Welcome to our
Online Policy & Procedure Manual

Table of Contents Sections:
[Click on the section to go to that part of the Table of Contents]

        Table of Contents:

1.A.1  PLANNING PROCESS

POLICY:   

        A formal planning process shall be undertaken each year.

PROCEDURE:

1. A program planning document shall be in place for:
   

1. Administration

2. Alcohol and Drug Programs

3. Mental Health

4. Family Initiatives

5. EFAP

• Treatment    

• Prevention

2. Each program plan shall include an outline of the services of the program, goals, how the goals will be implemented, how they are to be evaluated and an outcome measure.            

3. The program plans shall be revised each fiscal year and submitted to the Chief Executive Officer by the end of February and to the March board meeting for approval.

4. All program plans shall be available to all staff and board, and to the general public (upon request).

[Back to Table of Contents]

1.A.2            EVALUATION

 POLICY:

 An evaluation of the programs level of attainment of its' goals and objectives is undertaken.

  PROCEDURE:

1. The yearly outcome portion of the planning document shall be completed in April of each year.

2. This outcome shall form the basis for the current program planning document.

 [Back to Table of Contents]

1.A.3               POPULATION DEFINITION 

POLICY:

North East Counselling Services provides services for the areas of Dawson Creek, Chetwynd, Tumbler Ridge, Pouce Coupe, Rolla, Tomslake, Kelly Lake, Ground Birch, Progress, Bonanza, Fort Nelson, and Fort St. John. When indicated, non-residents would also be given assistance. Clients shall be seen in the North East Counselling Services offices in Dawson Creek, Chetwynd, Fort Nelson, Fort St. John,  and Tumbler Ridge, with the following exceptions:

1. clients may be seen at the hospital if they are inpatients

2. clients will be seen in the North East Counselling Offices, unless there is a need to be seen elsewhere, this must be negotiated with the Program Manager.

  The specific characteristics and distribution of the population to be served by each program is documented.

PROCEDURE:

1. Each program shall define the population in the program planning document.

2. Any specifically targeted group shall be identified in individual program planning documents (e.g. age, gender, educational level, cultural features, problem types etc.)

3. Numerical data shall be maintained of clients falling into the targeted groups.

[Back to Table of Contents]

1.A.4                 GUIDING PRINCIPLES

 POLICY:

 PROCEDURE:

1. Treatment and prevention services will not be denied or refused to any individual whose service requirements are within our mission, provided the safety and security of staff is not threatened.

2. The client's "Bill of Rights" is posted in the waiting room.

3. The safety and security of staff is primary to effective service delivery.

4. The "client" must be informed and involved in decisions that affect him/her whenever possible.

5. The least intrusive intervention consistent with client need should be utilized.

6. The staff must operate within the confines of the BCASW Code of Ethics at all times.

 See - BCASW CODE OF ETHICS   (Requires Acrobat Reader)

[Back to Table of Contents]

1.B.1                GOVERNING BODY

 POLICY:

North East Counselling Services is governed by the South Peace Health Council which is distinct in composition and function from the operating staff and administration of the program.

 PROCEDURE:

1. Provision of the governing body is outlined in the South Peace Health Council Constitution and Bylaws (revised, 1993), Constitution articles 1 through 5, and Bylaws articles 1 through 4. (Appendix 2)

2. The primary function of the Board of Trustees is the formulation of policy.

3. The Chief Executive Officers' core function is administration of the South Peace Health Council.

4. The Program Manager/Administrative “Supervisor’s” core functions are the administration of the programs within the parameters of policy determined by the board.

5.  Staff's function is service delivery.

6. The Board of Trustees is responsible for exercising full, legal authority for the overall conduct of the program and for all policies and planning functions, which establish the philosophy and principles of the program.

7.  The Board of Trustees is accountable through the Societies Act, the Constitution and By-laws             and the contracts signed with any funding source.

 See Appendix 2 - for the Dawson Creek and District Health Care Society Constitution and By-Laws   (revised 1993)

[Back to Table of Contents]

1.B.2     GOVERNING BODY  -  CONSTITUTION, REGULATIONS

POLICY:

The governing body of North East Counselling Services, South Peace Health Council, is a not-for-profit society with a Constitution and Bylaws in accordance with provincial requirements.

PROCEDURE:

1. Articles 1 through 5 of the constitution and articles 1 through 14 of the Bylaws outline the purpose and regulations of the South Peace Health Council. (Appendix 2)

2. The South Peace Health Council's Constitution is the legal instrument which establishes the operating authority and determines the nature and function(s) of the North East Counselling Services.

3. The by-laws provide the guidelines for the operation of the program by establishing the basic             principles and policies for the conduct of the program activities.

4. The by-laws should be in accordance with North East Counselling Services philosophy, goals and objectives.  They should also define the authority, responsibilities, procedures and time frames for selection of Board members and offices.

See Appendix 2: South Peace Health Council Constitution/By Laws   

 [Back to Table of Contents]

1.B.3            GOVERNING BODY  -  MEMBERSHIP

 POLICY:

The North East Health Council 's membership should reflect the concerns, interests, and perspectives of the communities in it's catchment area.

 PROCEDURE:

1. Procedures for membership in the South Peace Health Council are outlined in it's Bylaws, article 2, sec.1 through 11. (Appendix 2)

2.  Advisory Committees shall be struck to ensure representation of community interests.

 See Appendix 2 - for the South Peace Health Council Constitution /By-Laws (revised 1993)

[Back to Table of Contents]

1.B.4               GOVERNING BODY  -  RESPONSIBILITIES

POLICY:

 The Northern Health Authority Board shall have control over management and operations of the North East Counselling Services.

PROCEDURE:

1. The Board reviews all areas of program administration and operation.  This is done on a monthly basis through the Financial Statements and Program Progress Reports.

2. The Board shall review and approve Program Planning documents, Annual Budget documents and Policy and Procedures Manual.

3. The Board is not responsible for implementing the daily operations of the program but will establish an administrative position to do so.

4. The Board authorizes all policies - administrative and operational - indicating both its agreement and the fact that the policy is established at its direction.  This includes contracts with the various funding bodies.

5. The Administrators are responsible for overseeing the operations of the North East Counselling Services in the North East Health Services Region.  The Administrator speaks directly to the Board.

[Back to Table of Contents]

1.B.5               POLICY/PROCEDURE MANUAL - OPERATIONS

POLICY:

The program has an operations policy and procedures manual which describes the regulations, principles and policies/practices established by the governing body to determine the program's operation.

PROCEDURE:

1. The Program Manager/Administrative Supervisor is responsible for ensuring policies and procedures are developed for program operations.

2. A Policy and Procedures Manual is developed and updated as necessary.

3. Policies and Procedures outlined in the Manual are approved by the South Peace Health Council.

[Back to Table of Contents]

1.B.6        Current Operating System - Organizational Chart

North East Counselling Services

CURRENT  OPERATING SYSTEM

2002

[Back to Table of Contents]

1.C.1               FILE DESTRUCTION

 POLICY:       

Files will be destroyed by burning or shredding after the appropriate time period has lapsed.

 PROCEDURE: 

    1.         FILES TO BE RETAINED INDEFINITELY

• Personnel files (Individual)

• Audit

• Payroll Records Books

• Societies Branch Information

• Separation Slips

• Bank Synoptic - General Ledger entries           

• 25 year limit - inactive, adult (over 19) client files.

• 89 years inactive, youth (under 19) client files.

     2.         SEVEN YEAR LIMIT 

• Proposals for projects

• Revenue Canada Taxation

• Minutes of Meetings

• Agendas

• Budgets

• Agency Contracts

• Bank Statements and Financial Sheets with Permission of Revenue Canada

• Current Account Information

• Cheque Stubs

• Deposit Slips

• Annual Progress Reports

     3.         FIVE YEAR LIMIT

•  Correspondence for Additional Funding

    4.         THREE YEAR LIMIT

•  Progress Reports

    5.         TWO YEAR LIMIT

• Funding Applications                           

• Cost Sharing Reports

• SSTC Billing Copies                            

• Public Presentations

• Insurance Policies                                

• Statistics

• Appointment Books

    6.         ONE YEAR LIMIT

• Petty cash Receipts                              

• B.C. Telephone Receipts

• Advertising Receipts                            

• Travel Receipts

• Loomis Receipts                                  

• Publication Receipts

• Office Supply Receipts            

• Publications/Catalogues

• Membership Information                      

• Lease Agreements

• Questionnaires                         

• Policy and Program Manuals

• Provincial Description Manual

• General Correspondence (use discretion to retain)

     7.         SIX MONTH LIMIT

•  Letters of Support

• Applications

• Letters of Applicant Rejection

     8.         THREE MONTH LIMIT

     9.         CURRENT ONLY

• Address Lists

• Job Descriptions

• Treatment Centres Cost Updates and Information

    10.       TO BE DESTROYED AFTER VALIDITY DATE

• Young Canada Works Information

• Employment Postings

• Workshop Information

• Bank Cheque Deposit Ledger Books for Defunct Acts

• Referral Agencies

• Brochures

• Literature

• Film Confirmations

• Defunct Project Information

[Back to Table of Contents]

1.C.2            Peer Review

 POLICY:       

 It is the policy of this program that client files will be periodically reviewed by an outside source.

 PROCEDURE:

1. Files will be reviewed quarterly.

2. The Area Manager is the designated reviewing agent.

3. There is a standardized Case Review Form, that will be used to standardize all case management practices.

4. Case Reviews will be tabulated and changes will be made to clinical practice accordingly.

[Back to Table of Contents]

1.D.1           RESEARCH POLICIES AND PROCEDURES

 POLICY:

The program has written policies and procedures governing  the conduct of research involving clients. Any Research involving clients must meet ethical standards (BCASW).

 PROCEDURE:

1. The project must receive prior written approval from the Board of Directors, and the Ministry(s) which fund(s) the program(s) involved.

2. The Design must be adequate.

3. The individuals responsible for the direction and implementation of the project are adequately qualified to conduct the research.

4. The general benefits and risks of the project have been identified.

5. The specific benefits and risks of the project to subjects have been identified.

6. The design complies with accepted ethical standards.

7. Possible disruptions in programs activities are identified.

8. Procedures for dealing with any potentially harmful effects of the research activities are established.

9. Written informed consent is obtained from every subject prior to participation in a research project. Informed subject consent includes:
   

   1. A full verbal and written description of the research project including purpose.

   2. Use of language which the subject understands (non-technical; also, translators for non-English speaking subjects should also be available).

   3. A full description of all expected benefits to the subject and the general public.

   4. A full description of all potential risks and discomforts to the subject.

   5. A description of alternative procedures which may be equally advantageous but which are not used in the research project.

