged violation by the approved agency of any of the person’s rights set out in subsection 3 (1).
Complaint under par. 5 or 6 of subs. (1)
s. 39(2) Within 60 days after a complaint is made to an approved agency about a matter referred to in paragraph 5 or 6 of subsection (1), the approved agency shall review the complaint and respond to the person who made the complaint.
Complaint under par. 1, 2, 3 or 4 of subs. (1)
s. 39(3) Within 60 days after a complaint is made to an approved agency about a decision referred to in paragraph 1, 2, 3 or 4 of subsection (1), the approved agency shall,
(a) affirm the decision and give a written notice of the affirmation to the persons referred to in subsection (4);
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(b) rescind the decision and give a written notice of the rescission to the persons referred to in subsection (4); or
(c) rescind the decision, substitute a new decision in its place and give a copy of the new decision to the persons referred to in subsection (4).
Who must be given notice
s. 39(4) A notice under clause (3) (a) or (b) or a copy of a decision under clause (3) (c) shall be given,
(a) to the person to whom the decision relates; and
(b) if the person to whom the decision relates is mentally incapable, to the person who is lawfully authorized to make a decision on his or her behalf concerning the community service.
The CCAC must have a formal written process, approved by the board of directors, for receiving, reviewing and responding to complaints regarding community. The CCAC must review all complaints in accordance with section 39 of the LTCA.
A complaint may be made to the CCAC by the person affected by the CCAC’s decision or their substitute decision-maker. Complaints may also be made regarding CCAC services directly to the Ministry of Health and Long-Term Care (MOHLTC).
10.1.1 Decisions for Which the CCAC Must Have a Complaint Review Process
Pursuant to subsection 39(1) of the LTCA, the CCAC must establish a process for reviewing complaints made to it by a person about any of the following matters:• a decision by the CCAC that the person is not eligible to receive a particular community service;
• a decision by the CCAC to exclude a particular community service from the person's plan of service;
• a decision by the CCAC respecting the amount of any particular community service to be included in the person's plan of service;
• a decision by the CCAC to terminate the provision of a community service to the person;
• the quality of a community service provided to the person or arranged for the person by the CCAC; or
• an alleged violation by the CCAC of any of the person's rights set out in subsection 3(1).
(See the Bill of Rights for people receiving community services in subsection 3(1) of the LTCA or subsection #2.2.1 in this manual.)
10.1.2 Documentation Relating to Complaints
The CCAC must maintain a written record of all complaints concerning the above matters including the following information:
• name of the person who is the subject of the complaint;
• name of the person who is making the complaint, if it is different than the person who is the subject of the complaint;
• date of the complaint;
• substance of the complaint;
• review taken;
• outcome of the review;
• decision made and/or action taken;
• date of the decision and/or action taken;
• date feedback was provided to the person or his or her substitute decision-maker;
• reaction to the feedback;
• any follow-up action required; and
• monitoring plan if required.
10.1.3 Steps to Review a Complaint
The CCAC must implement a complaint review process which includes, but is not limited to, the following steps:
Clarifying the Complaint
The CCAC must listen to the person’s concerns, asking questions to obtain details (What happened? When and where did it happen? Who was involved?) and attempt to bring all parties to a consensus on the exact identification of the problem.
Early Resolution Through Information Exchange
It is possible that a complaint has been made as one or both parties have not clearly understood a particular situation. In addition, the complainant or the CCAC may have additional
information that may affect the outcome of the complaint. The CCAC must attempt to solicit all relevant and appropriate information that may result in the resolution of the complaint.
Clarifying the Process
If the complaint is not resolved at an early stage, the CCAC must:
• determine whether the complainant wishes to pursue the complaint further;
• explain the next steps in the complaints process; and
• advise the complainant when he or she may expect a response.
Information Gathering
The CCAC must interview staff and the affected person (where appropriate), the contracted service provider (where appropriate), and review documentation about the situation, such as application forms, client files, daily logs and incident reports. The CCAC must also review relevant legislation and agency/government policies.
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Action
Based on the above information, the CCAC must decide whether or not to support the CCAC’s original decision or action.
If any complaint suggests there is a systemic rather than an individual problem relating to the provision of community service by the CCAC, the CCAC must review its policies and procedures and determine whether any changes are necessary. Where system changes are necessary, the CCAC must make the changes and communicate them to staff to prevent reoccurrences and, if required, the CCAC must monitor to ensure that new policies and/or procedures are fully implemented in a timely fashion.
Feedback
Pursuant to subsection 39(2) of the LTCA, the CCAC must review any complaint relating to quality of service or alleged violation of the Bill of Rights and respond within 60 days to the person who made the complaint.
Pursuant to subsections 39(3) and (4) of the LTCA, within 60 days after a complaint is made relating to eligibility, exclusion of a particular community service from the plan of service, amount of service or termination of service, CCAC must do one of the following:
• affirm the decision and give a written notice of the affirmation;
• rescind the decision and give a written notice of the rescission; or
• rescind the decision, substitute a new decision and provide a copy of the new decision.
The CCAC must provide the notice or copy of the decision to the person to whom the decision relates or his or her substitute decision-maker.
10.1.4 Reporting Complaints to the MOHLTC
The MOHLTC has implemented a complaint reporting policy for the CCAC. The CCAC must report all client complaints to the MOHLTC’s regional offices at the time the CCAC submits its Annual Performance Report. The CCAC must report client complaints based on two categories:
• client complaints about CCAC decisions, (see subsection #10.1.1 in this manual); and
• client complaints about the quality of service by the CCAC and contracted service provider agencies.
For the purpose of reporting, a complaint is defined as any concern brought forward by a client or caregiver (or substitute decision-maker) concerning the services provided by the CCAC or any contracted service provider agency that is not resolved at the level of the case manager (i.e., the client/caregiver is referred to the manager/executive director for follow up). A complaint
can relate to any component of the services provided through the CCAC (e.g., placement, in-home services, medical supplies and equipment).