COMPLIANCE 2018

I want to congratulate all of us on a job well done!

The Ministry of Children and Community Social Services (MCCSS) Compliance Audit took place October 1-11, 2018. Three members from the MCCSS Developmental Services Compliance Team spent nine days visiting 24 residential sites in the Central, East and Toronto regions. Our practices, policies and procedures were reviewed against 259 indicators.

The compliance team reviewed 93 individuals’ behavioural support plans, documentation of individuals’ goals, safety and fire plans, water temperature procedural checks, and many other compliance requirements. The number of individuals’ plans reviewed is close to 40% of the total number of people we support in our residences.  In addition they reviewed 53 personnel files for orientation checks, education and training, and performance appraisals.

Out of all the thousands of checks that were done by the three surveyors, we had only 15 non-compliances, most of which, if not all will be corrected by the due date of October 26, 2018.

OUR OVERALL COMPLIANCE SCORE IS 97.7%!!!

There were many positive comments made by the compliance team:

  • The individuals are well supported by a caring, respectful and responsive staff.
  • The residential homes are well cared for and “felt homey”
  • The staff have creative ways to support people such as: fitbits to monitor sleep
  • Behavioral Support plans are very well done, especially the safeguards and “involvement”
  • The documentation of “goals for the individuals” have greatly improved over the past two years
  • The staff were very responsive to suggestions for needed repairs
  • Staffing levels were very well documented

We also have some areas for improvement:

  • Individuals interventions are not always signed (BSPs),
  • Results of PRN protocol interventions are not always documented
  • Some bathing protocols are outdated
  • Staff training, orientation documentation is not always completed

We only received two weeks notice prior to this compliance visit, and I know there was a lot of preparation to get ready. Ensuring that Quality Assurance Measures are in place at all times is our ongoing endeavour, and the work right before the visit and all the constant work you do to support the individuals in our homes was evident to our surveyors. They commented on the high quality of the support provided by the staff at KP, and the clinical, human resources and finance systems we have in place to make that support possible.

I would like to thank and congratulate all of you on these excellent compliance results. We look forward to receiving our Letter of Compliance by month’s end. You should be very proud!!



COMPLIANCE 2017

The Ministry of Community & Social Services compliance audit took place from August 7-18, 2017.

Three members from the MCSS spent ten days visiting individuals and staff in the residences, investigating community day programs, reviewing individual behavioral support plans, employee files, policies and procedures, and much more. Our practices were reviewed for compliance against 280 indicators in the EAST, 350 indicators in CENTRAL and 280 indicators in Toronto.

The overall results for Kerry’s Place were VERY positive!

The auditors noted Kerry’s Place has excellent behavior management strategies in place to enhance the lives of those we support, and they commented on the improvement they observed since our last audit. They also stated our incident reports and serious occurrences are well documented and followed up, especially situations involving suspected abuse. I especially liked their comment that it was evident to them that the staff go “the extra mile” for the individuals we support.

Our total non-compliant indicators for all three regions numbered 16, compared to 47 from the last visit. In fact, a total of 26 non-compliance issues were resolved “on the spot” during the compliance visit, significantly reducing the final number of non-compliant indicators. However, we do have some room for improvement:

  • Making sure our annual reviews are indeed done annually;
  • Having goals in place for individuals supported in our respite programs;
  • Finding a way to better link our ISP (individual support plan) with our PDP;
  • Ensuring documentation practices are consistent throughout the organization;
  • Making sure our medication (PRN protocols) match the behavioral support plan

The clinical, human resource and finance systems we have put in place make the excellent care we provide to the individuals we support possible.

CONGRATULATIONS TO ALL OF US FOR OUR 98.3% COMPLIANCE FOR KERRY’S PLACE!


MCSS Compliance Inspection: Highlights