   6. Provision for answering all subject inquiries regarding the research procedures and possible consequences.

   7. Providing the subject with assurance that a decision not to participate in the research will not jeopardize continuation of treatment.

   8. Informing the subject that informed consent may be withdrawn at any time.

   9. Provision for repeat of this process if goals and/or procedures change as the research proceeds.

10. Written consent does not require the subject  to waive any legal rights or  to release the program, staff  and/or research project and staff from liability for negligence.

11. The policies and procedures ensure that research results provide total anonymity to subjects.

12. All medical procedures in research projects are supervised by a physician.

13. Written approval from the Board of Directors and the Ministry involved is obtained before the research results are released and/or published.

[Back to Table of Contents]

1.E.1            FACILITY REGULATIONS

POLICY:

All applicable provincial and local facility requirements will be complied with (e.g. building, health and safety codes or zoning requirements)

 PROCEDURE:

1. Applicable facility requirements will be gathered and updated as necessary.

2. All policy standards audits will include a section evaluating facility compliance to provincial and local facility standards.

[Back to Table of Contents]

1.E.2         SPACE FOR ADMINISTRATIVE AND OPERATIONAL ACTIVITIES

POLICY:

Adequate space must be provided for all administrative and operational activities of the North East Counselling Services. This includes, but is not limited to, private individual counselling space as well as group space.

 PROCEDURES:

1. There will be a waiting room separate from counselling rooms.

2. The space for administrative and therapeutic purposes is separated.

3. All filing cabinets, doors and any other security measures must be locked and secure when the business office is closed.

4. File Room door shall remain closed (at all times) if out of range of sight.

5. Space should be fully accessible to persons with physical impairments.  If clients are unable to attend counselling sessions due to the physical locations of North East Counselling Services they may be seen in an alternative location, with the Program Managers/Administrative Supervisor approval.

6. Separate washrooms for staff and clients/visitors should be available.

[Back to Table of Contents]

1.E.3       EQUIPMENT, FURNISHINGS, SUPPLIES  

POLICY:

All necessary equipment, furniture and supplies will be provided.  In addition provision must be made for all necessary repairs and replacement of equipment, furniture and supplies.

PROCEDURE:  

1. Any equipment, furniture, supplies over $1000.00 will have multiple estimates and require approval of both Program Manager and South Peace Health Council.

2. Every reasonable effort should be made to purchase items on sale or at the most inexpensive cost.

3. The Clerk/Receptionist may purchase all office supplies under $200.00.

[Back to Table of Contents]

1.E.3a            EQUIPMENT, FURNISHINGS, SUPPLIES   - NEW

POLICY:

The Power Point Projector is available to individuals/agencies who will be responsible in their usage of this equipment.  Due to liability associated with equipment repair, all potential renters will be screened and accorded repair costs if the equipment is damaged while in their possession.

PROCEDURE:

1. All bookings for the projector will be done through the secretary at the Dawson Creek Office.

2. Any new applicants who are wishing to rent the equipment will be required to sign a liability sheet before the equipment is rented out.

3. All applicants will be screened by the Program Manager before the lessee is approved.

4. A rental fee will be accorded to all people outside of this agency for the usage of the projector.  A fee of $50.00 will be accorded for each half day.

5. All fees raised will be placed in a special allocation fund for clients in need of special assistance but are not eligible for funding through social services.  This fund is available to all staff in all three offices.

[Back to Table of Contents]

1.E.4            MEETING ROOM

POLICY:

The meeting rooms shall be made available to volunteer groups within the community.

PROCEDURE:

1. All self-help groups are offered access to the group rooms of the office building.

2. When a 12 step group is requesting use of the meeting room, the designated person, responsible for the keys, will have at least one year in recovery or of sobriety.

3. A key will be provided for the doors and access will be reviewed with group.

4. The keys will be signed out prior to their meetings and monitored by South Peace  Counselling Services personnel. The designated person must return the keys to this office when the group terminates. The designated person remains responsible for the keys until a formal change is made with this office. The new designated person then must sign for and be responsible for the keys.

5. There will be no access to confidential material.  Confidential material must be secured before group enters the building.

6. The meeting room is considered a donation to the group.  However, a small rental fee will be charged to the group, if they so desire. The fee will be considered revenue and for warded to the general operating fund of South Peace Counselling Services.

7. Use of South Peace Counselling Services’ meeting room, by groups, will be at the discretion of the Program Manager/Administrator, with the operational program requirements having priority.

[Back to Table of Contents]

1.E.5          NO - SMOKING POLICY

POLICY: 

REFERENCE NO. S-50 DAWSON CREEK AND DISTRICT HEALTH CARE SOCIETY ADMINISTRATION MANUAL (PERSONNEL POLICY)

[Back to Table of Contents]

1.E.6           Accessibility

POLICY:

It is the policy of this office to try and ensure that we are accessible to all clients who come to this office. (Our facility is wheelchair accessible and we can go to an alternate location to meet with clients who may be unable to come to our facility.)  ELEVATOR SYSTEM NEEDS TO BE ADDRESSED.

PROCEDURE:

1. Identify all clients who have potential needs beyond the usual ones.

2. If the needs are of a cognitive nature they can be accommodated by the staff of this program.

3. Once a client is identified as hearing impaired, resources are available at the North East Service Region area.  All efforts will be made to ensure these needs are met.

4. If the client speaks an alternate language we have some resources available to us through the hospital Staff Interpretation Program. However this is a limited program and if there are significant language barriers we may have to refer to another area in B.C.

5. It is an expectation of these offices to be creative around specific issues that have not been anticipated. We will endeavor to meet these needs as they arise.

[Back to Table of Contents]

1.F.1         PHYSICAL PLANT / FIRE EMERGENCIES

POLICY:

There is a written plan to deal with emergencies involving the physical facility.  All emergencies involving the physical facility must be treated as an emergency situation requiring evacuation until such time as it is apparent that alternative emergency procedures can be utilized.

PROCEDURE:

1. In the case of fire, if it can be contained with the fire extinguisher then do so.  Tumbler Ridge will operate under Tumbler Ridge Health Clinic standards for evacuation plan. Chetwynd/Dawson Creek will operate on their own evacuation plan.

2. If the fire cannot be contained quickly, the fire department must be notified either immediately, or if immediate evacuation is necessary as soon as everyone is out of the building.

3. The entire office must be notified of the fire and instructed to leave the building and in Chetwynd a pull station will be activated.

4. The receptionist or office manager/designate shall take the appointment book which shall account for all people in the office.

5. All counsellors and their clients shall evacuate the building by the safest and most expeditious exit.  Each counsellor shall aid their clients and the front office staff shall assist any clients in the waiting room.

6. All occupants shall meet at designated evacuation plan areas and the Office Manager/designate or, in his absence, the receptionist shall ensure that everyone is accounted for.  If someone is missing the fire department must be notified.

7. No one must return to the building until instructed by the fire department.

8. A fire drill should be practiced and documented at least quarterly and a report sent to the Chief Executive Officer of South Peace Health Council.

[Back to Table of Contents]

1.F.1.a            Physical Plant Emergency / Power Failure

POLICY:       

There is a written plan to deal with emergencies involving the physical plant. All emergencies involving the physical plant must be treated as an emergency situation requiring evacuation until such time it’s apparent that alternative emergency procedures can be utilized.

PROCEDURE:

1. All persons in the office will be instructed to leave the building.

2. The receptionist or office manager shall take the appointment book which shall account for all people in the office.

3. All counsellors and their clients shall evacuate the building by the safest and most expeditious exit. Each counsellor shall aid their clients and the front office staff shall assist any clients in the waiting room.

4. The office will be locked during the time period that the power remains off.

5. All occupants shall meet at the designated safe area and the Program Director or, in his absence, the receptionist shall ensure that everyone is accounted for.

[Back to Table of Contents]

1.F.1.b            Natural Disaster ( ie. earthquake, severe storm)

POLICY:

There is a written plan to deal with emergencies involving the physical plant. All emergencies involving the physical plant must be treated as an emergency situation. During natural disasters it may not be necessary or wise to evacuate the building.

PROCEDURE:

1. All identified risk areas are listed in the file room for staff.  They include windows, mirrors, hanging objects and tall unsecured furniture.

2. All staff will acquaint themselves with risk factors and safety procedures in the event of an earthquake / severe storm.

3. All staff and clients present in facility will immediately proceed to designated safe area during the earthquake / severe storm. Staff will be responsible for their own clients who have disabilities.

4. The receptionist/office manager shall take the appointment book that has record of everyone who is in the facility. 

5. All clients and staff will evacuate building immediately after earthquake / severe storm has occurred.

6. Thorough inspection of the plant must take place before building will be deemed safe to occupy.

[Back to Table of Contents]

1.F.2                CLIENT, STAFF AND PUBLIC EMERGENCIES

POLICY:

All staff should be knowledgeable of procedures to use in an emergency.

PROCEDURES:

1. If any serious or violent threat occurs, measures to ensure staff and client safety are of paramount concern.

2. In the case of an emergency in the front office, the situation should be contained there.

3. The R.C.M.P. should be contacted immediately by phone or by use of the emergency buzzer installed in the reception area, to diffuse the situation.

4. If a serious or violent episode occurs in a counsellor's office, the counsellor should do everything to try and diffuse the situation; and if necessary leave the office immediately.

5. If the situation warrants it,  all counsellor's should be made aware of the incident immediately so they may ask their clients to leave, and leave themselves if necessary, or at least, ensure their own clients avoid becoming involved in the situation.

6. The concern for staff and client safety outweighs the concern for the physical aspects of the building.

7. Incident reports must be written in the event of an occurrence.  South Peace Health Council forms will be used.

[Back to Table of Contents]

1.F.3               FIRST AID

POLICY:

North East Counselling Services identifies and adheres to all applicable Industrial Health and Safety Regulations.

PROCEDURE:

1. A First Aid kit is available in the kitchen area in Dawson Creek, in the file storage room in Chetwynd and Tumbler Ridge will access emergency First Aid kit at end of hallway.

2. Industrial Health and Safety Regulations (1980) are available to all staff.   

3. First aid and information is available through the hospital/clinics.

4. Any injury requiring further intervention will be referred to hospital emergency department.

5. Incident reports must be written for staff and clients who require medical intervention.

 [Back to Table of Contents]

1.F.4            COUNSELLOR SAFETY

POLICY:

It is the employer’s responsibility to ensure safe working conditions. It is all employees responsibility to assist in that process.

