Psychiatric Patient Advocate Office - Position Papers - Homes for Persons with Special Needs

Homes for Persons with Special Needs

October 27, 2000

Mr. Alexander Bezzina
Manager
Mental Health Strategic Policy Unit
Ministry of Health and Long-Term Care
56 Wellesley Street West, 15^th Floor
Toronto, Ontario
M5S 2S3

Dear Mr. Bezzina:

I wish to thank you for involving the Psychiatric Patient Advocate Office (PPAO) in your consultation process regarding Homes for Persons with Special Needs. You will find in the attached document that we have made several recommendations that we believe would benefit our clients and make the proposed model for service delivery even stronger. The PPAO has been involved in previous consultations around the homelessness initiative, Making it Happen and other initiatives that support mental health reform in Ontario.

We are an advocacy and rights protection program. While we are an internal program of the Ministry of Health and Long-Term Care, we enjoy a quasi-independent relationship with the Ministry to speak freely to the rights and entitlements of psychiatric patients. So, please view our comments in that context.

If you have any questions regarding our submission please contact me. Once again, thank you for the opportunity to participate.

________________________
Vahe Kehyayan
Director

Submission to the Ministry of Health and Long-Term Care and the Ministry of Community and Social Services regarding Homes for Persons with Special Needs

Psychiatric Patient Advocate Office
2195 Yonge Street, 6^th Floor
Toronto, Ontario, M4S 2B2
www.ppao.gov.on.ca

October 2000

Summary of Recommendations

Implementation Considerations

The PPAO recommends that all residents be referred to as tenants.
The PPAO recommends that the element of choice be seen as essential and that the individual always maintain the right to accept or refuse housing.
The PPAO recommends that the Ministry consider the establishment of respite beds and family units within the Homes for Persons with Special Needs program.
The PPAO recommends that the Personal Needs Allowance be increased from $112.00 to $160.00 to more accurately reflect the actual cost of living.
The PPAO recommends that individuals be provided with choice and options and that their decisions be respected.
The PPAO recommends that housing and co-operation with treatment plans not be linked.
The PPAO recommends that the Ministry address strategies on how to break the cycle of people being housed, hospitalized and at times homeless at discharge.
The PPAO recommends that drug control systems remain flexible to best meet the needs of all individuals and to encourage independence.
The PPAO recommends that the Ministry consider the development of specialized housing for individuals with a dual diagnosis and serious mental illness.
The PPAO recommends that standards be flexible enough to allow each home to be individualized to best meet the needs of the tenants that reside there.
The PPAO recommends that standards be flexible enough to allow each home to be individualized to best meet the needs of the tenants that reside there.
The PPAO recommends that the Ministry provide funding for transportation, recreation and social activities.
The PPAO recommends that the requirement for 24 hour supervision be reviewed and be flexible enough to reflect the needs of the tenants residing in the home.
The PPAO recommends the establishment of a field worker position similar to that available to individuals who reside in a Homes for Special Care.
The PPAO recommends that the rights adviser not be obstructed from fulfilling their mandate.
The PPAO recommends that crisis intervention and specialized services be available to all tenants.
The PPAO recommends that there be an increase in the number of spaces available in Homes for Persons with Special Needs.
The PPAO recommends that a review and evaluation of the Homes for Persons with Special Needs be undertaken no less than three years after implementation and that tenants, families, community agencies and other interested parties be involved in the review.
The PPAO recommends that the Ministry change the name of the program to "Care Homes Program" to reflect the nature of the housing and not the housed.

Standards

The PPAO recommends that there be strict adherence to the Tenant Protection Act and that the information be made available.
The PPAO recommends that MCSS review policies around the shelter allowance and make them more flexible for tenants who require hospitalization for a period greater than three months.
The PPAO recommends that tenants be part of an advisory committee that provides advice and consultation to the third party administrator.

