Policies and Resources

1. Policy Statement

Pegasus continuously strives to provide high quality supports and services and recognizes that feedback and complaints from stakeholders play an important role in identifying areas where improvement may be needed.  Feedback and complaints may identify needs for improvement both in the delivery of services and supports, as well as in administrative processes that oversee service delivery.

In order to encourage and facilitate feedback and complaints, Pegasus has developed a process for eliciting and receiving feedback and complaints, and addressing them in a fair, timely and well informed manner. This process provides a timely and effective mechanism for all stakeholders to communicate with Pegasus.

The process guarantees confidentiality and enables Pegasus to respond to a changing environment and to adapt its systems as required.

Pegasus complies with the requirements for a feedback process that are set out in the Accessibility Standards for Customer Services, Ontario Regulation 429/07, made under the Accessibility for Ontarians with Disabilities Act, 2005. 

2. Scope of the Policy

This policy applies to all participants, families, support persons, others acting on their behalf, employees, volunteers, and the general public.

3. Terms of Reference

Pegasus welcomes the opportunity to communicate with all its stakeholders.  As an organization that was founded by community and family members, and that is committed to serving individual needs in a community setting, Pegasus believes that the dynamic interaction amongst all its stakeholders can enhance and improve supports and services.   

4. Definitions

4.1. Feedback:

Feedback is an opinion expressed about the services and supports that Pegasus offers.  Feedback can be solicited or unsolicited, and it can be positive or negative.  Examples of solicited feedback include surveys or questionnaires published by the agency. Examples of unsolicited feedback include a conversation, a letter or a phone call to the agency.

4.2. Complaint:

A complaint is expression of dissatisfaction about the service and supports provided by Pegasus. It is negative feedback.  A complaint may be expressed by a person with a developmental disability who is receiving services and supports from the Pegasus, or a person acting on their behalf, or by the general public, regarding the services and supports that are provided by Pegasus.  A complaint can be formal, such as a letter, or informal, such as a verbal complaint expressed to a staff person, or board member if about senior management.

5. Fair Review Process

Pegasus is committed to a fair complaints process. All participants and other stakeholders have the right to deliver feedback and complaints free from coercion, intimidation, bias, harassment, threats, fear of losing service, or other negative consequences.  Pegasus upholds this right and will train all its staff and Board of Directors to respond appropriately and professionally to feedback and complaints.

The regular and repeated distribution of this policy to participants and those that act on their behalf also serves to reinforce Pegasus’ commitment to their right to give feedback.

Where reasonable and necessary, and in accordance with the Regulation on Quality Assurance Measures and agency’s policies and procedures, Pegasus shall investigate complaints/ feedback received.

A person who submits a complaint or provides feedback is not at risk of having their services and supports negatively impact or withdrawn, as a consequence of submitting the complaint/feedback, and Pegasus makes the person aware that their services and supports will not be impacted in that way.

6. Responsibility of Complainants

Complainants must at all times treat Pegasus staff with respect and courtesy. If a person is rude or harasses an employee in the course of delivering a complaint, the employee will ask the complainant to address the Program Manager, if it is program related, or the Executive Director.  Employees will not receive or respond to complaints that are delivered in a disrespectful manner.

7. Invalid Complaints

Pegasus is not obligated to apply this process with complaints that it judges to be vexatious, frivolous, personal in nature, or not made in good faith. However, at its own discretion the agency may address complaints of this nature.

8. Confidentiality

In compliance with agency Privacy Policies and Confidentiality processes, every effort will be made to keep all aspects of the complaint confidential.

9. Conflict of Interest

No staff member, participant or Board member who has a potential or real conflict of interest with the complaint or the complainant should be involved in the review, documentation, investigation, resolution or notification/confirmation of any complaint.

They should declare the conflict of interest immediately, so as to avoid the perception that the decision-making process is not objective. People receiving supports and services from Pegasus should not have to be concerned that their needs are secondary to any individual’s or group’s personal gain.

A conflict of interest is defined as a situation in which a person has a private or personal interest sufficient to appear to influence the objective exercise of their official duties as an employee.  Some examples of types of conflict of interest include financial, political, or personal.