PROCEDURE:

1. Clients should never be seen for the first time when there is no support staff available.

2. If the counselling session of a first time client extends past 4:30 the Receptionist or office manager should contact the counsellor by telephone to receive the counsellor’s instruction. It is the counsellor’s responsibility to ask someone to stay if there is any concern about their own safety. The counsellor shall then do everything to complete the session and rebook at a suitable time.

3. If a client session goes significantly over time and the counsellor has not notified the reception of any pre-planned reason for this the support staff should contact the counsellor to verify their safety.

4. If the counsellor senses any concern about his/her safety the session should be terminated immediately.

5. If any person threatens, intimidates, harasses or becomes violent and refuses to leave the premises, all staff are to be notified of the potentially dangerous situation and are to evacuate the premises immediately.

6. If a counsellor feels there may be potential violence, they will not put themselves at risk.

7. Counsellors shall arrange their offices to ensure maximum counsellor/client safety.

8. Any concern about counsellor safety should be reported to the Program Manager/Administrator immediately.

9. Any incident concerning counselling safety should be reported to the Program Manager/Administrator and an incident report shall be given to the Program Manager/Administrator.

10. If any criminal act occurs, the RCMP shall be notified and appropriate charges shall be laid.

[Back to Table of Contents]

1.F.4.a       Staff Safety When Entering Premises in the Morning

POLICY:

Staff members must avoid situations that are potentially harmful which includes clients who are “hanging out” at the front door in the morning. Any Clients who are potentially violent, make the staff feel uncomfortable or are unknown by the staff fall within this category.

PROCEDURE:

1. All staff are asked to observe the front entrance before they stop their vehicle.

2. If there is someone sitting on the front step the staff member must visually identify the person.

3. If the person is recognized and falls within the risk category the staff member will leave the vicinity.

4. The staff member will wait at the post office for another staff member to arrive.

5. Both staff will go to the office together.

6. If there are no other staff coming to the office the staff member will go to the hospital to receive further instructions.

[Back to Table of Contents]

1.F.5                MEDICAL EMERGENCIES

POLICY:

All medical emergencies should be responded to immediately to ensure the safety and well being of all staff  and clients.

PROCEDURE:

1. For any medical incidents prompt emergency care should be given.

2. For any serious illness or injury the victim shall be requested to seek medical treatment.

3. If the incident is extremely serious or if there is any question about the health and/or safety of the individual appropriate emergency staff should be contacted immediately.

4. North East Counselling Services would prefer that emergency services were used too quickly than too slowly.

5. All attempts shall be made to ensure the victim’s comfort and privacy while waiting for an ambulance i.e. if the incident is in the waiting room, clients shall be diverted away from that area.

6. Any serious illness or injury whether or not the incident gives rise to injuries requiring medical treatment shall be reported to the Program Manager/Administrator.

7. A recording of the essential facts surrounding the incident shall be made and placed in a file marked “Emergency Incidents”.

8. Any recommendations or actions indicated shall be passed in policy by the Program Manager/Administrator.

[Back to Table of Contents]

1.F.6      INCIDENT REPORT DOCUMENTATION

POLICY:       

All serious and emergency incidents, including serious illnesses, injuries, alleged cases of abuse and/or neglect, physical plant/facility incidents, will be documented and submitted to the Program Manager/Administrator within 48 hours of the incident.

 PROCEDURE:

1. All incidents will be reported promptly to the Program Manager/Administrator by completing an Incident Report Form.

2. All essential facts will be recorded including any actions taken.

3. The Program Manager/Administrator will review all incidents reported and ensure follow-up procedures occur.

4. The Program Manager/Administrator will formulate and document recommendations and actions to address the incident/emergency situation. This will also be presented to the Program Administrator or designate.

[Back to Table of Contents]

1.F.7          ILLICIT DRUGS ON PREMISES

POLICY:

All drugs that are left on the premises either voluntarily or mistakenly will be dealt with in a consistent manner.

PROCEDURE:

1. If a client chooses to disclose possession of an illicit drug they will be informed that the law will have to be involved if they choose to leave it here.

2. If a substance is discovered on the premises with no apparent owner and it is discovered by a staff member it will be visually examined   (do not touch it),  to identify if it is an illegal substance.

3. Once it has been identified the RCMP will be called to come and pick up the substance.

4. If a client chooses to leave the substance,  after informing them of the legal ramifications, a staff member will stay in visual range of the substance and the RCMP will be called. The same staff member will remain in visual range of the substance until the RCMP arrive to take the substance away.

[Back to Table of Contents]

1.G.1          LIABILITY AND PROPERTY

POLICY:

There must be full insurance coverage, including complete liability insurance for all             employees and directors, full contents insurance, tenants legal liability.

PROCEDURES:

1. The policy should be reviewed on an annual basis (March of each year) to ensure that there is full coverage.  This is to be carried out by Senior Management.

[Back to Table of Contents]

1.G.2         VEHICLE INSURANCE

POLICY:

Employees of North East Counselling Services are responsible for insuring their personal vehicles.

PROCEDURE:

1. Employees are responsible for insuring their personal vehicles for business use.

2. Upon presentation of proof, employee will be reimbursed by the contractor for the difference between pleasure and business use.

[Back to Table of Contents]

1.H.1          CLIENT, STAFF OR PUBLIC COMPLAINTS

POLICY:

The program has and follows a written plan for dealing with client, staff and/or public complaints.

PROCEDURE:

Serious Complaints

A serious complaint is one where physical harm is alleged to have occurred to clients, staff or the public, and includes negligence and/or abuse. For serious complaints, the following procedures are to be used:

1. The person receiving the serious complaint shall document the allegation as specifically as possible including the time the serious complaint is received, the nature of the serious complaint, the name of the person making the complaint, and the person alleged to have caused harm.

2. The person receiving the complaint will, at the earliest opportunity, take the information to his or her immediate supervisor, who will forward the complaint to the South Peace Health Council Chief Executive Officer (CEO). The CEO will bring the matter to the attention of the Health Care Society Board Chairperson and the Alcohol & Drug Regional Manager.

 OTHER COMPLAINTS

Clients, staff, or the public can have complaints formally addressed.  If staff have an employment related complaint, they will use procedures as outlined in the HEU/HSA collective agreements to address their complaints.

Clients or members of the public can have complaints addressed by submitting them in writing to the South Peace Counselling Services Program Manager or to the CEO of the South Peace Health Council. The CEO or his designate will investigate the complaint and respond to the person making the complaint in writing within 14 days of receiving it.

[Back to Table of Contents]

1.H.2               MEDIA

 POLICY:

 North East Counselling Services will respond to media inquiries for information.

PROCEDURES:

1. Inquiries from the media for program information may be referred to the Program Manager/Administrator.

2. Staff may respond to media inquiries regarding services provided they have prior approval from the Program Manager/Administrator.

3. Media inquiries of a controversial nature will be referred to the Chief Executive Officer of the South Peace Health Council.

[Back to Table of Contents]

1.I.1         PLAN

POLICY:

The acting upon of warrants or arrests of clients or employees shall not be interfered with by staff.

PROCEDURES:

1. Requests for search of relevant documents will only be accommodated if documents are requested with client or employee approval or, documents are requested through appropriate legal channels.

2. If a request for a search for relevant documents is placed, the required material shall be placed in a sealed envelope with instructions that the seal be broken only by the legal recipient of the documents.

3. If uncertainty exists as to the legal requirements concerning a search of relevant documents, North East Counselling Services may seek legal council with prior approval from the Program Manager/Administrator of the South Peace Health Council.

[Back to Table of Contents]

2.A.1               PERSONNEL RECORDS

POLICY:

There shall be a personnel file on every employee, and it will be located at the Health Council’s business address.

PROCEDURE:

1. The file shall include the employees resume, reference checks, criminal record check, probation and annual evaluations and any disciplinary actions taken, and all other relevant personnel records.

2. Employee's own records are available to them for review, comment and appropriate correction.

3. Personnel records are stored in locked files.

[Back to Table of Contents]

2.A.2         STAFF RESPONSIBILITIES - JOB DESCRIPTIONS

POLICY:

The program has a written job description for each staff  position.  

PROCEDURE:

1. Job descriptions shall specify required qualifications, duties, and experience for each position and will be updated when necessary.

2. Each employee will be provided with a copy of his/her job description upon commencement of employment.

[Back to Table of Contents]

2.A.2a        EMPLOYEE RECRUITMENT - Non Discrimination

POLICY:

No applicant shall be discriminated against on the basis of race, religion, sex, ethnicity, age, disability, or sexual preference.

PROCEDURE:

1. In all employee recruitment the most suitable candidate shall be the successful candidate.

2. If the most suitable candidate is disabled then the employer shall endeavour to make all reasonable adjustments to the work site to accommodate those disabilities.

3. All allegations of discrimination will be responded to both verbally and in writing.

[Back to Table of Contents]

2.A.3      TRAINING AND STAFF DEVELOPMENT

POLICY:

The employer recognizes that professional development is necessary, and promotes attendance when short-term training opportunities arise.

PROCEDURE:

1. The employer shall endeavour to provide at least 1 professional development opportunity per year for each full-time employee as funding and contract requirements permit.

2. Employees must submit a request in advance according to the lines of authority. Request shall include costs, and the training shall be related to the employee's position.

3. Each request shall be dealt with separately.

[Back to Table of Contents]

2.A.3a       PROFESSIONAL DEVELOPMENT POLICY

POLICY:

It is the policy of this service to provide on going professional development of its staff.  We encourage all staff to participate in on going training and development.

PROCEDURE:

1. All staff will be provided opportunities on a regular basis to improve their skills.

2. There will be a $1200.00 Per Deum offered each year to each staff in South Peace Counselling Services.  Other program funding may be prorated depending on money available in the contract.

3. Staff may use this money to pay for one training event or use parts of it for other training as the need arises.

4. We will pay for one day of travel each year for each staff.  For all training events after that the staff will be responsible to get to and from the event on their own time.

5. Any training offered by the province that is being paid for by the province is separate from this policy.

[Back to Table of Contents]

2.A.4           VOLUNTEER RECORDS

POLICY:

A record is maintained for each volunteer.

PROCEDURE:

1. Each Volunteer Record Shall Include:

1. Completed registration form.

2. Volunteers specific assignment/s in writing.

3. Documentation stating that the volunteer has completed an orientation program.

4. Reviews of volunteer's performance.

5. Signed oath of confidentiality form.

6. Completed criminal records check.

[Back to Table of Contents]

2.A.5        PERSONAL PERFORMANCE APPRAISALS

POLICY:

Personal Performance Appraisal procedures are developed and documented for each position on the program staff.

