Accountability

Kinark’s Code of Conduct applies to everyone at Kinark Child and Family Services (“Kinark”) – all staff, contracted professionals and independent contractors, the Board of Directors and other volunteers, students and vendors, for the time they are working for, or with, Kinark.

Read the Code of Conduct

Media enquiries should be directed to the Communications Department (communications@kinark.on.ca). Kinark employees, students and volunteers should not provide any information or commentary to the media without the specific authorization of the Chief Executive Officer. Requests from the media for information regarding a client must be referred to the Chief Executive Officer or designate.

For those employees who have been given access to the Internet from their company assigned notebook computer, or from within Kinark’s internal systems, occasional use of the internet and email for personal business outside of working hours is acceptable if it does not interfere with individual productivity or the company’s business. Frivolous use of email facilities, such as the transmission of chain-letters, will not be tolerated. Solicitation of non-company business or any use of the company Internet and email resources for personal commercial gain, is prohibited.

Employees must not use their business email address to register on-line for any personal business including personal newsletters, membership to any personal group or forum or chat room. Be careful what you do and say.  Remember that you are a representative of your agency, in all of your dealings with clients, families, other professionals and peers.

There may be situations in which a young person or member of his or her family is dissatisfied with the service provided by Kinark. As part of Kinark’s commitment to advocacy on behalf of young people and their families, complaint procedures are available to all clients.

The client should be encouraged to discuss his/her concern or complaint with the staff most directly involved with him or her and every effort should be made to resolve the concern at this level. If resolution cannot be reached, or the client is not comfortable with discussing the issue directly, the matter may be directed to the next supervisory level. For more information, please click here.

Other Employment – Kinark understands that some employees may wish to consider private practice, or employment or volunteer opportunities in the social service, education, or health service sectors while employed at Kinark. It is the responsibility of all employees to declare to Kinark any potential conflict of interest.

Kinark, in consultation with the Chief Executive Officer, will consider each conflict or potential conflict on a case-by-case basis. This will be done while taking into consideration the best interests of Kinark and its clients. Efforts will be made to cooperate with employees in dealing with any problems that may arise. All disclosures will be treated as confidential between the employees involved and the supervisor, Vice-President, HR Services, Chief Executive Officer, and the Board of Directors.

All applications for consideration of a conflict of interest situation must be submitted before proceeding with either employment or volunteer opportunities outside of the current Kinark employment relationship.

• Kinark employees may use Kinark services, as long as no preferential treatment is given or perceived to be given to children of employees.
• Kinark will not employ relatives of current clients or relatives of clients who have received service less than five years prior to applying for work with Kinark.
• Kinark will not hire current clients.
• Kinark employees do not take Kinark clients to their homes.
• Kinark employees do not socialize with Kinark clients.

Kinark employees, volunteers and students must immediately report to the Chief Executive Officer any questionable conduct including, but not limited to professional misconduct, fraud or dishonesty.

Kinark Personnel will follow the requirements set out in the Broader Public Sector Perquisites Directive, which is based on the principles of accountability, transparency, and value for money

Read the Policy

Kinark Personnel and Board Members will comply with the Broader Public Sector (BPS) Expenses Directive and the Travel, Meal and Hospitality Expenses Directive in the submission of expenses undertaken to fulfill the duties and objectives of the Agency.

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Kinark is committed to ensuring that publicly funded goods and services are acquired through a process that is open, fair and transparent by following the Broader Public Sector Procurement Directive (BPS).

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Purpose

To ensure the security and confidentiality of client information at all times.

Policy

Kinark will take all necessary steps to protect personal health information within its custody or control against theft, loss and unauthorized use or disclosure. Methods of protecting client information will include physical safeguards, administrative procedures and technical security mechanisms.

Procedures

General

1. Within agency offices and facilities, confidential client information will be maintained in locked cabinets and/or file rooms designated for the specific purpose, and will be accessible only by authorized personnel. Agency offices and facilities will be secured by lock and alarm.
2. Appropriate measures will be established to safeguard the security of file rooms, observation rooms, computer/electronic devices, printers, fax machines, audiovisual equipment and tapes, and all other means of storage.
3. Authorized personnel will follow specific sign-out and tracking procedures prior to removing any client file or information from the designated storage area, to ensure the whereabouts of client records is known at all times.
4. Client files or information will be returned promptly to secure storage when no longer required and not later than the close of the workday.
5. Client records will only be removed from an agency office or facility with prior approval of the Chief Executive Officer, Program Director, or the Kinark Privacy Officer. Prior approval will include confirmation of the purpose for removal, the  means of securely transporting the record, and the intended destination and return date.
6. Upon termination of active service, a closed file will remain in secure storage in the local office or facility for a period not to exceed six months, when it will be transferred by secure means and established procedures to the corporate office to be archived. Contracted offsite archive storage will be administered according to agency standards and applicable legislation.
7. Unless otherwise authorized by the Chief Executive Officer or designate, all client records will be retained indefinitely.