The PPAO recommends that tenants be involved in as many areas as possible from sitting on hiring committees, to planning meals and recreational and social activities.
The PPAO recommends that every effort should be made to provide tenants with their own private self-contained room, facilities for locking up personal possessions and wherever possible to be able to lock the door to their personal area.
The PPAO recommends that support staff be available to tenants to assist them with activities of daily living and to be a resource to the tenant.
The PPAO recommends that tenants be involved in the hiring process for positions that most closely affect them.
The PPAO recommends that provisions be made such that a single point of access does not limit people's choices.
The PPAO recommends that a process be developed for the distribution of best practices to home operators across the province.
The PPAO recommends that provincial standards be set which harmonize municipal bylaws and allow for uniform enforcement of the standards.
The PPAO recommends that home operators should not be involved in the Community Treatment Order process.

Safeguards/Accountability

The PPAO recommends that tenants be provided with information and education on their rights, community resources available to assist them if their rights have been violated and have access to information on how to make a complaint.
The PPAO recommends that tenants and operators be provided with regular education sessions on the Tenant Protection Act.

The PPAO recommends that compliance with the Tenant Protection Act be monitored.

The PPAO recommends that a Tenants' Bill of Rights be adopted that would clearly articulate tenant rights and that would be posted in each home. The Bill of Rights must also have a 1-800 number for tenants to call if their rights have been violated and if they require information and/or assistance.
The PPAO recommends that when a tenant has a complaint about the third party administrator that a neutral party be available to assist with the resolution of the complaint, which might include the Ministry appointing such a person or an independent office.

The PPAO recommends that the complaints process be transparent, accessible and clearly articulated so that tenants know what the process is and how to access it.
The PPAO recommends that independent advocacy services be available to tenants.
The PPAO recommends that ongoing education sessions be provided to home operators on topics such as harm reduction, understanding mental illness, sexual abuse, harassment, discrimination, quality of care issues and other topics of interest.
The PPAO recommends that annual tenant satisfaction surveys be completed by a neutral third party, ideally a consumer survivor group, who could forward the information to the appropriate governing body.

Psychiatric Patient Advocate Office

Submission to the Ministry of Health and Long-Term Care and the Ministry of Community and Social Services regarding Homes for Persons with Special Needs

Introduction
The Psychiatric Patient Advocate Office (PPAO), established in 1983, is an arms-length program of the Ministry of Health and Long-Term Care in Ontario. The purpose of the Office is to provide advocacy and rights advice services to the inpatients of Ontario's eight provincial psychiatric hospitals, the Queen Street site of the Centre for Addiction and Mental Health and the Royal Ottawa Hospital, Brockville site. We do this through conducting client-instructed advocacy, systemic advocacy and non-instructed advocacy. We also provide information on issues related to mental health and psychiatric patient rights to the Ministry of Health and Long-Term Care, other Ministries and members of the public. The PPAO does not speak on behalf of the Ministry.

Implementation Considerations

Use of Language
During the public consultation there was discussion on how individuals residing in Homes for Persons with Special Needs should be referred to. The discussion centered on the use of the term "tenant" versus "client". The fact that individuals pay rent to the home operator means that in law they are tenants as defined in the Tenant Protection Act and not clients.

The PPAO recommends that all residents be referred to as tenants.
Choice
It is essential that individuals be provided with choice and be offered several housing options from which to choose. Individuals must have the ability to move to other homes if they believe that they are better suited to their needs, or would prefer to live in another home. Mobility rights must be guaranteed so that tenants always maintain the freedom to move to other homes, if they desire. The person's satisfaction with their housing is a factor in their quality of life.

The PPAO recommends that the element of choice be seen as essential and that the individual always maintain the right to accept or refuse housing.
Respite care and family units
At times an individual may require temporary or short-term housing either because of circumstances at their current place of residence or their care provider needs a break. It is essential that the proposed homes provide for such situations and are able to accommodate these circumstances. Section 3(l) of the Tenant Protection Act exempts ALiving accommodation in a care home occupied by a person for the purpose of receiving short term respite care@. Under this provision, Care Homes could provide short-term care for individuals whose regular caregivers require a break.