PROCEDURE:

1.  Refer to South Peace Health Council Personnel Policy  PER: P-30 .

[Back to Table of Contents]

2.A.6               JOB PERFORMANCE PROBLEMS

POLICY:

The program has a written policy and procedure to assist employees who have problems which interfere with acceptable job performance.

PROCEDURE:

1. See South Peace Health Council Personnel Policy Manual.

[Back to Table of Contents]

2.A.7           NEW EMPLOYEES

POLICY:

New employees of the South Peace Counselling Services Program will have no history of alcohol or drug abuse in the two (2) years previous to their employment commencement date.

PROCEDURE:

1. The above policy will be provided to potential new employees prior to their commencement date.

2. The onus for disclosure of alcohol or drug abuse by new employees shall rest with the employee and shall be documented on the employees personnel file.

3. Supervision is required for all staff and includes clinical debriefing which can be either peer to peer or with the clinical supervisor.

4. Employees who meet this policy and relapse during the course of employment shall be dealt with according to Personnel Policy PER: S-80 in the South Peace Health Council Policy/Procedure Manual.

[Back to Table of Contents]

2.A.7a             SUPERVISION AND SUPPORT

POLICY:

 The Program Manager is to ensure that staff meetings are held on a regular basis.

PROCEDURE:

1. A supervision schedule will be set up on an individual basis with each new employee by Program Manager, or the staff member's immediate supervisor.

2. The Program Manager will be available for ongoing supervision on an as needed basis.

[Back to Table of Contents]

2.A.8         BULLETIN BOARDS

POLICY:

Bulletin Boards are available for informational purposes in a number of locations in the Hospital/Agencies.  No information is to be posted or removed without prior authorization from the attending personnel.

PROCEDURE:

1. Bulletin Boards are located at and are the responsibility of:

1. Basement North - Representative Unions

2. Basement Centre - In-service Education

3. Basement Near Elevator - General Information - Admin Secretary

4. Basement Near Elevator - Job Postings - Personnel Secretary

5. Each Counselling Office - General Info - Secretary

2. All items posted on Boards without approval are subject to removal.

3. South Peace Counselling Services will provide a Bulletin Board for informational purposes, in each site.

4. See Appendix 3 - Dawson Creek and District Hospital Policy/Procedure REF: B-90

 [Back to Table of Contents]

2.A.9         CONFLICT OF INTEREST - CLIENT RELATIONS

POLICY:

 The employer does not condone intimate, personal relationships between employees and current clients.

PROCEDURE:

1. The rational for this policy is based on issues of confidentiality and the need to establish a therapeutic relationship.

2. The employer discourages intimate, personal relationships between employees and former clients.

3. Friendships between current clients and their primary counsellor/worker are not encouraged.  Employees shall not provide treatment services for their friends, and may refer the person to another appropriate resource. The ability to be objective and remain objective is essential in client/counsellor relationships.

4. Employees shall not provide treatment for their family members, but rather offer them alternative resources.

5. It is unethical for employees to initiate contact with clients following discharge because that would be using privileged information.

6. If a client contacts an employee outside the agency, he or she must use their best judgement in responding. At the earliest opportunity, this should be discussed with the Program Manager.

7. This will be in force for 2 years after clients termination from program.

8. Counsellors may provide a home contact number for a short term solution. Counsellors will consult Program Manager when an event like this arises:

1. Client is Suicidal

2. Employee primary contact.

3. Employee has energy/ability/time to do so.

9. This is considered and extremely rare event and is a short term solution. Counsellors will consult Program Manger when an event like this arises.

 [Back to Table of Contents]

2.A.10      EMPLOYEE RECRUITMENT - Criminal Record Check

POLICY:       

New South Peace Counselling Services employees must consent to a criminal record check as a condition of employment.

PROCEDURE:

1. The client's safety and well-being is paramount. Once a review has been completed, should there be any doubt or concern regarding potential safety for a client, the applicant is not to be considered as a potential employee of South Peace Counselling Services.

2. Any person with a previous record of sexual abuse or violence shall not be considered as an employee. The following criteria are to be applied to determine if there is a cause to reject a person's application or to terminate their services if they are already an employee.

• number and type of charges, convictions and diversions;

• time between past criminal activity and present;

• age and circumstances of the individual since the offense;

• likelihood of individual repeating any offenses;

• relevance of criminal activity to provision of service.

 [Back to Table of Contents]

2.A.11             LABOUR STANDARDS

POLICY:

The employer recognizes and adheres to the Employment Standards Act, the Labour Code       and Human Rights legislation as they are stated provincially and federally.

[Back to Table of Contents]

2.A.12             TIMESHEETS

POLICY:

Time sheets shall be maintained by all employees.

PROCEDURE:

1. Time sheets shall be completed bi-weekly and submitted to the Payroll Department.

2. The Program Manager will initial all time sheets in Chetwynd, Tumbler Ridge and Dawson Creek  and forward the completed time sheets.

[Back to Table of Contents]

2.A.13             Professional Code of Conduct

POLICY:

It is the policy of this program to protect human rights and the dignity of persons served.

PROCEDURE:

1. The use of physical force on a client is strictly forbidden, other than in self defense. If physical force is required, the RCMP will be contacted.

2. Physical restraining devices will not be used in these programs.

3. Psychological abuse on the part of counsellors will not be tolerated. This includes humiliating, threatening or exploiting actions.

4. Staff will be expected to comply with BCASW Standards at all times. (See Appendix)

[Back to Table of Contents]

3.A.1         BUDGET

POLICY:

 The program uses a formal written procedure to prepare a revenue and expense budget.

PROCEDURE:

1. A Revenue and Expense Budget will be developed on an annual basis for submission in a Program Proposal to Ministry of Children and Families by the Program Manager.

2. The Revenue and Expense budget shall be developed based on the previous year's actual costs and anticipated program requirements for the coming year.

3. The Revenue and Expense budget require the approval of the Addictions Manager and South Peace Health Council or designate, prior to submission to Contract Manager for the Ministry of Children and Family Development.

[Back to Table of Contents]

3.A.2       ACCOUNTING

POLICY:

All Accounts Payable and Receivable data will be entered into the Accounts Payable and General Ledger component of the ACCPAC computer system. Reporting will be completed in 13 monthly periods per year.

PROCEDURE:

Accounts Payable:

1. All invoices for goods & services delivered to the South Peace Counselling Service’s offices will be checked & acknowledged when received.

2. Acknowledged invoices will then be processed and coded with the appropriate General Ledger account number.

3. All requests for payment must have appropriate back-up information - ie. Invoices, petty cash voucher, inter office memo.

4. Coded invoices will be authorized for payment by the South Peace Counselling Service’s Program Manager.

5. All authorized invoices with prepared cheques will be delivered to the South Peace Health Council Administration Departments for final approval and signatures. Cheques and back-ups will then be returned to the South Peace Counselling Service’s offices for distribution.

6. The South Peace Counselling Service’s business offices must ensure that all invoices be presented for the appropriate accounting period.

7. All Accounts Payable will be input/posted in the ACCPAC Accounts Payable Manual check program. When check data input has been completed and posted a batch list and check register will be printed. 

Accounts Receivable:

Direct deposit Grant Payments, Bank Interest income, Travel Reimbursements, and other miscellaneous revenue if any, will be recorded in period Journal Entries, as per Monthly Bank Statement. The recorder must ensure that the appropriate G/L account numbers are noted for each transaction.      

 General Ledger:

1. All Journal Entry data will be “in put” in the ACCPAC G/L transaction program and posted.

2. All Accounts Payable data will be retrieved from the Accounts Payable component and posted to the G/L.

3. When all data input has been completed and posted for the period the following reports will be printed:- G/L transaction Batch List, General Ledger Listing, Trial Balance Worksheet, and Monthly Balance Sheet, & Monthly Income and Expense Statement.

4. Two copies of the Monthly Balance Sheet & Income and Expense Statement will be delivered to the at the end of each period.

5. Copies of all accounting reports, invoices, back-ups and bank statements are kept on file at the South Peace Counselling Service’s business offices.

[Back to Table of Contents]

3.A.2a        ACCOUNTING SYSTEM

POLICY:

The program uses an accounting system for nonprofit operations with the capacity to ensure proper use of funds and thorough documentation of financial transactions.

PROCEDURE:

The accounting system for South Peace Counselling Services shall comply with standards for nonprofit operations including:

1. A monthly financial statement and balance sheet provided to the Program Manager.

2. Quarterly financial reports provided to Contract Manager/Administrator Supervisor for the Ministry of Children and Families.

3. Monthly submission of Federal/Provincial Cost Sharing forms to Contract Manager/Administrator Supervisor for the Ministry of Children and Families.

4. An annual audit of accounts completed by an independent accounting firm.

[Back to Table of Contents]

3.A.3        ACCOUNTING CONTROLS  - PETTY CASH

POLICY:       

Cash handling controls are established for the subsequent and proper handling of petty cash receipts and disbursements.

PROCEDURE:

1. Petty cash shall consist of up to $500.00 to be replenished at the end of each month.

2. Any cash disbursement must be accompanied by a receipt and an Internal Petty Cash Voucher.

3. Petty cash shall be in a cash box, in a locked cabinet, and audited by secretaries.

[Back to Table of Contents]

3.A.4         AUDIT

POLICY:

The program conducts annual financial audits to ensure that funds are received, handled and disbursed in a proper fashion.

PROCEDURE:

1. The audit shall be completed by an appropriate accounting firm.

2. The audit shall be performed as of March 31st of each year.

3. The audit report presents the financial position of the program at the time of audit and assesses accounting policies, procedures and operations in light of generally accepted accounting principles for non-profit operations.

4. The audit report is available to the Board of Trustees, the Chief Executive Officer, the Program Manager/Administrator Supervisor and program staff.

5. A copy of the annual audit report shall be sent to Ministries of Children and Families, Contract Manager and other contractors upon request and the Societies Act.

[Back to Table of Contents]

3.A.5        REPORTING REQUIREMENTS

POLICY:

 All programs must fulfill all requirements imposed by the funding source.

PROCEDURE:

1. The following reports must be submitted:

2. Federal - Provincial Cost Sharing Forms shall be submitted bi-monthly.

[Back to Table of Contents]

4.A.1     Philosophy and Treatment Approach

POLICY:

There is a written description of the program's philosophical approach to treatment.

MISSION:

South Peace Counselling Services mission is:                       

  “People working co-operatively with community to promote balance and quality of life.”

HOPE - Health and wellness, Openness for change, People helping people, Equality for all.

PHILOSOPHY:

South Peace Counselling Services respects the integrity of each human being and believes that each person has the ability to change and to accept personal responsibility for physical, psychological, emotional and social health.

