MOMIJI HEALTH CARE SOCIETY
Developer:
Program & Service
Committee
Effective Date:
April 2020

Category:
OperationsCorporate

Domain:Community
Service/SupportService

Subject Title:
Whistle Blowing Protection ofTenants and Clients
Reviewed/Revised Next Review Supersedes:
Date:
Date:
N/A
April 2023

PolicyNumber:OPSCS/SS-(#)
Approval:
Executive
Director
Pages:
4

POLICY
Momiji is committed to addressing tenants’/clients’/substitute decision-makers’/volunteers’
concerns and complaints in a prompt, fair, thorough, and expedited manner in order to improve
quality of care.
Effective protection of tenants/clients/substitute decision-makers/volunteers (whistle blowers)
against retaliation and reprisal is a reflection of Momiji’s culture of commitment to ensuring
openness, transparency, and accountability. Momiji has Zero Tolerance for retaliation against
whistle blowers. All allegations of retaliation will be handled in a confidential manner and shallbe carefully investigated and appropriate action shall be taken.
SCOPE
This policy applies to all staff, volunteers, students, and contracted service providers. At thesame time, the staff and volunteers in charge of partnered long-term care facilities should beprotected by their Whistle blowing policy so that they are able to conduct advocacy role forresidents/clients.
DEFINITIONS
Whistle blowing
The disclosure of information, filing a complaint or expressing a concern by atenant/client/substitute decision-maker/volunteer, and staff members about a perceived wrong
doing committed by Momiji or by individual or group of staff or service providers of the Momiji
centre or risk thereof. The disclosure can be made internally to Momiji staff, service provider,volunteer or externally to Ministry or other entities believed to be able to effect action.
Whistle blower
Tenants, Clients, substitute decision-maker, volunteer, family members, or staff members whowhistle blow.
Retaliation

Any action that aims at silencing, isolating, threatening, intimidating, ridiculing, humiliating,and/or marginalizing the whistle blower. It also includes but not limited to intentionally denying,delaying or providing substandard care to whistle blower.
PROCEDURES
1. All staff/volunteers/service providers will be informed of this policy during orientation.
Annual review of the policy is mandatory.
2. All new tenants/clients will be provided with copies of this policy upon admission.
3. On becoming aware of retaliation, the person(s) first having knowledge of this shallimmediately inform the Executive Director.
4. The Executive Director will immediately notify the Substitute Decision Makers of thetenant/client about the suspected retaliation and assure them that an investigation hasproceeded, following the Momiji’s policy and the tenant/client will be protected during theprocess.
5. The person(s) first having knowledge of this shall immediately prepare a signed, dated
statement, indicating all information witnessed or acquired after verbally reporting theincident. The written report shall include:Name(s) of the individual who committed the suspected retaliatory action.

Name(s) of the tenant/client against whom the suspected retaliatory action wascommitted.

Description of retaliatory action.

Time and location of the suspected retaliatory action.

Witnesses to the suspected retaliatory action and/or names of individuals who may haveknowledge of the incident.

Any other significant information pertaining to the incident.

6. Executive Director shall follow the Momiji’s Zero Tolerance of Abuse Policy (exist?) if
abuse is suspected.
7. If the alleged retaliatory action is conducted by contracted service provider, the ExecutiveDirector shall inform the service provider and their employer if applicable immediately.
8. If the alleged retaliatory action is conducted by student, the Executive Director shall informthe education institution immediately.
9. If the alleged retaliatory action is conducted by volunteer, the Executive Director shallinform volunteer manager immediately.
210. Executive Director or his/her designate shall conduct investigation within 24 hours withsupport from Human Resources department, as appropriate.
11. Where abuse or an incident of suspected retaliation occurs, the employee(s) shallimmediately be placed on a Leave of Absence with pay from active duty pending furtherinvestigation. Volunteer(s) who conducted suspected retaliation will not be permitted to carryout volunteer activities pending further investigation with the possibility of termination ofvolunteer activities with the Momiji Centre to follow. Contracted service providers who havebeen suspected of abuse shall not be permitted to provide service to the complainant pending
investigation.
12. The Executive Director will notify the Chair of the Momiji Board of Directors of allsuspected/alleged retaliation.
13. Investigation shall be completed within 10 business days.
14. Executive Director/designate shall inform tenant/client/substitute decision-maker/volunteer
of results of investigation.
15. Executive Director shall take disciplinary actions, including and up to termination inaccording to Human Resources Policy if retaliatory action conducted by staff is confirmed.
16. Executive Director shall inform Volunteer Manager if retaliatory action conducted byvolunteer is confirmed. Sanctions taken may include and up to banning the volunteer from
the Momiji Centre.
17. Executive Director shall inform service provider and his/her employer if applicable if
retaliatory action conducted by contracted service provider is confirmed. Follow up actions
shall be taken in according to terms of service agreement. Sanctions may include and up tobanning the individual from the Momiji Centre.
18. Executive Director shall inform education institution if retaliatory action conducted bystudent is confirmed. Sanctions may include and up to banning the student from the Momiji
Centre.
19. Executive Director or Support Service Director will keep the family/substitute decision
maker, or others specified in the tenant/client’s plan of care, informed within the guidelinesof the Freedom of Information and Protection of Privacy Act.
20. Where applicable, Support Service Director will report the confirmed incident to the staff
member’s professional regulatory bodies.
21. Referral to support resources will be made available to all parties involved in the alleged
retaliation. Resources for tenants/clients include:

The tenants’/clients’/families’ places of worshipThe tenants’/clients’/families’ physician3The social workerThe consulting psychiatrist

The Advocacy Centre for the Elderly or other legal clinics

The staff person involved will be referred to the Employee Assistance Program.
22. Executive Director shall complete all necessary reports according to Momiji’s policies aswell as the requirements from Ministry of Health. Executive Director shall provide a written
report to the Chair of the Momiji Board of Directors within one month of the conclusion ofthe incident.

4