If Homes for Persons with Special Needs are to be considered as "permanent housing" for some patients, then family units may be required. This is especially important if spouses want to share accommodation. It would be unreasonable and unfair to separate them simply because such housing units were not available or because the Ministry did not support this housing option for individuals that might require the level of support offered by these homes. As the population ages, this housing option may become more of an issue for consideration. Dignity and respect for the individual should be a cornerstone of all housing options and must govern the activities of all operators.

The PPAO recommends that the Ministry consider the establishment of respite beds and family units within the Homes for Persons with Special Needs program.
Increase in Personal Needs Allowance
The Personal Needs Allowance (PNA) does not adequately cover the cost of items that individuals are required to purchase on a monthly basis. The PNA is used to purchase clothing, hygiene items, pay for social and recreational activities and other items related to comfort and quality of life. The PNA currently is $112.00, which is less than $3.75 per day for an average month of 30 days. A consumer/survivor organization conducted research and concluded that based on current costs, the PNA should be increased to $160.00 if it was to adequately cover the needs of individuals receiving this benefit. At the current rate, people are left to beg off friends or strangers, plead continually with their guardians for money that is not there and at times this may lead to their victimization. Providing individuals with the finances to purchase the basic necessities of life provides the individual with a level of dignity and self-respect.

The PPAO recommends that the Personal Needs Allowance be increased from $112.00 to $160.00 to more accurately reflect the actual cost of living.
Provision of services that the client wants
Individuals must be involved in all decisions that affect their care, life and treatment and services must be provided in this spirit. Individuals should be provided with the services that they want and need, when they want them and in the location that best suits their needs. In addition to being provided with choices and options, the individuals decisions must be respected.

The PPAO recommends that individuals be provided with choice and options and that their decisions be respected.
Linking treatment plans to place of residence
People have a right to housing. This right is not dependent on co-operation with a treatment plan. Even people who refuse to co-operate with their treatment plans, have a right to housing. This is part of the reason for ensuring that this housing falls under the Tenant Protection Act. It would make it more difficult to evict someone from their housing simply because they didn't co-operate with their treatment plan. If hospitalization were required then the process provided under the Mental Health Act, would need to be followed. An individual's housing must not be linked to their co-operation with a treatment plan.

The PPAO recommends that housing and co-operation with treatment plans not be linked.
Breaking the cycle of being housed/hospitalized/homeless
Individuals often find themselves in a cycle of first being housed, then hospitalized, and at times homeless at discharge from hospital. Such a cycle must be broken if individuals are going to have stability with respect to where they live. Breaking the cycle is important because once a person is trapped in the cycle there is a toll on the persons physical and mental health, on their well-being and quality of life. Unfortunately, when housing providers are paid a per diem rate, it is not in their interest to have a bed vacant for a long period of time. In order to break this cycle the Ministry will need to review how it funds and addresses tenants who find themselves in this situation. One of the difficulties of not breaking this cycle is that it is difficult for tenants to maintain their possessions because often they are not provided with financial assistance to pay for either moving or storage of their belongings until such time as they require them again. A review of how home operators are paid and entitlement programs for tenants are administered is required if this cycle is to be broken, for the benefit of all tenants.

The PPAO recommends that the Ministry address strategies on how to break the cycle of people being housed, hospitalized and at times homeless at discharge.
Self medication and supporting independence
There are some individuals who currently self medicate and who do this as part of their plan for re-integration into the community and more independent living. It is hoped that the ability to do this will not be lost by a desire on the part of the Ministry to set a requirement that all medication be dispensed by a regulated health practitioner. Drug control systems must remain flexible to meet the needs of individuals and to allow for situations as described above. The desire of the Ministry to provide a supervised and safe environment must be balanced with individual needs and abilities and the desire to learn self-care and foster a higher level of independence.