 PROCEDURE:

1. Treatment - South Peace Counselling Services provides individual, family, and group counselling to people experiencing problems because of their own alcohol & drug consumption or because they are adversely affected by someone else's alcohol & drug consumption.

Treatment activities may include:

• Intake, situational assessment and screening

• Life areas assessment

• Referral to other resources

• Individual, family, group counselling

• Information and skill development workshops

• Aftercare, relapse prevention, and Follow-up services

Consultation and collaboration with other professionals providing services to individuals or families where alcohol and drug problems exist is also available.

2. Prevention - South Peace Counselling Services provides supportive counselling and education to people considered "at risk" for developing substance abuse problems.  Community and school information presentations are also available in Dawson Creek and surrounding areas.

 Prevention activities may include:

•  Educational presentations to schools, community groups, and allied professionals.

• Program Development and implementation for harm reduction strategies, competency skills, values clarification and decision-making for "at risk" populations.

• Training programs to recognize and respond to substance abuse for allied professionals.

• Media liaison and inter-agency liaison.

All prevention activities will be directly related to preventing the onset of substance abuse problems, reducing the harm resulting from substance abuse, or preventing further problems as a result of substance abuse.

 [Back to Table of Contents]

4.A.1.a    OBTAINING INPUT FROM PERSONS SERVED

POLICY:

South Peace Counselling Services will obtain input from the persons served.

PROCEDURE:

1. A suggestion box is readily available.

2. Each client is given an information package and encouraged to speak to their counsellor about any concern they may have.

3. Each client is asked to participate in their  treatment planning, and case conferences.

4. Each client is asked to sign the necessary documentation to allow for the exchange of information concerning them.

5. A monthly satisfaction survey is handed out at random to seek further input from consumers.

6. All clients are provided with a discharge questionnaire and a satisfaction survey 6 months after termination with the program.

7. An open house is held once each year to facilitate communication and feedback.

8. South Peace Counselling Services seeks feedback, in the form of a satisfaction survey, from all consumer groups/agencies using our program.

9. South Peace Counselling Services is actively involved in many community agencies to ensure ongoing feedback and communication.

10. All comments are examined and incorporated into the program when feasible.

11. Reports and recommendations are regularly submitted to appropriate personnel to ensure consistency and follow - up.

[Back to Table of Contents]

4.A.2         CLIENT RIGHTS

POLICY:

All clients shall be informed of their rights.

PROCEDURE:

1. The “Clients Bill of Rights”, “Code of Ethics”, and “Grievance Procedures”,  will be posted in the waiting area.

2. The orientation package will include a copy of the “Clients Bill of Rights”, The “Clients Responsibilities” and “Safety Information”.

3. The “Clients Responsibilities” and “Safety Information” will be discussed with each client during  the orientation process.

4. Counselling staff will provide advocacy on behalf of any client who is experiencing difficulty accessing services.

5. Any concerns will be discussed with the Client.

6. Statement of confidentiality included in package.

7. Expectations they can have of us and what we have of them

8. All treatment will be based on “informed consent”.

[Back to Table of Contents]

4.A.2.a        CLIENT GRIEVANCES

POLICY:

South Peace Counselling Services undertakes to provide fair and equitable treatment of all clients and provides an opportunity for clients to express a grievance with regards to staff and/or services provided and to receive a response to inappropriate staff or treatment activities. This will include any activities that may be deemed unethical.

PROCEDURE:

At the time of orientation each client will be informed about the procedure for expressing a grievance concerning staff or services. The Grievance Procedure is posted in the waiting area.

The procedure for expressing a grievance is as follows:

1. It is suggested that the client first meet with his/her counsellor to seek resolution, (within 48 hours).

2. If (a) is not sufficient it is suggested that the client seek a meeting with the Program Manager/Administration Manager to address the grievance further, (within one week).

3. If (a) or (b) do not resolve the issue the client is encouraged to discuss the grievance with the Chief Executive Officer of the South Peace Health Council, (within one month).

4. Either a, b, or c, may be the first step depending on the nature of the grievance or the individual involved, (within 2 months).

At the time of orientation each client will be informed about the procedure for expressing a grievance concerning staff or services. The Grievance Procedure is posted in the waiting area.

In the event that none of the above procedures resolve the issue the client is encouraged to write (within 3 months) to:

Board Chairperson
South Peace Health Council
11100 13th St.,  Dawson Creek, BC
V1G 3W8

Clients may also contact:   

South Peace Counselling Services, Program Manager
1001 - 110th St., Dawson Creek, BC  V1G 4X3

 [Back to Table of Contents]

4.A.3      NONDISCRIMINATION

POLICY:

There will be no discrimination on the basis of race, religion, sex, ethnicity, age, disability, sexual preference or for high risk or carriers of communicable diseases in any admission or treatment activities; unless the service is provided to a specific population.

PROCEDURE:

1. A list of alternate resources shall be made available to any clients needing service where our target population is not all inclusive.

2. Referral services are made available to individuals ineligible for admission to the program.

[Back to Table of Contents]

4.A.4    INDIVIDUALIZED TREATMENT

POLICY:

 All clients shall have a documented individualized treatment plan.

PROCEDURE:

1. The client shall have an opportunity to participate in planning their treatment plan.

2. Treatment planning shall address ongoing treatment and care within the context of community and client resources by the use of immediate and long range goals.

3. A treatment plan form shall be used which outlines immediate and long range goals, tasks, and number of sessions to accomplish goals.  The treatment plan form will include counsellor and client signatures and will be considered a contract for service. The treatment plan will be completed for all clients by the end of the fifth counselling session.

[Back to Table of Contents]

4.A.5         DISPENSING OF DRUGS

POLICY:

Under no circumstances will employees or volunteers dispense mood altering drugs to clients.

Only under special circumstances will South Peace Counselling Service’s staff dispense Anitbuse to clients.

PROCEDURE:

1. Clients requesting South Peace Counselling Service’s staff monitor medication must do so in writing and sign Release of Information form concerning the prescribing physician.

2. South Peace Counselling Service’s staff will contact the prescribing physician to determine if staff monitor medication to this client is appropriate.

3. South Peace Counselling Service’s staff will request approval from the Program Manager prior to monitor medication to any client.

4. Daily records indicating date, time and amount will be initialed by staff and the client for any monitor medication by South Peace Counselling Services.

 [Back to Table of Contents]

4.A.6       RESOURCE ORDERING

POLICY:

Counsellors are encouraged to increase and augment the current resources.

PROCEDURE:

1. Counsellors may request resource material (books, posters, videos, art supplies, etc.) with permission from the Program Manager and subject to budgeting restraints.

2. The request may be taken to a staff meeting if the counsellor is unsure of the effectiveness or merit of a particular item.

3. The person who orders the resource is responsible for reviewing the item once received, and deciding whether it's for general (public) use or counsellor use.

4. If not appropriate, the resource should be returned for a refund.

5. If appropriate, item should be brought to a staff meeting for general information.

[Back to Table of Contents]

4.A.7        INTOXICATED PERSONS

POLICY:

The program has a written policy describing the procedures for dealing with intoxicated or behaviourly disturbed persons.

PROCEDURE:

Individuals who arrive at South Peace Counselling Services offices and appear intoxicated will be dealt with according to protocols for crisis management. Given that staff  have no immediate concerns for their own safety in a situation with an intoxicated person, there will be treatment available for most intoxicated individuals:

1. A course of action may be proposed to ensure the intoxicated person is safe, and, if appropriate, able to receive a medical assessment.

2. A course of action may be proposed to assist the  intoxicated person to withdraw under conditions that are not medically supervised.

3. All counselling for intoxicated individuals shall be undertaken for crisis management only.

[Back to Table of Contents]

4.A.7.a            Transportation of clients to Detox 

Policy:

The program has a written policy describing the procedure for providing transportation for all clients who are in need of attending a Detox facility.

Procedure:

A screening interview will be carried out with each client requesting help.  The Detox screening process will include specific criteria as follows:

1. Is the person capable of detoxing on their own.  If no:

2. Do they need a referral to an outside agency. If yes, then are they suitable for a detox unit - or - do they need to be in a hospital. If the hospital is a question we refer the client to their physician or emergency. If the client is suitable for a detox unit. We contact the unit ensuring a bed and fax out a referral form to the designated unit.

3. Once a referral has been made we arrange for transportation. Can the client get there on their own. Do they have a means of transportation they can access. If the client is on a mood altering substance they can not drive their own vehicle.

4. If they cannot arrange their own transportation we will contact social services to arrange bus transportation. If withdrawal management needs to happen before they can access the bus system we refer them to their own physician or Emergency.

5. In the very rare event that Social Services cannot provide a bus ticket we will search for an alternate form of transportation.

• contact AA people

• provide a small dollar value to each person will to provide transportation (20.00)

• wait until the following day to arrange transportation

6. On very rare circumstances when the client is acting out and are a danger to themselves or others the RCMP will be called.

7. If the client is in need of protection and all other resources have failed only then will our own resources be accessed. We may transport ourselves (if we are safe) or call New Horizons to access support.                  

[Back to Table of Contents]

4.A.8       BEHAVIORALLY DISTURBED PERSONS

POLICY:

Client exhibiting a behavioral disturbance which eliminates the ability to provide outpatient counselling shall be referred to a more appropriate resource.

PROCEDURE:

1. Clients may be referred to the hospital, then a physician, if necessary.

2. The RCMP  shall be called if their behaviour is of danger to themselves or others in the office.

3. If RCMP is called, an incident report needs to be written.

[Back to Table of Contents]

4.A.8.a          SUICIDAL CLIENTS          

POLICY:

Every client who indicates suicidal ideation will be assessed and contracted with to ensure that they do no harm. A referral to a mental health professional should also be provided if the risk is imminent.

PROCEDURE:

1. All clients who are indicating suicidal thinking will be assessed for level of risk.

2.  Level of risk will include an assessment of immanency, plan, opportunity and causal factors in their life, etc.

3.  If the client is clearly at risk of imminent suicidal behaviour the client is given an immediate referral to the hospital for treatment.

4.  If the client refuses to go to the hospital the client is informed that the RCMP will be called to ensure that they arrive and are seen at the hospital.

5. If the client is not seen as imminently suicidal then the counsellor will develop a safety plan with them to ensure that they remain safe.

6. The safety plan will include having friends or family staying with them during times of crises, having an emergency list of numbers they can call for help, a signed contract between counsellor and client indicating that the client agrees to the terms laid out in the contract, etc.