Community-based, home-based, or mobile staff

Generally, all agency privacy policies and requirements apply to all staff regardless of location. Additionally, for staff providing community-based or mobile service, or service in any location other than a Kinark office, the following procedures will apply:

8. The official client record/file will be maintained in a Kinark office. Staff will deliver original hard copy client documents and information to the main file in a secure manner and as promptly as possible. Electronic information will be entered into the Kinark client information system (KIDS) from remote locations in an approved manner and according to established guidelines. Any working copies of client records kept in offsite or non-office locations (e.g., school-based programs, community-based residential facilities) will be maintained in a secure manner, as outlined in general procedures above.
9. Community-based, home-based and mobile staff will transport and maintain client information in a secure manner at all times (e.g., locked briefcase or records case; locked vehicle trunk,) and will prevent unauthorized access to client information at all times.
10. Wherever possible, client-related documents prepared in the community should omit identifying information such as the client’s name. Client initials may be replaced with the full name once the documents are transferred to the main file.
11. Staff may complete rough written notes in the course of providing client service (e.g., during a family session, during assessment procedures). If the purpose of these notes is to provide material for another form of client documentation (e.g., contact notes in KIDS; clinical reports on approved agency format or template), the rough notes are not considered part of the client record and should be destroyed upon transfer of the information to the client record. If the information is not intended for transfer to the client record in another format, then the rough notes become part of the client record and should be maintained, filed and managed in the same manner as all client information.

In addition to specific policies and procedures regarding Kinark’s information system and information technology, the following procedures apply to management of client information:

Electronic Communication

12. Staff may communicate client information to authorized personnel within the agency by means of the agency’s secure password-protected e-mail system. Wherever possible, such internal communication should contain client initials as opposed to full names.
13. With a client’s consent, and only after a client has initiated such contact, staff may communicate with clients electronically (e.g., e-mail, texting) for the purpose of coordinating or confirming service, and not for the communication of personal health information. Staff will not use electronic methods to share or communicate clinical information or the agency’s reports. At the client’s discretion, Kinark may receive but not send personal health information, whether between Kinark and the client or Kinark and another organization or individual.
14. In exceptional time-sensitive circumstances, electronic transmission of client information may occur with the prior approval of the Chief Executive Officer or designate (Privacy Officer).

Voicemail

15. Agency voicemail will be password protected to ensure messages left by clients are retrieved only by authorized personnel.
16. To protect client information during extended staff absence, voicemail greetings will inform callers of the expected duration of the absence.

Use of home or personal phones to contact clients

17. The use of staff home or personal telephones for client contact is discouraged and should only occur in exceptional circumstances. If such contact is required, staff are expected to ensure client privacy during the call and with respect to any documentation made in relation to the call. Staff should also take reasonable steps to ensure their own privacy and to maintain professional boundaries for themselves and clients (e.g., use of call blocking).

Answering Machines

18. Staff will not leave messages on a client’s answering machine that identifies Kinark or the client’s status with Kinark. Staff may indicate for whom the message is intended, the staff’s name, a return number, and basic non-detailed information regarding the purpose of the call (e.g., concerns an appointment).

Fax Machines

19. Unless otherwise required or approved by the Chief Executive Officer or designate (Privacy Officer), identifying personal health information will not be sent from Kinark to other parties by fax. Exceptions include Ministry Serious Occurrence reporting or in situations where information sharing is required with Youth Justice personnel or courts in a time sensitive manner.
20. Kinark’s office procedures will ensure that fax messages containing client-related information include:
21. Incoming faxes are received in a confidential manner (e.g., location of machines, machines checked and cleared regularly, password-protected access, no messages left at close of business).
    b. Outgoing faxes are sent in a confidential manner (material marked confidential, follow-up call to ensure material was received securely).
    c. Tracking system to record the receipt and sending of faxes (i.e., cover sheets filed in the client file).

Computer Networks

21. Electronic client information will be entered and stored in the secure Kinark Information Database System (KIDS). Authorized access to KIDS is approved by the appropriate Supervisor and facilitated by Kinark’s Information Technology (IT) support staff. Specific IT policies and procedures ensure the safety of electronic client information and establish rules related to password protection, encryption, server security, and all matters related to data storage and security.
22. Staff with approved access to KIDS are expected to manage their work, workspace and computer terminals to ensure confidentiality (e.g., logging off upon completion of work or when the monitor will be unattended) in accordance with the Electronic Communications policy.

Cellular Phones

23. The preferred and most secure form of telephone communication with clients is by means of an agency landline, established for business purposes. When an agency-provided cellular phone is used for client contact, or for staff–to–staff communication regarding specific clients, staff will take reasonable precautions to protect client information (e.g., minimize length of call, avoid use of client names).