The PPAO recommends that drug control systems remain flexible to best meet the needs of all individuals and to encourage independence.
Specialized housing for specialized populations
The new program will provide housing for persons with mental illness and other individuals with special needs who have reached their maximum level of functioning, but still require ongoing personal care and support services to maintain that level of functioning. It may be necessary to provide specialized housing for specialized populations such as those with a dual diagnosis. Individuals with dual diagnosis have special needs that may require modification of both the physical set up of the home as well as the nature of the support services that are to be offered. Concern has been expressed by some service providers and advocates about the vulnerability of these individuals and the need for an environment that provides an additional level of safety and perhaps supervision. The per diem will need to reflect the diversity of the needs of this population and be flexible enough to accommodate their special needs and the impact it may have on service delivery.

The PPAO recommends that the Ministry consider the development of specialized housing for individuals with a dual diagnosis and serious mental illness.
Housing provider not manage tenants' money
Some housing providers have acted as informal trustees for individuals and have managed the money of both financially capable and incapable persons. This should be seen as a conflict of interest and housing providers should be encouraged to seek out trustees who are independent and not connected to their facility. Individuals deemed financially capable should not be subjected to any form of trusteeship, unless they have requested such assistance. In addition to the Public Guardian and Trustee, there are a multitude of voluntary trusteeship programs in the community that could assume such responsibility.

The PPAO recommends that housing providers not manage the money of their tenants.
Not making these homes "mini institutions"
In an effort to set standards it is important that these be flexible enough to allow each home to be individualized to best meet the needs of it's residents. Homes should be encouraged to establish environments that are home-like and which simply do not resemble mini institutions. Individualization can incorporate the standards set by the Ministry with respect to the quality of physical plant and the provision of care, whether that be cleaning, food or programming. Standards should be seen as a way to set common denominators across the program but tenants must be provided with a range of options, services and programs that reflect the uniqueness of that home and the tenants who reside there. In addition to the establishment of standards, outcomes should be measured and evaluated on a regular basis.

The PPAO recommends that standards be flexible enough to allow each home to be individualized to best meet the needs of the tenants that reside there.
Providing funding for transportation, recreation and social activities
It is very important that reasonable levels of funding be provided for transportation, recreation and social activities and that these expenses be incorporated into the per diem rate. These activities are essential in increasing individual motivation and supports rehabilitation and integration into the community, as well as enhancing the quality of life of tenants. Tenants must have a range of activities available to them and have the option of participating in those that they choose.

The PPAO recommends that the Ministry provide funding for transportation, recreation and social activities.
24 hour supervision
The Ministry is proposing that all Homes for Persons with Special Needs provide 24 hour supervision. The PPAO is concerned that such a requirement may result in tenants being asked to leave their residence when staffing is not available as the Ministry is proposing that the residence never be left unsupervised. Although the PPAO is supportive of the concept of 24-hour supervision, there may be homes or unique circumstances where such supervision is not required due to the level of functioning of the tenants. Standards should be flexible enough to accommodate these unique circumstances. Home operators should be able to modify this requirement, in consultation with the Ministry.

The PPAO recommends that the requirement for 24 hour supervision be reviewed and be flexible enough to reflect the needs of the tenants residing in the home.
Field worker position
Many individuals who currently reside in a Homes for Special Care have access to a field worker who can provide them with assistance on a range of issues. This position should be maintained in the proposed model as the field worker can be a valuable resource to both the individual and the home operator. The field worker can also assist the tenant in coordinating services, attending appointments with them and advocating on their behalf, when required. The field worker can be the primary contact person between the tenant, treatment team and the home operator and can co-ordinate access to services.

The PPAO recommends the establishment of a field worker position similar to that available to individuals who reside in a Homes for Special Care.
Rights advice
Some tenants may be on a Community Treatment Order while residing in the home. There will be a legal requirement that the individual and their substitute decision maker receive rights advice. As such, it may be necessary for the rights adviser to meet with the individual in their home and the rights adviser will need to have access to the person so that they can be provided with the information. The home owner cannot obstruct the rights adviser from fulfilling their mandate and providing the information to the tenant.