7. All information is reported to the Program Manager and information is documented on the clients file.

[Back to Table of Contents]

4.A.9        NO SHOW CLIENTS

POLICY:

Clients or people requesting counselling services who fail to cancel their counselling appointment for 2 consecutive times will be referred to their counsellor before more appointments are scheduled.

PROCEDURE:

1. The Counsellor will discuss the missed appointments with the client prior to scheduling more appointments.

2. The Counsellor will treat consecutive missed appointments as a treatment issue.

3. The Counsellor and the client will develop and act on appropriate strategies for dealing with consecutive appointments missed by the client.

[Back to Table of Contents]

4.A.10         REFERRAL SERVICES

POLICY:

The treatment planning process recognizes other service needs of the client.

PROCEDURE:

1. Information from other resources may be necessary to complete an assessment or treatment plan. A release of information will be obtained for such a purpose.

2. If a further assessment is needed to complete this office's assessment, the client will be referred and the assessment obtained, with the appropriate release.

3. Clients may be referred to other programs and community resources during or after the treatment process.

4. Specific referrals will be made based upon assessment, identification and goal setting.

[Back to Table of Contents]

4.A.11     CASE CONFERENCING

POLICY:

Case conferencing is available for purposes of case management.

PROCEDURE:

1. Case conferencing may occur at anytime with the Program Manager or another counsellor or agency.

2. Case conferencing can be used for 2 purposes:

1. to continue ongoing education and skill development of staff.

2. ensures good treatment planning and implementation.

3. Case Management will occur in-house with own counsellors or with an inter-agency approach and follow-up.

4. All case conferences will have a designated case manager and a minute taker.

5. All minutes outcomes and follow-up will be recorded in clients chart.

[Back to Table of Contents]

4.B.1   ADMISSIONS CRITERIA AND PROCEDURES

POLICY:

South Peace Counselling Services has written criteria for admission to treatment.

PROCEDURE:

1. Anyone may access this program for initial contact and a brief screening to determine eligibility and appropriateness to the program. Once eligibility has been established, the assessment package will be completed within 5 sessions, and if appropriate, a treatment plan developed.

2. For Addictions - admission criteria for this program will include those who’s lives are affected by their own or someone else’s alcohol and/or drug misuse.  For all other programs, the admissions criteria is set by the contract.

3. If a clients concerns are not related to program contract criteria, then appropriate referral sources will be found.

4. Priority will be given to people presenting with a medical emergency. These people will be referred to the appropriate agency (ie Hospital Emergency Dept. or doctor).

5. Pregnant women who are actively using will also be viewed as a medical emergency and will be seen immediately, then referred to the appropriate agency/doctor. 

Levels of Priority:

[Back to Table of Contents]

4.B.1a          REFERRALS

POLICY:

Clients will be referred to other services as needed.

PROCEDURE:

1. Clients who are identified as being ineligible for this program will be referred to an appropriate agency. A contact person will be identified and a Consent to Exchange of Information form will be signed by the client. A follow-up contact with the identified contact person will be carried out and documented on the client file.

2. Client who may benefit from the services of another agency in conjunction with this program will be referred to the appropriate agency. A Consent to Exchange of Information will be signed by the client. A contact will be established with the referred agency and follow-up documentation will be  requested by this agency.

3. Clients who are receiving care from another agency and are requested to attend this office for purposes of counselling will be asked to sign Consent to Release of Information Form. The assigned counsellor will contact the referral source and request documentation on involvement and areas of concern. Documentation will be placed on the client file.

[Back to Table of Contents]

4.B.2      INTAKE PROCEDURES

POLICY:

There is a written intake procedure for clients accessing treatment services.

PROCEDURE:

1. Initial Contact by Phone:

• Clients will be offered an appointment time with a counsellor, the option of drop-in for information will be offered.  This includes the self-help group lists and other resources in the community.           

• If a crisis situation is apparent, receptionist will attempt to slot client between regular sessions.  Information of how to access Detox facilities can be offered by the receptionist, as well as information on other available services.

2. Initial Contact in Person:

• Drop in client will be required to fill out an initial intake form and will be given a date for a scheduled (nearest possible) appointment. If a counsellor is available they may then proceed with the orientation procedure which consists of information on local community services and residential or Detox  treatment options.

• Boundaries of confidentiality and depression or suicide evaluation will be completed.

• If client appears threatening to staff, RCMP will be notified immediately.

• Counsellor can take whatever steps necessary to ensure clients physical safety.

3. Intake Form:

• The receptionist will assist the client in completing an intake form prior to first appointment. This form will offer enough information to start a complete file with Personal Health Care Number.  At this point, the receptionist will offer to give the client a reminder call for scheduled appointments.

[Back to Table of Contents]

4.B.3         ORIENTATION

POLICY:

All clients receive an orientation to the program, at the first  opportunity.

PROCEDURE:

1. Clients shall, at their intake session, be informed of:

1. The Nature and Goals of the program

2. The Process for Assessment and Treatment Services

3. Frequency and Duration of Counselling Sessions

4. Any Fees or Costs involved in Service

5. Confidentiality, Release of Information, and Limitations

6. Client Bill of Rights

7. Safety Procedures

2. The counsellor will provide an orientation to the program prior to developing a service contract with a client.

[Back to Table of Contents]

4.C.1      CLIENT STATISTICS

POLICY:

An up-to-date record of program utilization shall be maintained.

PROCEDURE:

1. The Clerk/Receptionist, as directed by the Program Manager, will compile a summary of client service utilization on a monthly basis. 

2. The Clerk/Receptionist will develop a data base which includes the total number of counselling sessions attended by each client receiving counselling services.

3. The Clerk/Receptionist, as directed by the Program Manager, will summarize the program activities undertaken by South Peace Counselling Services on a monthly basis.

[Back to Table of Contents]

4.C.1.a       CLIENT WAIT LIST

POLICY:

A waiting list will be maintained on all clients unable to access our program within two weeks.

PROCEDURE:

1. A wait list will be maintained for all clients needing to access our program and who must wait for more than two weeks for an appointment.

2. The client wait list will include the reason for attending this program and referral source.

3. The client wait list will be maintained indefinitely.

[Back to Table of Contents]

4.C.1.b          REFERRED CLIENTS

POLICY:

All clients being referred by other agencies will be tracked.

PROCEDURE:           

1. All clients being referred by outside agencies will be channeled through the secretary.

2. Each new referral will be noted in a confidential location with an anticipated intake date recorded.  The secretary will document this information.

3. Any new bookings for the client will be recorded in one central appointment book for each office.

4. The appointment book will be used as a second check to ensure that all clients have been in contact with the office.

[Back to Table of Contents]

4.C.2         CLIENT RECORD SYSTEM

POLICY:

There is a standardized client record-keeping system.

PROCEDURE:

1. Each client file shall contain:

1. Signed Permission to Treat form

2. Completed Intake Measures form

3. Medical Information form

4. Client assessment

5. MAST

6. DAST

7. Medical Triggers

8. Client Treatment plan (signed)

9. Case Notes

10. AIMS Form

11. Outcome Measures Form

2. Each contact (in person, by phone, or out of office) with the client shall be recorded.  The date, length of contact and purpose of contact will be noted.

3. In addition a brief overview of the session’s content shall be recorded. This shall include any change in client's status, goals worked on, and plan for next session.

4. The counsellor writing the client record will add his or her signature, in full,  for all case notes kept.

[Back to Table of Contents]

4.C.2.a     ADOLESCENT RECORD SYSTEM

POLICY:

There is a standardized client record-keeping system.

PROCEDURE:

1. Each client file shall contain:

1. Signed Permission to Treat form.

2. Completed Intake Measures form.

3. Medical Information Form.

4. Adolescent Assessment.

5. MAST

6. DAST

7. Medical Triggers

8. Client Treatment Plan (signed)

9. Case Notes

10. AIMS Form

11. Outcome Measures Form

12. PESQ

2. Each contact (in person, by phone, or out of office) with the client shall be recorded.  The date, length of contact and purpose of contact will be noted.

3. In addition a brief overview of the session’s content shall be recorded.  This shall include any change in client’s status, goals worked on, and plan for next session.

4. The counsellor writing the client record will add his or her signature, in full, for all case notes kept.

[Back to Table of Contents]

4.C.2b      Client Records - Confidentiality

POLICY: 

All client files and correspondence relating to clients must be kept in a secure area.

PROCEDURE:

1. All client files and correspondence relating to clients must be returned at the end of each day to the locked file room for safekeeping.

2. No client information will be left in areas to which the public has access.

3. If the file room isn’t visible from the reception area, the file room door must be kept closed at all times, and locked at the end of each work day.

[Back to Table of Contents]

4.C.3     CONFIDENTIALITY

POLICY:

It is essential for the protection of the client and the credibility of the treatment service that all matters pertaining to clients be kept in strictest confidence. Therefore, no employee or volunteer shall disclose any information, verbal or written, which refers to a client without written permission.

PROCEDURE:

1. INFORMATION ON CLIENTS MAY BE DISCLOSED WITHOUT WRITTEN CLIENT CONSENT FOR THE FOLLOWING:

1. In cases of suspected child abuse or neglect, and in cases of current or past sexual abuse in which the offender may have present access to minor aged children, ADS staff  is obliged to inform appropriate authorities in the Ministry of Human Resources, Ministry of Children & Families.
2. When a client states that he/she intends to inflict bodily harm to another person, staff will attempt to notify the potential victim(s) and encourage him/her to take appropriate action.  Staff will notify the police.
3. Upon subpoena to testify in court at the direction of a judge, or other court order.
4. When a person appears unfit to operate a vehicle and is known to intend to drive upon leaving the clinic, police will be notified.
5. When a client states that he/she intends to commit suicide staff may notify emergency services deemed necessary to save the individual's life.
6. When information is required by the Workers' Compensation Board as part of an investigation of a compensation claim.
7. When consistency of service is required counsellor gives necessary information to another agency “LESS IS BEST” is rule of thumb.

2. Release of Information by a client shall be on a standard “Client Consent to Exchange of Information” form signed by the client which states what information will be released, to whom, and for what purpose, within a specified time frame.
3. Apparent breaches of confidentiality shall be investigated and appropriate action taken.  Procedures for investigation shall be used as outlined in the Policy on Complaints, Policy # P-10, of the South Peace Health Council Administration Manual.

[Back to Table of Contents]

4.C.4      Intake Process

Policy:

There will be an intake process for everyone admitted to the program.