10. Procedures

10.1. Eliciting Feedback

Pegasus elicits feedback from its stakeholders on a regular basis as follows:

• As part of each participant’s annual review process (PGPR/ISP)
• As part of the Executive Director’s newsletters to families and group homes
• In surveys of satisfaction with supports and services, sent to all participants, families and support person.
• In a survey following any new service or support being offered

10.2. Complaints Process

10.2.1  Communicating the existence of the complaints process:

10.2.1.1.    All participants, families, and staff are informed of this process. Participants and families are given a copy of this policy at the time of intake. The process will be reviewed yearly thereafter. 

10.2.1.2      Other community members can access this process on the agency website and in general newsletters.

10.2.1.3      Anyone may request a copy of any agency policies and procedures by contacting the administrative offices.

10.2.2     Accessible formats

Pegasus accepts complaints in the following formats: in person, by telephone, email, letter, picture symbols or other e-submission format.

Communications support or alternate formats can be arranged upon request. (As per AODA regulation 191/11 Section 11).

10.2.3.                    Level 1:

10.2.3.1.    Any staff member can receive a complaint. Complainants should approach the staff member that they judge to be the most appropriate to receive the complaint.

10.2.3.2.    The staff who receives the complaint should tell their immediate Supervisor about it as soon as possible and within the same day. 

10.2.3.3.    Staff should not discuss the complaint.  This assures that the complaint is dealt with in a clear fashion and makes it clear to the complainant that the process is followed.  It also reduces the risk of gossip and taking sides.

10.2.3.4.    Supervisors should respond to the complainant as soon as possible, within 2 business days maximum. A Supervisor may discuss the issue with the Program Manager before approaching the complainant. They should request that the complaint be explained and discuss the issue. If an acceptable solution is found, the complaint is considered resolved.

10.2.3.5.    No staff should respond to a complaint in a casual manner. If a complaint is stated to a staff at a time when the staff is busy working with a participant, the staff should request that the complainant wait a few minutes, and then discuss the complaint in private and in a formal manner. 

10.2.3.6.    Record keeping: the Supervisor should keep a record of the complaint, and the way it was resolved, in the Supervisor’s journal.  The record should include date, time, description of the issue, resolution, and any information that would inform policy review and revisions.  The report should include records of conversations. In addition, relevant documentation will be collected, including Incident Reports, Serious Occurrence Reports and electronic correspondence.

10.2.3.7.    Reported to the police (i.e., as in the case of alleged, suspected or witnessed abuse that may constitute a criminal offence, as required by Ontario Regulation 299/10 regarding quality assurance measures made under the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008)

10.2.3.8.    If a solution is not found, the complaint proceeds to the Level 2 process.

10.2.4.                    Level 2

Complaints that are not resolved at Level 1 proceed to the Level 2 process.  

Level 2 complaints must be put in writing. If a complainant is unable to put it in writing, communications support or alternate formats can be arranged upon request. (As per AODA regulation 191/11 Section 11).

Level 2 complaints should be handled as follows:

10.2.4.1.    By the Program Manager: if it is from a participant, family, or other support persons regarding a participant.

10.2.4.2.    By the Executive Director: all other complaints, including those from the general public.

10.2.4.3.    By the Board of Directors: All complaints about the Executive Director.

Contact information is made available to all families and members of support networks. In addition, email addresses and phone numbers of the above persons can be found on the agency website.  

10.3. Responding to Complaints

The Program Manager, or Executive Director, will review and discuss the complaint with other staff or Board members as needed. Participants may be involved in the review process as frequently as possible and if they consent. Adequate information to prepare the participant using the communication method appropriate for that person will be offered.

A conversation will be set up with the complainant, either in person or on the phone.  During the conversation, further information and clarifications will be sought, and a preliminary solution will be suggested.  If the complainant is satisfied with the solution, it will be put in writing and both parties will sign the document. 

10.3.1.          Possible Solutions to a Complaint

Staff who are dealing with a complaint should consider many options, which include, but are not limited to, the following:

• A clarification of the reason behind current agency practices
• A commitment to review current practices
• A change to specific services or supports as they affect a specific person
• A commitment to additional knowledge transfer to staff
• A commitment to further investigate, and setting time limits for the investigation
• A change to current policies and/or procedures
• A decision can be made to uphold all policies and procedures and that the situation was not in violation of any policies and procedures.

10.3.2.          Time limits

Pegasus will meet the following timeframes:

• 2 business days to contact the complainant to resolve the issue or acknowledge receipt of the complaint.
• If not resolved within 2 business days, 15 days to formally respond to the complaint after review of documents and to arrange a conversation with the complainant.
• If not resolved after the conversation with the complainant, both parties will agree to future deadlines.

