The purpose of this report is to summarize the various external review processes and appeal mechanisms which impact on the Board’s activities and which govern the actions of staff. All of the following external control processes impact either directly and specifically on the Board’s five major programs or generally on all Board activities. The external control processes are grouped by program or under General Program Support if the impact is across all programs.

These external controls are usually directly provided for in the legislation which supports program delivery or in generic legislation which impact on governmental activities. External control processes rely on specific program directives, provincial program policies and Local Services Realignment (LSR) program transfer orders. These directives, provincial program policies and LSR program transfer orders often go well beyond the legal requirements of the legislation. The impact of these will be the subject of another separate report.

MCFCS is responsible for the licensing of regulated child care under the Day Nurseries Act. The Act establishes minimum standards including physical space, staff qualifications, child to staff ratio, health and safety, nutrition, and basic programming which operators of day nurseries and private-home day care agencies must meet. Ministry staff ensure that these standards are in place to ensure the safety and quality of care for children. Appropriate municipal zoning is part of the initial licensing process.

Ministry of Children, Family and Community Services (MCFCS) – Program Review

MCFCS Program Review officers conduct periodic reviews to ensure that only eligible persons are provided with child care fee subsidy. They do this through a formalized review process which includes office visits and may include client contact. The Operational Review Reports are shared with the Board Chair, CAO and the DSSAB Children’s Service Manager. At ADSAB, these are posted on the Board website. The reports summarize compliance with the legislation and directives. The reports may require specific follow up action.

Child Care providers, who receive in excess of $75,000, in subsidy must have a professional audit completed. That audit must be submitted to this Board as part of the local service agreement. These audits are reviewed by both the Director of Finance and the Children’s Services Manager. The purpose of this review is to confirm the financial viability of those providers with which the Board had service agreements. This review also helps to ensure the potential repayment of the Fee Subsidy advances provided to providers.

This Board has formal service agreements with all providers. In addition to requiring external audits, these agreements provide for the provision of specific reports which come from external sources. These include, but are not limited to, play ground equipment inspections, health inspections, fire inspections and related safety inspections. The service agreements provide for parent surveys which gather parents’ perception of the quality of care provided.

The ADSAB Child Care Manager conducts formal reviews at least yearly of providers. These reviews are designed to ensure that the child care operators are running their operations in a manner which protects our financial interests and mitigates the risk of purchased services. The following are the components of the lengthy detailed review process.

Financial: auditor’s management letter, year to date reports, management representation report, budget approval, financial reports, parental contribution arrears, seat vacancy loss, insurance, bank statement review, signing authorities/cheque signing, purchasing policies and practices, external agreements, financial position.

Parent relations: communication, waiting list, parent/child file review. Serious occurrence reporting

The Emergency Health Services Branch Investigations, Certification and Regulatory Compliance Group conducts detailed certification reviews on a scheduled basis or as a result of complaints. The review is conducted by a number of Ministry staff who complete on site and in ambulance inspections. Following the review, the Ministry distributes an Ambulance Service Review Report. That report measures a huge number of items under the following general groupings. The report provides very specific directions on any improvements which are required.

ACRs are completed on a mandatory basis for all calls. The data is input into a province wide system known as Ambulance Reporting Information System (ARIS). This data base is used by several external entities to identify exceptional delays in response times. The ACR’s are also reviewed by the ADSAB EMS Divisional Supervisors to identify any exceptional issues.

Dispatching of ambulances is done by the provincially operated CACC. The CACC monitors overall response times and creates incident reports if the total response time exceeds standards. The CACC Manager then brings these incidents to the local delivery agent Manager for investigation and remedial action. If the situation was extreme or if it consistently occurs, the Regional office of the Ministry may also be notified and become involved in the review.

The Land Ambulance Act provides for mandatory levels of education and training of all paramedics. In addition, the paramedic must not have committed an act of moral turpitude. In order to employ a paramedic we must submit proof of educational and licensing requirements to the branch. The compliance branch approves or denies the individual for a badge. The individual must first be issued a badge by this branch before they can work. The branch also has the power to revoke a badge if licensing has lapsed or if the individual has been convicted of an offense deemed by the branch to be one of moral turpitude.

Each EMS service is associated with a Base Hospital Program. In the ADSAB jurisdiction, the Base Hospital Program is run by the Sault Area Hospital. The Base Hospital Program provides direction in pre-hospital care to all pre-hospital services including EMS. The Base Hospital staff and EMS staff strive for quality improvements through Continuous Quality Improvement (CQI) and Continued Medical Education (CME). The Medical Director for the Base Hospital program governs the license under which paramedics perform the medically controlled acts of defibrillation and the administration of symptom relief medications. The Base Hospital provides and reviews on an ongoing basis Advanced Life Support (ALS) policies and procedures.