Procedure:

1. Every person contacting this office for an appointment will be given an appointment time and date or waitlist.

2. A brief screening will be done by the contact person.

3. Client will be given the following forms to complete on initial visit:

1. Intake Form

2. MAST

3. DAST

4. Client Bill of Rights

5. Intake Measures Form, and

6. Asked to sign the Consent to Treatment Form

4. Counsellor will score the MAST & DAST and determine if admission to this program is appropriate.

5. If admission is appropriate, the client will be booked for an assessment at time of next visit.

[Back to Table of Contents]

4.C.4a        Adolescent Assessments

Policy:

All adolescents will receive an individual assessment if they are admitted to the program.

Procedure:

1. All adolescents will receive a screening when they ask to see us.

2. Adolescents who meet requirements of the program will be offered an admission.

3. Adolescents who are admitted will be assessed over an 8 to 10 session time period.

4. The physical assessment will need to be carried out a designated physician in the community. The assessment will include information regarding motor development and functioning, speech, hearing and language functioning; visual functioning; immunization status; evaluation of developmental age factors; learning ability; and intellectual functioning.

5. All adolescents who are admitted will receive an assessment in the form of a Personal Experience Screening Questionnaire (PESQ).

6. All goals and objectives will be age specific.

[Back to Table of Contents]

4.C.4.b       Assessment Process

Policy:

All clients identified as being appropriate for this program will undergo a formal assessment.

Procedure:

1. Each client coming into this office will receive a screening interview.

2. Upon deciding that this client meets our program mandate we will begin an assessment process.

3. The assessment will include all areas in their life including: physical characteristics, presenting problem, family of origin information, alcohol/drug use, physical and emotional health, education, occupational history, social/life skills, religion, finances, marital history/sexuality/HIV risk etc, legal issues, present living arrangements, strengths and limitations, and an interpretive summary.

4. All assessments will do goals setting. This will include both short and long term goals. The assessment will also ask for specific behaviours the client wishes to change in order to achieve their goals identified.

5. All assessments will have client input and must be signed by the client at the end of the assessment process.

6. All assessments will be revised as clients progress with their treatment.

7. All assessments will be completed by the fourth session. If a written assessment is not completed the reasons must be documented.

[Back to Table of Contents]

4.C.5    TREATMENT PLAN

POLICY:

An individualized treatment plan must be developed for each client following the assessment and clinical impression; ie: by the third client visit or by 30 days from the date of admission.  Mental health will be completed by the 5th visit.

PROCEDURE:

1. The treatment plan shall be written on the client’s file.  The plan identifies.

1. Goals for the treatment of each identified client problem (the desired outcomes and expectations of the client and counsellor).

2. Time frame for goal achievement.

3. Measurable objectives (treatment strategies) to be utilized to achieve the specific outcomes or identified goals.

4. Person(s) responsible for implementing the treatment plan/strategies.

5. Frequency and duration of treatment strategies.

6. Description of the structured program, services, activities planned for the client. 

2. Clients will sign their individual treatment plan once formulated and agreed to by the counsellor and client.  There is periodic review of the treatment plan by the client’s primary counsellor and the primary counsellor’s supervisor.

3. The counsellor shall discuss the treatment plan with the client acknowledging strengths and weaknesses of the plan, possible outcomes, length of treatment, and other alternatives.

4. The treatment components shall be presented to the client in terms that are understandable to him/her.

[Back to Table of Contents]

4.C.5.a        Gynecological and Obstetric Needs

POLICY:

All women who have been identified as being pregnant and are substance abusers will be referred to a family physician.

PROCEDURE:

1. All new female clients will be screened for pregnancy.

2. All female clients with a positive response to the screening test will be referred to a family physician for physical examination and follow up.

3. The client will be asked to sign the necessary Release of Information form so that the attending physician can be contacted. All documentation will be recorded in clients file.

4. A risk assessment for Sexually Transmitted Diseases (STD’s) will be initiated on all female clients during the assessment process.

[Back to Table of Contents]

4.C.6     RUNNING RECORDS

POLICY:

Running Records will be maintained on each client file.

PROCEDURE:

1. Each contact (in person, by phone, out of office), with the client will be recorded. The date client was seen, the length of contact and the date the record was made will be noted.

2. In addition a brief overview of the content of the session will be recorded.  This will include the purpose of the interview, any change in clients’ status, description of services provided, goals worked on, the counsellor’s professional assessment or “impressions” and plan for the next session.

3. All records will be typed, grammatically clear, correct  and concise.

4. All records will be in chronological order.

5. All entries will be signed and dated (the date they are signed).  Any errors should be changed and initialed.

[Back to Table of Contents]

4.C.7        CASE CLOSURE

POLICY:

The closure and destruction of client records shall occur in order to maintain accurate case-load data and shall protect client confidentiality.

PROCEDURE:

1. The closed file shall contain at a minimum:

1. Clients intake sheet

1. Signed permission to treat form

2. Completed intake measure form

2. Client assessment

3. Treatment plan (signed)

4. Contact record (AIMS forms) if only for AAS

5. Termination summary

2. A case shall be closed when there has been no face-to-face contact for a period of 90 days.  Telephone calls to do aftercare or follow-up may have occurred.

3. Completion of treatment occurs when either:

1. the original treatment plan has been completed, or

2. the client and counsellor agree that treatment has been completed as far as the client can go at that time.

4. An inactive case is one where the client has no-showed last appointment and lost contact.

5. Client records shall be securely stored for the time periods specified in

Policy 1.C.1  QUALITY ASSURANCE - FILE DESTRUCTION.

6. Client records shall be destroyed by burning or shredding.

[Back to Table of Contents]

4.C.7.a      Discharge Summary

POLICY:

Each discharged client file shall contain a discharge summary.

PROCEDURE:

If the client does not fit our mandate we will refer them to an appropriate community agency. Reason for the referral will be stated in client file.

1. The following shall be included:

1. Clients name, date of event and reason for referral.

2. Name of contact person.

3. Report of outcome (if available).

2. The discharge summary will include:

1. Issues identified.

2. Summary of Treatment.

3. Desired outcomes and expectations.

4. Reason for discharge.

3. Recommendations will be included. A follow up form will be sent, six months after discharge, to each client if he/she indicates they wish to be contacted after they have been formally discharged from the program.

[Back to Table of Contents]

4.C.7.b    DISCHARGE POLICY

POLICY:

All files that are closed will have a discharge summary attached to the file.

PROCEDURE:

1. All files will be closed after a four-month duration within which there has been no contacted by the client.

2. All files will have a discharge summary written by the counsellor and attached to the file.

3. All Addiction Staff will mark their files complete only after the treatment plan has been signed off by the client. All other files will be closed and marked incomplete on the AIMS form.

4. All other staff will consider the file incomplete if the assessment information needed on the client has not been completed during the time the client was seeing the counsellor.

5. All staff will use the client discharge form designed for their program.

6. It is considered “best practice” if all progress notes and discharge summaries are typed and attached to the file.

[Back to Table of Contents]

4.C.7.c      File Management

POLICY:

All files that have client content are property of MCFD and are protected under their policies.  There is to be no destruction of any material except under specific circumstances.

PROCEDURE:

1. All files will be reviewed and filed following case closure procedures.

2. All appointment books are considered part of file information and are not to be destroyed.

3. Any notes made about the client including informal notes for the counsellor are considered part of the client file and are to be placed on the file.

4. Appointment books are to be kept for two years after they are no longer in use.

5. Client files are to be maintained following MCFD criteria.  Adult files are to be stored for 25 years.  All files begun when the client is a child/youth are to be stored for 89 years.

6. Any information gathered that falls outside the above guide lines, is to be referred to the Program Manager for final decision.

[Back to Table of Contents]

4.C.8      CASE CONFERENCING re: Client Management

POLICY:

Case Conferencing is available for purposes of case management.

PROCEDURE:

1. Case conferencing may occur at anytime with the Program Manager or another counsellor.

2. Case conferencing may occur at a staff meeting allowing for group input on more complex cases, or where more than one counsellor is involved on an ongoing basis.

3. In the circumstance of Case Conferencing for professional development purposes, the client name will be changed.

4. Any information received in Case Conferencing will not be used for any other purposes.  It is confidential and only to be used for Case Management purposes.  It may not be divulged to other agencies without a signed release of information. Unless continuity of service is required (FOI).

 [Back to Table of Contents]

4.C.8a     AFTERCARE

POLICY:

Aftercare occurs for clients who have had their file closed and request one or two extra sessions for supportive or crisis counselling.

PROCEDURE:

1. Aftercare shall be a maximum of four sessions (more than that the file should be reopened).

2. The content of the session is to review the tools the client has learned and review their choices.

3. The file shall be reopened if the client has new issues to work on.

[Back to Table of Contents]

4.C.8b     FOLLOW-UP

POLICY:

Follow-up occurs for the purpose of program effectiveness, evaluations or individual outcome.

PROCEDURE:

1. Three months following the Discharge Event, a Satisfaction Survey and Outcome Measures Survey will be mailed to those clients who indicated on the Consent To Treatment Form that they would be willing to participate in this follow-up procedure.

2. Information gathered will be tabulated in the annual report.

[Back to Table of Contents]

4.C.8c       Formal Assessment Requests

POLICY:

It is the policy of Dawson Creek Alcohol & Drug Services to provide up-to-date formal assessments on request.

PROCEDURE:

1. Assessments will be provided to community agencies when requested.

2. Assessments will follow a standard format.

3. Assessments will be summarized, typewritten and forwarded to requesting agency.

4. All assessment information will be maintained as part of the client file and will be subject to policies on confidentiality (4.C.2 and 4.C.2a).

[Back to Table of Contents]

4.C.9     CASE REVIEW

POLICY:

All clients who have been in treatment for longer than 90 days will be reviewed at 90 days, 6 months and 1 year.

PROCEDURE:

1. Clients may be identified from the length of stay statistics available from AIMS Database.

2. The Program Manager in conjunction with the counsellor will review clients’ treatment plan and progress.

3. The Case Conferencing Form will be used for this purpose.

[Back to Table of Contents]

4.C.9a     CLIENT SERVICES SURVEY

POLICY:

Clients should be provided opportunities to give feedback about services being provided and ongoing program development.

PROCEDURE:

1. A survey will be distributed monthly to all clients who come to our program on one specific day.

2. All clients who come on that day will be asked to answer the questions on the Client Services Survey.  Time will be provided for them to complete the questionnaire before they receive the services of the program.

3. The survey will be distributed on a different day of the week to maximize distribution to target population.

4. A yearly tabulation of results will be conducted and submitted with annual report for review and recommendations.

[Back to Table of Contents]

4.C.10       PROGRAM EVALUATION

POLICY:

It is the policy of this program that it will ensure that all levels of the organization will have an outcome based evaluation process.