10.3.3.          When a resolution is not found using channels as stated above, the following one or all of the following should occur: 

10.3.3.1.    The Board of Directors can carry out an investigation and suggest resolutions.

10.3.3.2.    An outside agency can be requested to review the situation.

10.3.3.3.    Ministry of Children, Community and Social Services can be asked by the Executive Director or Board of Directors to review the situation.

10.3.4.          Investigation Process

The investigation will consist of gathering detailed information about the complaint and all circumstances surrounding it.  It may require speaking to other stakeholders and community members.  It may require consulting with other service providers.  A decision should not be made until the investigator is satisfied that all the necessary information and points of view have been obtained.

11. Involvement of External Parties

In certain cases, the complaint process will involve the police.  One example that would require Pegasus to contact the police would be if there is an allegation of abuse.

In certain cases, Pegasus would file a Serious Occurrence Report to the Ministry of Children, Community and Social Services (MCCSS) in accordance with Ministry directives and reporting requirements in the Services and Supports to Promote the Social Inclusion of Persons with Developmental Disabilities Act, 2008.  MCCSS would be contacted if there was involvement of the police or if there were other complaints about situations that trigger a Serious Occurrence Report.

12. Training

12.1     Staff training

All staff will be educated on this policy as part of initial orientation and annually thereafter.

12.2     Participant training

All participants will be educated, in plain language, and in an appropriate communication method, on their rights to complain and give feedback.  Training will emphasize that complaining will not threaten their right to receive supports, or their relationships with staff and other stakeholders.

13.  Policy Review

This policy will be reviewed annually by the Executive Director and the Program Manager. 

Revisions will be reviewed by the Executive Director and the Board of Directors.

1. Policy Statement

Pegasus recognizes that privacy is a key component of its relationship of trust with all its stakeholders. In accordance with applicable privacy legislation, Pegasus protects and maintains the privacy of the personal information of its participants, donors, volunteers and other stakeholders.

Pegasus does not rent, sell or trade any personal information, including our mailing lists, with outside parties.

All employees are required to maintain confidentiality regarding all information relating to stakeholders, service and support functions, personnel matters and the business matters of Pegasus. Employees are required to sign a confidentiality agreement upon hire and renew on an annual basis. Volunteers and other stakeholders will be required to sign a confidentiality agreement as required.

Pegasus is committed to promoting responsible and transparent practices in the confidentiality and management of personal information. Pegasus will review this policy on an annual basis to ensure that it is relevant and current with changing laws and technologies.

2. Policy Outline

Pegasus adheres, to the maximum extent possible, to the principles of fair information practices laid out in the Canadian Standards Association Model Code for the Protection of Personal Information and the Personal Health Information Protection Act (PHIPA).

Pegasus also complies with all other applicable laws and established ethical guidelines for charitable organizations.

3. Scope

This policy covers all personal and health information related to participants, volunteers and donors held by Pegasus in various formats (e.g. paper, electronic).

Pegasus employee information is not subject to this policy. Our employee personal and health information is safeguarded according to industry standard best practices and other relevant legislation.

Personal information within this policy is inclusive of health or clinical information (physical, mental and/or behavioural) of participants.

In addition, this policy covers all matters related to the business activity of Pegasus including all intellectual property.

4. Definitions

Personal Information is information about an identifiable person (not including business contact information). Examples of personal information include the history of a person’s donations to Pegasus, school records, health records or family information.

Pegasus collects personal information in a variety of different ways and for a variety of purposes e.g. when a participant joins our services and supports or when we conduct fundraising activities or volunteer drives.  The personal information that Pegasus collects could include:

• Name, address, email, telephone number and other contact information

• Income, employment information, personal and social history
• Information about participant’s support, health and welfare
• Donation/fundraising details or history of giving

Consent is voluntary agreement with what is being done or proposed. Consent can be either expressly given, either orally or in writing, or implied. Implied consent is where consent may reasonably be inferred from the action or inaction of a person.

Appropriate purpose is where an organization may collect, use or disclose personal information only for purposes that a reasonable person would consider are appropriate in the circumstances or to comply with duty of care for participants, staff and volunteers as part of support and day to day programming.

Records includes any correspondence, memorandum, book, plan, map, drawing, diagram, pictorial or graphic work, photograph, film, microform, sound recording, videotape, machine-readable record and any other documentary material, regardless of physical form or characteristics, and any copy of any of those things.