The Base Hospital staff and the EMS Quality Assurance Supervisor work together to monitor the quality of care provided by paramedics. The Base Hospital audits patient care documentation concerning controlled acts. The EMS Quality Assurance Supervisor audits a much higher number of patient care reports as well as conducting regular skills evaluations, ride-alongs, client satisfaction surveys and other assessment processes.

Social Benefits Tribunal (SBT) (see Ontario Works section for full description)

The NISU has a direct involvement in arriving at a conclusion of ineligibility and thus has a relationship with the SBT. The NISU reaches a conclusion but not a final decision of ineligibility for new applicants for Ontario Works. The applicant is advised by letter of the conclusion of ineligibility and their right to appeal that conclusion included in this letter is the appeal process. If the applicant wishes to appeal, the NISU has an internal appeal process in which a Supervisor other then the one involved in the original decision conducts a review about the appropriateness of the original conclusion to ensure no change in circumstance has occurred and that the correct legislative conclusion was originally made. If the original conclusion of ineligibility is upheld and the applicant wishes to continue the appeal, the applicant is booked an appointment at the local Ontario Works Delivery Agent’s office. The local office makes the formal decision of ineligibility and the SBT process is handled by them from that point forward.

Ministry of Children, Family and Community Services (MCFCS) – Operational Review

MCFCS corporate staff conducts irregular reviews of the work going on at each ISU. The reports on the NISU have been distributed over the Board website.

Ministry of Children, Family and Community Services (MCFCS) – Intake Screening Review

MCFCS corporate staff have conducted a global review of the performance of all ISU as part of the policy process to determine the future number and role of the ISU’s. That process will inform the Request For Proposals (RFP) process which will occur in 2004. We do not know if we will have access to this report.

Ministry of Children, Family and Community Services (MCFCS) – ISU Monthly Performance Summary Report

This report is distributed monthly to all 47 Ontario Works Delivery Agents. At ADSAB, these reports are added to the Board website as received. The report specifies the performance of each ISU giving both data of individual ISUs and a province wide roll up. If the performance of a particular ISU is below the norm there is follow up by both Ministry corporate and the local program Supervisor to identify issues and suggest corrective action.

Screen out rate number and percentage (broken down by choose to discontinue and concluded ineligible)

The NISU provides services to 12 Ontario Works Delivery agents in Northern Ontario. Those Delivery Agents pay the cost of operating the NISU. As a result they monitor and comment on any performance problems at the NISU. They receive quarterly reports on performance with explanations of any problems or performance changes. They expect and receive quarterly reports from the NISU Manager.

Ministry of Children, Family and Community Services (MCFCS) – Operational Review

MCFCS regional office staff conducts regular but unscheduled reviews of the work going on at each Ontario Works (OW) delivery agent. The reports on the OW program are distributed over the Board website. The reviews focus on a variety of issues. They may focus on new initiatives to ensure they have been implementing according to Ministry standards. The reviews are sometimes focused on areas in which program reviews have identified problems in other offices. At ADSAB, these reports are added to the Board website as received.

The SBT is a provincial body which hears appeals on any decision to deny, vary or cancel of an allowance. We are required to supply a letter for any ineligible applicant and on any decision to terminate a case. The standardized letter includes a description of the local delivery agent's internal appeal process and the SBT process.

Each delivery agent must have a formal internal appeal process. ADSAB has had such an internal appeal process for many years. That process includes a Supervisor or Manager other than the one who made the original decision reviewing the appeal. The individual must complete the internal appeal before they can access the Social Benefits Tribunal. The letter advises the client that they must begin the internal appeal no later than 14 days following the date of the letter or 10 days following it being handed to them. The extra time of 4 days is allowed for mail processing. If the client does not act within the specified time frame, they will be denied the internal appeal and will also denied access to SBT. These times can be varied if there are good reasons the client could not meet them.

The request for an internal appeal must be in writing. However, this can be varied if the client lacks the ability to do this. The internal review process is a formal one. It must be tracked at each stage and responses must be in writing. The delivery agent has an absolute obligation to meet the 10 day internal review requirement. Once the internal review process is complete the client may then appeal to SBT. SBT has the authority to order interim assistance for all appeals. Interim assistance ordered by SBT can be considered an overpayment if the client loses their appeal.

If the client appeals to SBT, the delivery agent will be requested to make a submission justifying, through legislation, the original decision. The submission must be completed within 30 days of the receipt of the notice of hearing. These submissions are lengthy documents identifying the client circumstances and the legislation which supports the denial, reduction or termination of assistance. The client automatically loses the appeal if they fail to appear without just cause. Board staff normally attended all SBt hearings and this will likely continue with the SBT. Under SBT, any supplementary evidence from either party must be provided to all parties at least 10 days prior to the hearing date. it is possible to have decisions reconsidered or to take them to a higher court. The Divisional court remains the next level of appeal under SBT.