The PPAO recommends that the rights adviser not be obstructed from fulfilling their mandate.
Access to crisis intervention services/specialized services
Crisis intervention and specialized services must be available and accessible to all tenants. This would include having access to the services after regular working hours, on weekends and holidays. Having access to such services may mean that the tenant is more likely to maintain their housing when in crisis and will have assistance in resolving difficulties.

The PPAO recommends that crisis intervention and specialized services be available to all tenants.
Increase in the number of residential spaces
The number of available spaces (beds) has not increased in several years, resulting in waiting lists and tenants being unable to access the housing that best meets their needs. In order to ensure that those requiring housing are able to secure it without remaining on waiting lists for extended periods of time, it is essential that the actual number of spaces in these homes be increased to reflect the need. Such an increase would support the recommendations made in "Making it Happen" with respect to this type of housing for individuals with serious mental illness. The Ministry may want to evaluate the need for such housing and set achievable and realistic targets for when this housing will be made available. The allocation of spaces and Care Homes should be reviewed to address the need in rural and northern areas where homes may not be currently available. Individuals should have access to this type of housing in their own community where they are connected to their informal and formal support networks. This would also support the objective of eventual reintegration into the community of choice.

The PPAO recommends that there be an increase in the number of spaces available in Homes for Persons with Special Needs.
Program Review and Evaluation
The PPAO believes that the effectiveness of the proposed program should be reviewed not less than three years after implementation. The review must include tenants of the program from all parts of the province, family members, service providers, advocacy groups and other members of the community. The review process should be clearly defined, transparent and consultations should allow adequate time for individuals to respond. The review must define consistent satisfactory performance levels and indicators to measure desired outcomes for programs.

The PPAO recommends that a review and evaluation of the Homes for Persons with Special Needs be undertaken no less than three years after implementation and that tenants, families, community agencies and other interested parties be involved in the review.
Name of program
The program title is demeaning and should describe the homes, not the persons who will reside there. The feeling that this approach is institutional in nature and that it deals with people as if they have a static level of functioning or wellness, begins with the AHomes for Persons with Special Needs@ title. The Tenant Protection Act already has a definition of Care Homes that is clearly intended to cover this type of housing. The Ministry should refer to this program as Care Homes Program, thereby defining the housing, and not the people who are housed. The individuals residing in the homes could then more properly be referred to as Care Home tenants. APersons with Special Needs@ is a step backwards as it labels individuals and does not empower them as would the term tenant. In part, this is due to the fact that the word tenant infers some individual rights, indicates a level of individual involvement and some sense of a personal stake in the housing.

The PPAO recommends that the Ministry change the name of the program to "Care Homes Program" to reflect the nature of the housing and not the housed.

Standards

Strict adherence to the Tenant Protection Act (TPA)
The TPA covers Care Homes and all home operators must have a good working knowledge of this legislation. The landlord must provide the tenant with information about their rights under the TPA when the tenancy agreement is made. On the yearly anniversary of the tenancy agreement the landlord again must provide the tenant with information on their rights under the TPA. Copies of information regarding tenant rights in care homes must be available in a visible place at all times for tenants and families. As well, information on how to contact the Ontario Rental Housing Tribunal in the event of a dispute must be made available to tenants. The Ontario Human Rights Code applies to all residents of Ontario including tenants of these homes. Information regarding how to contact the OHRC must be available to the tenant and families.

It is also recommended that the Ministry develop a standardized tenants package, based on the information required in the Care Homes Information Package (CHIP), as a best practice and that all tenants receive this information.

The PPAO recommends that there be strict adherence to the Tenant Protection Act and that the information be made available.
Tenure during re-hospitalization
It is extremely important that individuals be able to be re-hospitalized, without the fear of losing their homes. The standard length of time allowed by ODSP, before they cut off the shelter allowance, is three months. This seems to be a reasonable period of time but policies should be flexible enough to accommodate specific and individual circumstances, beyond the three-month period. Ideally, there should also be a formalized process in place, which clearly articulates what the process is and how tenants can access it.