Laptop and Personal Computers

24. Agency laptops are used primarily to connect with the secure agency information system and are not to be used for saving and storing confidential client information. All laptop computers will be password-protected and will be checked regularly upon being signed out and returned to ensure they are free of client information.
25. Staff may use personal computers, including personal laptops, at home or away from the office to prepare or access client information and data, but only by accessing Kinark’s secure information system. At no time will staff be permitted to prepare or store client-related information on personal computers independent of the secure Kinark information and technology system.

Portable Electronic Storage Devices

26. Portable electronic storage devices, including diskettes, disks and USB “memory sticks” will not be used to store confidential client information. Staff will use remote access to the secure Kinark information system to prepare, save or store confidential client information.

Videotapes, Audiotapes and Digital recording

27. Upon admission to voluntary Kinark services, clients have the option of providing or withholding consent regarding the use of audiovisual technology during the course of assessment and service provision. Typically, when such technology is employed, tapes will be permanently erased once the intended purpose has been met (e.g., staff supervision and training, clinical consultation). During the period of active use, and for any tapes retained as part of the client record, the taped information will be stored and maintained securely according to existing client records management practices.
28. Where audiovisual technology is employed for general program or facility security purposes (e.g., secure custody and treatment settings), posted notices will inform all occupants, including clients, of the presence and use of such technology. The technology and tapes will be maintained in a secure manner consistent with established client records management practices, and will be accessible only by authorized personnel.

Responding to a Privacy Breach

29. Upon becoming aware that client personal health information has been lost, stolen or disclosed to unauthorized individuals, staff will notify their immediate Supervisor, who will ensure that Kinark’s Privacy Officer is also notified. At the first opportunity, Kinark will notify the client or a person authorized to act on his or her behalf, and will take steps required to locate and retrieve the personal health information, and to minimize the likelihood of a similar breach in the future. Should clients wish to make a complaint regarding a breach, they should be directed to the agency’s Complaints Policy.

Disposal of Client Information

30. Kinark retains original client records indefinitely. Some client information may be destroyed promptly upon completion of its intended use (e.g., draft reports, rough notes, recording media, working or additional copies of reports). For paper hard copy records, such information will be shredded using agency-provided and approved shredders or contracted records destruction services. For electronic records, information will be deleted according to established agency information technology systems and procedures.

Definitions
Electronic Communication devices include smartphones, PDA’s, instant messaging devices, and cell phones.

Purpose

To respect and protect the privacy of the agency’s clients and their personal health information.
To establish a framework for the collection, use and disclosure of clients’ personal health information.

Policy

Kinark recognizes the importance of, and the legal right of clients to, privacy regarding personal health information. As a health information custodian, Kinark requires that all staff, volunteers and agents maintain the highest standard of confidentiality and perform their duties in compliance with applicable legislation.

Unless specified otherwise in law, Kinark will only collect, use or disclose a client’s personal health information with knowledgeable consent of the individual client or other person authorized to consent on the client’s behalf. Exceptions to consent and limitations to confidentiality will be explained to clients upon admission to service.

Procedure

1. Relevant material regarding the agency’s information policies and practices will be made available to individual clients upon admission to service, and to all clients and the community at large on an ongoing basis (e.g., Kinark’s website).
2. Staff, volunteers and other agents (e.g., consultants, accreditors) will be made aware of the agency’s information policies and practices upon commencing employment or involvement with Kinark, and will sign an oath of confidentiality (Agreement Regarding Confidentiality, Conflict of Interest and Protecting Information Resources). This oath will continue indefinitely, including upon completion of an individual’s employment or involvement with Kinark.
3. Unless stated otherwise, the terms “client information”, “personal Information”, and “information practices” refer to personal health information, defined in PHIPA as follows:

Identifying information about an individual in oral or recorded form, if the information:

• relates to the physical or mental health of an individual, including information that consists of the health history of the individual’s family;
• relates to the providing of health care to an individual, including the identification of a person as a provider of health care to an individual;
• identifies an individual’s substitute decision maker or
• identifies an individual’s health card number.

4. Kinark will maintain a client record for each identified client. “Client record” refers to all client information in the agency’s custody and control, in any form or medium, whether written, printed, photographic, electronic or otherwise.
5. Non-identifying aggregate client information may be used to support the agency’s and community’s commitment to effective analysis, planning, management, research and accountability. Client consent will be obtained if identifying case-specific information is to be used for these purposes or for the purpose of public education or public relations.
6. Agency staff will make every effort to collect and use only personal information considered reasonably necessary for the provision of assessment, counseling, treatment or other services requested by, or recommended for, a particular client.
7. If there is any doubt with respect to confidentiality, consent or other matters regarding client information, staff, volunteers and agents will consult with agency management, including the Privacy Officer as required.
8. From time to time, Kinark may revise or establish specific operational procedures to support its privacy policies and information practices. If such revisions or additions significantly alter how the agency uses, maintains or discloses previously collected personal information, affected individuals will be notified and consent will be obtained where required.
9. Kinark will provide relevant privacy education and training to ensure the staff is knowledgeable regarding its obligations in this area.