The SBT is constrained in the issues it can consider. The Ontario Works Act specifically does not allow SBT to hear appeals relating to : decisions related to employment assistance, decisions related to discretionary benefits, a decision to issue to a trustee, any variation, refusal or cancellation arising from a legislated change or emergency assistance.

Legal Clinics

Ontario Legal Aid funds legal clinics to assist applicants and recipients appeal decisions related to Ontario Works. There is a high level of communication with legal clinic staff related to both eligibility decisions and discretionary benefits

Social Housing

Ontario Rental Housing Tribunal

This Board is the landlord for the transferred public housing units. As a landlord it is governed by the Tenant Protection Act and also the Ontario Rental Housing Tribunal. The Tribunal was created with the enactment of the Tenant Protection Act in June, 1998. The Act gives residential landlords and tenants specific rights and obligations, and sets out a process for how these rights and obligations can be exercised and enforced. The Act also sets certain rules governing rent increases for residential rental accommodation, and gives the Tribunal authority to enforce these rules.

In general, the role or mandate of the Tribunal is to:

~ Resolve disputes between landlords and tenants through either mediation or adjudication.

~ Regulate rent increases in most residential rental dwellings

~ Educate landlords and tenants about the rights and obligations each has under the Tenant Protection Act. Such as, starting a tenancy, maintenance and repair, privacy and entry, rent, rent deposits, other fees and charges; it also outlines illegal charges, the setting of rent the rent increase and decreases guidelines, a rent increase above the guideline, and notices and applications, and terminating a tenancy items including renewing a lease, termination of tenancy, death of a tenant, and abandoned rental unit.

~ Social Housing tenants must be informed of their rights under the Tenant protection Act and their right to appeal decisions covered by that act to the tribunal. The Tribunal does not hear appeals related to Rent Geared to Income calculations.

The Ontario Rental Housing Tribunal is one of Ontario’s “quasi-judicial” tribunals. “Quasi-judicial” means “almost like a court of law.” Resolve disputes between landlords and tenants through either mediation or adjudication. Because of its quasi-judicial status, the Tribunal is an independent agency. Any decision which the Tribunal makes about the rights or obligations of individual landlords or tenants is not subject to any influence or direction by any Member of Provincial Parliament or Minister of the Crown.

The Tenant Protection Act is not the only law in Ontario which gives landlords and tenants rights and obligations. Other laws also provide specific rights and obligations. Some of these include the Human Rights Code, the Condominium Act, the Co-operative Corporations Act, and the Fire Safety and Prevention Act.

Ministry of Municipal Affairs and Housing Public Housing Program Review

Staff from the Ministry conducts reviews to ensure compliance to the Social Housing Reform Act. The focus of these reviews is ensuring compliance to the:

Corporate Reporting

§ And reconciliation of the Federal Subsidy

§ The Service Level Standards (the number of needy household housed)

§ Participation in the Investment Program

§ Ministerial Consents

§ Communication with stakeholders

Rent Geared to Income Assistance processes:

Ø Appropriate application for housing forms

Ø The adherence to Ministry priority ranking for family violence victims

Ø Eligibility reviews

Ø Operation of Centralized Waiting Lists

Ø The selection and placement of tenants as per the Occupancy Standards

Ø The amount of geared to income rent charges

Ø The Internal review and Opportunity to Comment requirements and process

Operating Framework for Non-Profit Housing providers:

· The setting of annual operating budgets, the calculating/adjusting of monthly subsidy payments, the monitoring of payments.

· The renewal of mortgages and subsequent subsidy adjustments.

· The Year End Settlement and Reconciliation procedures. The review of the providers Annual Information Returns and Financial Statements reports and subsequent subsidy adjustments.

· The calculating of the investment of capital reserves with the Social Housing Services Corporation.

· Risk Management processes to monitor, identify, respond and report on Projects in Difficult.

Ministry of Municipal Affairs and Housing ~ Federal Projects Review

Staff from the Ministry conduct reviews to ensure that the Federal Projects are being administrated correctly. These reviews focus on:

- Compliance to the original commitments/operating agreements being honoured

- That the selection and placement of tenants and the setting of rent geared to income are completed in accordance with the agreement

-That all corporate reporting including the setting of the annual budget, the setting of monthly subsidies, the renewal of mortgages, the year end settlements and reconciliations are completed in accordance with the agreement.

-The adherence to approved capital plans.