PROCEDURE:

1. There will be goals and objectives set for all components of the program.

2. All goals will have target dates set with periodic reviews to ensure target dates are met.

3. There will be a written evaluation for each program component that will be reported to the appropriate governing bodies.

[Back to Table of Contents]

4.C.11        CLIENT’S ACCESS TO FILES

POLICY:

Clients can review his/her own case file under provisions of the Freedom of Information and Protection of Privacy Act (FOIPP)(1993).

PROCEDURE:

1. Clients who wish to see their files should make a request to the counsellor or supervisor. If the request is in writing, a determination of whether it is a routine or formal request must be conducted immediately as the FOIPP response time-frame of 30 days begins the moment the request is received.

2. Is it a routine release of formal FOIPP request?

1. If there are potential exemptions or concerns about the release of the file then the file cannot be routinely released and the request must be treated as a formal FOIPP request (this will almost always be the case with client files).  If a minor’s file is requested by a parent, the request must be treated as a formal request because of access and privacy issues related to guardianship, custody and mature minors.  If a record contains personal information of more than one individual, then it must be handled as a formal request under FOIPP.

2. If there are no potential exemptions (see 3 below) or concerns about release of the file, the file can be routinely released to the client by supplying him/her with a copy of the file or allowing the client to examine the original file.

3. The counsellor should review the client file to determine if it contains information which   could be exempted from release to the client, such as:

1. Information which could invade the personal privacy of a third party (S.32)

2. Information which could be harmful to business interests of a third party (S.21)

3. Information that could reasonably be expected to threaten anyone else’s safety or mental or physical health (s.19(1), and

4. Information that could reasonably be expected to cause immediate and grave harm to the applicant’s safety or mental or physical health (s.19(2)).

4. If the request must be treated as an official FOIPP request (2.a above), the request must be in writing such as a letter or completed FOIPP request form (copies of the request form are available from regional office).  The client requesting the file should be contacted to obtain this written request.

5. The formal written request should be forwarded to the central Information and Privacy Program (IPP) office in Victoria, as soon as it is received (telephone 952-2626).

6. The request will then be assigned to a regional IPP manager (MIP) and regional ADP program area contact (PAC).

7. The regional PAC will notify the direct service or funded agency that he/she will need to retrieve a copy of the file.

8. The agency will send a copy of the file to the regional PAC: the original file should not leave the agency.  If there are any issues in copying the file, please contact the regional PAC or MIP.  Agency staff should also indicate any concerns or issues about the content of the file or the manner in which it should be released.

9. The copy of the file will be reviewed by the PAC/MIP and all required severing will be performed.

10. When the file is released to the client, the following means may be used:

1. Client may view file in direct service or funded agency,

2. Through the IPP central or regional office,

3. Through the mail/courier (collect),

4. Picked up in person.

 The MIP will co-ordinate release of the severed client file, and advise agency as required.

[Back to Table of Contents]

4.C.12      RELEASE OF INFORMATION

POLICY:

Release of information forms shall be used to obtain the client’s written permission to share information about him/her with other agencies.  However to ensure continuity of service is maintained information may be shared with another agency at the request of the agency.

PROCEDURE:

1. Information about clients should not be given over the telephone unless the caller has the necessary authorization and is known to the person taking the call.

2. CONSENT TO OBTAIN INFORMATION.  If the agency requires information from another agency.  A form should be signed.  Although discretionary information maybe shared in accordance with the FOI Act.

3. CONSENT TO RELEASE INFORMATION 

1. If another agency wishes this agency to release information about a client, the client must first give his/her permission by signing the appropriate consent form.  If any discretionary information is shared the client should be informed afterwards.

2. It is the responsibility of each agency to ensure that appropriate Release of Information forms are signed prior to releasing information.

3. When copies of letter or reports are forwarded to other agencies, the name of the receiving agency and the date sent should be noted at the bottom of the original document in the client’s file.

[Back to Table of Contents]

4.C.13     SUICIDE RESPONSE - HIGH RISK FOR SUICIDE

POLICY:

Any individual at high risk for suicide shall be provided services to ensure their immediate safety.

PROCEDURE:

1. Any child, adolescent or adult who is threatening suicide or indicating they are a suicide risk shall be taken seriously and seen as an emergency.

2. The client may be interviewed at South Peace Counselling Services or at a community agency such as the hospital, RCMP station or Mental Health.

3. An assessment of suicide risk to include the following areas shall be conducted:

1. Feeling tone of interview

2. Suicide plan (lethality, availability, specificity)

3. Client history of suicide

4. Client symptoms

5. Client strengths (support system, future plans, ability to see other options)

6. Family history

4. An appropriate short-term contract shall be made with the client depending on the degree of risk to ensure client safety.

5. Any individual assessed as high-risk for a suicide attempt should be case conferenced immediately with the Program Manager/Doctor, if available, or another senior counsellor.

6. Any individual assessed as high-risk forfeits their rights to confidentiality to ensure their own safety.

7. Refer to hospital or family physician.

[Back to Table of Contents]

4.D.1     DISCHARGE PLANNING

POLICY:

A discharge plan shall be developed for all clients for the purpose of aftercare, follow-up, continued support, and evaluation of treatment outcome.

PROCEDURE:

A written termination summary shall be included on clients file which includes:

1. an evaluation of the client's progress toward anticipated treatment outcome,

2. any referrals made to other organizations at time of discharge, and

3. aftercare plans.

[Back to Table of Contents]

4.D.2       PROGRAM EVALUATION OF CLIENT OUTCOME

POLICY:

South Peace Counselling Services will establish a Program Evaluation System to enable the organization to identify the results of services and the effects of the program on the persons served.

PROCEDURE:

1. A Program Evaluation System will be created to:
   

   1. Measure outcomes of the agency programs and services.

   2. Regularly measure the progress of persons served in relation to program goals.

   3. Evaluate client success three months after discharge.

   4. Measure service delivery effectiveness and efficiency.

   5. Measure satisfaction of person served.

2. All persons served or a representative sample will be utilized in assessing agency/program performance and individual outcomes.

3. Data retrieved from the Program Evaluation System will be utilized in developing service delivery techniques at all levels of the organization including administrative and program functions.

4. The Program Evaluation System will be in operation by December 1999.

[Back to Table of Contents]

4.E.1      OUTREACH PLANNING

POLICY:

Any outreach activities necessary to ensure coordination of clients needs shall occur.

PROCEDURE:

1. The Program Manager or his designate shall participate on community committees that address  issues related to substance abuse or health promotion and are consistent with South Peace Counselling Services Mission and Philosophy.          

[Back to Table of Contents]

4.E.2         ANCILLARY SERVICES

POLICY:

A directory of appropriate providers who offer related and ancillary services which supplement the principle services of the program shall be provided.

PROCEDURE:

1. A listing of Support Services, including self-help support groups shall be available for counsellors and the public.

2. A directory of local and regional services shall be available for counsellors and the public.

3. These directories shall be updated at least annually.

[Back to Table of Contents]

4.E.3           SELF-HELP GROUPS

POLICY:

South Peace Counselling Services promotes and encourages individuals in their recovery to participate in and/or develop self-help groups.

PROCEDURE:

1. All clients shall be provided with the information about current self-help groups running in the South Peace.

2. If an individual is interested in developing a self-help group, we shall provide any information, contacts, etc. that we have for that group, as information on group processes, facilitation skills, etc.

3. If we have available room and resources we shall endeavor to provide those resources to any group that has a philosophy consistent with this service’s constitution.

4. When our resources are needed for ongoing program service delivery, the self-help group shall be assisted in developing similar resources elsewhere in the community.

[Back to Table of Contents]

4.E.3a        Prevention Activities

Philosophy:

Our program mandate is provide prevention services to the South Peace Region and area. We are given the opportunity to provide input in any area that may lead to the decrease of the use and abuse of alcohol and drugs. We will be allocating 25% if each counsellors time to be used in pursuing prevention activities.

Objectives:

There are three objectives for our organization:

1. To provide education, resources, in services to those who have not begun to abuse substances.

2. To impact systemic issues that lead to substance use and abuse.

3. To promote general health and well being in the community.

 Procedure:

1. This office will use the “Precede/Proceed” model of prevention.

2. Once the concerns are identified using this model resources will be allocated to address concerns.

3. The greatest impact in prevention will come from consistency of service delivery.  Our program will endeavor to do this at all times.

[Back to Table of Contents]

4.E.4        STUDENT PRACTICUM RECRUITMENT

 POLICY:

We shall endeavor to provide a worthwhile learning environment with opportunities to experience a variety of skills.

PROCEDURE:

1. Each student shall provide an up-to-date resume and complete a Criminal Records Check.

2. All students shall adhere to the policies and procedures of South Peace Counselling Services.

3. A Student Practicum supervisor shall be assigned from the staff.  The student is responsible directly to his/her supervisor.

4. If a student’s practicum behaviour is contrary to the agency’s goals and philosophy and/or their behaviour is unethical, their Educational Supervisor and the student shall be notified and their practicum shall be terminated.

5. A student can be asked to leave if he/she is under the influence of any mood altering substance.

6. At the beginning of the practicum, a set of goals shall be developed in conjunction with the educational institution, student and supervisor.

7. Student/Supervisor meetings shall be held at least monthly to give feedback, review procedures and set goals.

8. The Student Practicum Supervisor shall meet with the Educational Supervisor and provide reports (etc.) as requested by the educational institute.

[Back to Table of Contents]

4.E.4a       STUDENT PRACTICUM TRAINING AND ORIENTATION

POLICY:

The student shall be viewed as a member of the team and oriented similarly to staff members.

PROCEDURE:

1. The student shall be given a copy of the South Peace Counselling Services Policy and Procedures Manual at the start of their practicum.

2. The Policy and Procedures Manual shall include:

1. Overview of South Peace Counselling Services

2. Program information

3. Client information

4. Information on support services

3. The Supervisor and/or Program Manager shall review the Policy Manual, conditions of practicum, expectations of educational institute, on-site resources and confidentiality.

4. An individualized practicum guide shall be developed with each practicum student.

5. The student shall be introduced to, and become familiar with, all staff  and their programs.

[Back to Table of Contents]

4.E.4b       STUDENT PRACTICUM RECORDS

POLICY:

A personnel record is maintained for all students.

PROCEDURE:

1. Each student record is maintained for all include:

1. Current resume

2. Criminal records check

3. Orientation plan

4. Program plan for the student practicum

5. Any reports to the educational institution

6. Any disciplinary actions including the reasons and outcome

[Back to Table of Contents]

© North East Counselling Services, 2003, 2004.
 All rights reserved.  Disclaimer.
e-mail: info@necs.bc.ca