It also includes any information or records regarding participants that are deemed necessary for the support, safety and day to day programming. Discretion of what information is necessary to share with employees or volunteers is applied, dependent on the circumstance or event.

5. Property

All personal records, including health information, will remain the property of Pegasus. Staff and volunteers are required to sign a Confidentiality Agreement or Annual Employee Confirmation (Appendix 1 & 2) and maintain the privacy and confidentiality of all records during and after their employment or service ends.

6. Privacy and Confidentiality Principles

Pegasus is committed to upholding the following principles to ensure privacy and confidentiality of information is correctly maintained:

6.1. Identifying Purposes

Pegasus will – at or before the time of collecting personal information – identify the purposes for which personal information is collected to the person from whom the information is being collected. Pegasus will also inform the person of any new purpose for personal information and obtain consent to use the information for that new purpose.

Personal information may be used by Pegasus for the following purposes:

• Planning and providing supports, services, programs or information about Pegasus
• Educating program supervisors and staff or volunteers about participants’ health conditions and other information that is relevant to appropriate care and supervision
• Providing information to third parties only when consent has been given
• Fundraising and promotional activities
• Evaluation of our services
• Contact information among volunteers for the purpose of co-ordination of schedules and committees.

6.2. Consent

The knowledge and consent of the person are required for the collection, use, or disclosure of personal information, except where inappropriate. Pegasus may also disclose personal information without knowledge or consent in the case of life threatening emergencies or to comply with the law (e.g. a subpoena).

By providing us with your personal information during the intake process, we will assume that you consent to our collection and use of that information for the purposes identified in this policy. Pegasus will obtain participants written consent to collect and release information from and to third parties e.g. other service agencies (Appendix 3: Authorization to Collect, Use and Release Information for Services).

To obtain consent:

6.2.1.    Pegasus will make reasonable efforts to ensure that the persons are advised verbally or in writing of the purposes and use for the collection. Purposes shall be stated in a manner that can reasonably be understood by the persons in their language. 

6.2.2.    Under normal circumstances, Pegasus will seek consent at the time of collection for the use and disclosure of personal information. However, Pegasus may seek consent after it has been collected, but before it has been disclosed or used, for a new purpose.

6.2.3.    In determining the appropriate form of consent, Pegasus shall take into account the sensitivity of the personal information and the reasonable expectations of the individual.

• • Express consent – verbal or written, including an email, letter or a form that you sign describing the intended uses and disclosures of personal information (Appendix 3).
  • Implied consent – for example, when you provide information necessary for a service you have requested, or where Pegasus has given notice about using your personal information and you have not withdrawn your consent for the identified purpose (e.g. using opt-out option provided).

Consent may also be given by your authorized representative (e.g. legal guardian) on your behalf.

6.3. Accuracy

Personal information will be as accurate, complete and up to date as possible at all times.  This minimizes the possibility that inappropriate information may be used to make a decision about a person. Persons can contact Pegasus at any time to update their personal information, and Pegasus may retain the original information for reference purposes.

6.4. Accountability

Pegasus is responsible for maintaining and protecting the personal information we hold. Pegasus has appointed an Information Officer who ensures that Pegasus complies with this policy in accordance with applicable privacy legislation. The information officer also responds to any inquiries and complaints related to privacy matters, as well as requests for access or correction of records (see sections 6.i. and 6.j. below for more information).    

Pegasus maintains strict control over access to personal information once it has been shared with Pegasus. Access to information is granted only to authorized employees who need the information to fulfil their job requirements. Certain health and behavioural information about participants is only accessible by staff members who require the information to support people safely.

Some information about participants can be shared on a case by case basis, with permission such as contact information for a charity event, or information to volunteers if they are working directly with participants. Information may be shared on a case to case basis in service planning, supervision and internal reviews or investigations.

All Pegasus staff and volunteers are trained in this policy at the time of orientation and sign a Confidentiality Agreement (Appendix 1) that specifies personal information cannot be discussed or used outside of Pegasus.  Pegasus has also developed information that explains how personal information is protected and the procedures and processes followed if a complaint arises for participants, volunteers and donors (Appendix 4: Procedures for ensuring and maintaining the protection of confidentiality and privacy of information).

6.5. Safeguards

Pegasus protects personal information by security safeguards appropriate to the sensitivity of the information. Pegasus has processes and systems in place to protect personal information against such risks as loss or theft, unauthorized access, disclosure, copying, use modification or disposal, through appropriate security measures. Pegasus will protect the information regardless of the format in which it is held.