- Risk Management processes to monitor, identify, respond and report on Projects in Difficult.

External Professional Audits of Non-profit Providers

Non-profit providers must have a professional audit completed. That audit must be submitted to this Board as part of the local service agreement/operating framework. These audits are reviewed by both the Director of Finance and the Social Housing Manager. The purpose of this review is to confirm the financial viability of those providers with which the Board has service agreements.

ADSAB Internal Review of Non-Profit Housing Providers

The ADSAB Social Housing Manager conducts formal reviews at least yearly of non-profit providers. These reviews are designed to ensure that our oversight obligations under the Social Housing Reform Act are fulfilled. The following are the components of the lengthy detailed review process.

Corporate Requirements: minutes, annual general meeting, quorum.

Conflict of Interest: bylaw, declarations, identified conflicts

Property Management: agreement, competitive process

Financial: auditor’s management letter, annual information return, management representation report, budget approval, financial reports, rent arrears, vacancy loss, insurance, bank statement review, signing authorities/cheque signing, purchasing policies and practices, non-shelter agreements, financial position.

Resident/tenant Relations: market rent, rent deposits, leases, targeting, waiting list, tenant file review.

Maintenance administration: elevator safety, fire safety, roof anchors, WHMIS, maintenance records, preventative maintenance, emergency maintenance plan, work orders, general reviewer comments

General Program Support

Audit

The Board is required under the District Social Services Administration Board’s Act to have an external audit completed each year. The audit is conducted on the Board’s books at beginning of each calendar year based on the prior year’s transactions. The professional audit firms use a range of techniques to ensure the validity of the audit within generally accepted auditing principles. These techniques include:

· Assessment and documentation of Board policies and procedures for the purpose of planning the audit and identifying key internal controls.

· Testing internal controls to ensure compliance and effectiveness. Highlights potential weaknesses and makes recommendations for improvement. Perform additional work as needed (substantive and analytical).

· Analytical review – identifies areas where additional work is needed based on reasonableness.

· Substantive testing – checking and reviewing of supporting documentation for completeness and validity.

· Third party confirmation of key balances.

· Ensures reports meet any disclosure requirements and proper presentation.

When the audit has been completed a formal hard copy of the audit is distributed to: every Board member, every member municipality and the appropriate Ministries. The audit is normally accompanied by a Management letter which will identify any problems with internal financial controls.

Ministry Financial Audits

Each Ministry conducts financial reviews to ensure that requests for subsidy are consistent with actual and allowable expenditures. All monies flowed to this Board are done so under specific program service contracts. These service contracts allow for the recovery of subsidy if program rules have not been followed.

The service contracts specify the program deliverables and usually set performance targets which must be met in order to retain subsidy funding. The fact that funds were expended in the program area is not sufficient to ensure payment or retention of subsidy. Program rules musty be followed and targets met in order for the subsidy to be retained. If program rules are not followed subsidy is recovered.

Annual Information Returns (AIR)

The Ministry requires Childcare and Social Housing to submit Annual Information Returns (AIR) which summarizes financial and key statistical information in a standard format. The AIR must be reviewed by the external auditor as the financial information is a derivative of the Board’s audit.

In addition to the AIR’s, all programs which have a service contract with a Ministry (Childcare, Ontario Works and North Intake Screening Unit) must submit quarterly reports which contain financial and statistical information for review.

Human Resources

Ministry of Labour

Ministry of Labour employment standards officers have the right to look into possible violations of the ESA and they can inspect workplaces. The ministry can directly order the Board to take specific actions.

Human Rights Commission

The Ontario Human Rights Commission is an arm’s length agency of government, accountable to the Legislature of Ontario. through the Minister of Citizenship. The Commission’s principal functions are set out in the Ontario Human Rights Code and include the investigation and settlement of human rights complaints. The Commission’s mandate under the Code includes: investigating complaints of discrimination and harassment; making efforts to settle complaints between parties; preventing discrimination through public education and public policy; looking into situations where discriminatory behaviour exists. The Commission can directly order the Board to take specific actions.

Pay Equity Commission

The Pay Equity Office (PEO) is responsible for implementing and enforcing the Pay Equity Act. The PEO investigates, mediates and resolves complaints under the Pay Equity Act. The Pay Equity Hearings Tribunal (PEHT) is responsible for adjudicating disputes that arise under the Pay Equity Act. The Commission can directly order the Board to take specific actions.

Arbitration

The Board has agreed through it Collective Agreement to settle grievances through the use of an arbitrator where the prior settlement steps have failed to produce a settlement. Accordingly the arbitrator following a formal review process can order a settlement which the Board and union are obliged to honour. Rulings by an arbitrator are subject to judicial review.