Pegasus will protect personal information disclosed to third parties by contractual agreements stipulating the confidentiality of the information and the purposes for which it is to be used.

6.6. Openness

Pegasus will make readily available to the person specific information about its policies and practices relating to the management of personal information. This information will be made available in multiple formats.  Pegasus will also make readily available:

6.6.1.    The name or title, address of person or persons accountable for compliance of the Privacy of Information and Confidentiality Policy within Pegasus and to whom complaints and inquiries can be forwarded.

6.6.2.    The means of gaining access to personal information held by Pegasus.

6.6.3.    A description of the type of personal information held by Pegasus, including a general account of its use.

6.6.4.    Publicly available copies of any information that explains Pegasus’ policies, processes and principles.

6.7. Limiting Collection

The collection of personal information will be limited to that which is necessary for the purposes identified by Pegasus. Information will be collected by fair and lawful means.

6.7.1.    Pegasus will not collect personal information indiscriminately. The amount and type of information collected will be limited to the minimum amount necessary to satisfy the purpose.

6.7.2.    As much as possible, personal information will be collected directly from the individual.

6.8. Individual Access

If a participant, donor or volunteer request, Pegasus will provide them access to their personal information. Pegasus will respond to requests for access within 30 days, unless 30 days would unreasonably interfere with our activities or more time is required to undertake the consultations necessary to respond to the request.

A participant, donor or volunteer can challenge the accuracy and completeness of the information and have it amended as appropriate.

If you would like to access or amend Pegasus’ file of your personal information, write to:

The Information Officer

Pegasus Community Project

931 Kingston Road

Toronto, M4E 1S6 

Your right to access or correct your personal information is subject to applicable legal, security, and solicitor-client litigation privilege or commercial restrictions. Other restrictions include information that is costly to provide or information that contains certain references to other persons or if access to person’s information entails access to third party information.

Upon request, Pegasus will give the person a reasonable time to review their personal information on file and will provide copies in an understandable format if requested. If the information access request is related to information given to third parties, Pegasus will provide a list of organizations where personal information has been disclosed.

6.9. Limiting Use, Disclosure and Retention

Personal information will not be used or disclosed for purposes other than those for which it is collected, except with the consent of the person or as required by law. Pegasus will retain personal information as long as necessary for the fulfilment of those purposes or as legally required.

6.9.1.    Only Pegasus employees, or authorized agents with a need to know for organization purposes, or whose duties reasonably so require, are granted access to personal information about participants, volunteers or donors.

6.9.2.    Pegasus does not allow third parties access to its participants, volunteer or donor lists

6.9.3.    Pegasus is committed to managing and controlling information through best practice processes and documentation management systems. This includes retention and regular destruction of information that is no longer necessary or is made anonymous.

6.10. Challenging compliance

Pegasus is committed to maintaining best practice procedures for all complaints and inquiries regarding compliance of this policy. Pegasus widely communicates this policy and trains staff, participants and volunteers on the systems and procedures in place around privacy of information and confidentiality.

A person can challenge Pegasus compliance with this policy at any time. The Information Officer will raise the concern to the Executive Director who will investigate all complaints within a reasonable time period. External advice may be sought in certain cases before a final written response is given.  If a complaint is found to be justified, all appropriate measures will be taken which may include amendment of policies and procedures. The person will be informed of the outcome of the investigation.

7. Withdrawal of consent to collection, use and disclosure of personal information

You may withdraw your consent to collection, use and disclosure of personal information at any time, subject to contractual and legal restrictions and reasonable notice in writing.

If you withdraw your consent to certain uses of your personal information, we may no longer be able to provide you with certain supports or services or to continue our working agreement with you.

8. Policy Violations

Employees who do not follow this policy will be subject to disciplinary action, which may include termination. Examples of violations include:

• Violation of client confidentiality agreements
• Misusing, disclosing without authorization, making unauthorized or agreed amendments to personal information.
• Breaking electronic security processes by sharing passwords.

9. Training

9.1. Staff

Staff will receive training on this policy as a part of their initial orientation

9.2. Participants

Participants will be trained on policies and procedures related to privacy of information and confidentiality in a language and manner, and with a level of support, that is appropriate to their needs. This training will take place during intake and annually thereafter or as often as needed.

10. Policy Review

This policy will be reviewed annually by the Executive Director and the Program Manager. 

Revisions will be reviewed by the Executive Director and the Board of Directors.