The PPAO recommends that MCSS review policies around the shelter allowance and make them more flexible for tenants who require hospitalization for a period greater than three months.
Tenant involvement
There needs to be a concerted effort to provide tenant involvement in as many areas as possible. This can mean everything from helping to choose meals, having a say in programs and social recreation activities offered, to sitting in on interviews as part of the hiring committee, or even sitting on the board of directors if the home is a non-profit enterprise. Tenants should also be involved in an advisory committee that provides advice and consultation to the third party administrator. This will ensure that tenants are involved at all levels and that a "tenant first" perspective will be present.

The PPAO recommends that tenants be part of an advisory committee that provides advice and consultation to the third party administrator.

The PPAO recommends that tenants be involved in as many areas as possible from sitting on hiring committees, to planning meals and recreational and social activities.
Personal space
Every effort should be made for each individual to have a self-contained room. It is important for people to have a place to which they can withdraw and be alone. Many difficulties arise in shared accommodation solely because of the fact that the threshold of tolerance for behaviour is much lower. Also, the ideal in shared accommodation is that individuals be able to provide some level of support to their peers. The chance of this happening increases if people have their own personal space to retreat to. There should also be an effort to provide private and locked storage space, especially in those cases where an individual room is not possible. It is also important that individuals be permitted to display and use personal belongings including radios, televisions and computers.

The PPAO recommends that every effort should be made to provide tenants with their own private self-contained room, facilities for locking up personal possessions and wherever possible to be able to lock the door to their personal area.
Support staff
This really addresses an artificial distinction made in the Homes for Persons with Special Needs Backgrounder. On page 5, paragraph 3 of the Proposed Client Group section, there is a distinction made between supportive housing being more independent and rehabilitative, as opposed to the provision of a Asafe, supervised environmentY..personal care services, such as meals, housekeeping and assistance with activities of daily living in order to maintain health outcomes.@ The fact is, these are not mutually exclusive, and although there is a group of people who require more assistance in order to maintain their housing, they also require, and are entitled to, the proactive, skill building, informal counseling which is provided in a supportive housing model. Each home cannot provide the vast array of services that a diverse group of tenants may wish or require. However ensuring each home has a support worker whose job it is to build a relationship with the individual tenants and be a bridge to community resources can go a long way. This person would be able to focus on individual needs, make appropriate referrals to community resources, and provide informal counseling around issues. Apart from the requirements of physical needs being satisfied, the most important resource a vulnerable person can have is a person in their life who is constant, non-judgmental, and trustworthy.

The PPAO recommends that support staff be available to tenants to assist them with activities of daily living and to be a resource to the tenant.
Qualifications of staff
All staff must demonstrate personal suitability, commitment to the tenant group and understanding of mental illness and respect for the individual. These qualities should be considered in the hiring process in addition to the applicant's education and employment background. Ideally, tenants should be sitting in on the hiring for positions which most closely affect them.

The PPAO recommends that tenants be involved in the hiring process for positions that most closely affect them.
Single point of access
The PPAO is concerned about single point of access, simply because it makes it easier to deny people a broad range of housing and services. There should be steps taken to ensure that the single point of access increases the efficiency of filling vacancies, but not by removing people's choice. Those denied access should be given the reasons why in writing, and should have access to an appeal process. Also, the principle that people should have the right to request a move without cause should be enshrined, and of course balanced with the fact that they would have to meet the criteria for the home they wished to move to.

The PPAO recommends that provisions be made such that a single point of access does not limit people's choices.
Process for sharing best practices
In the course of service delivery some home operators will develop best practices with respect to service delivery, quality of care standards and the development of tenant centered policies. It would be helpful if a mechanism was established to provide for the distribution of best practices to other home operators across the province. This would benefit both the operators and the tenants.

The PPAO recommends that a process be developed for the distribution of best practices to home operators across the province.
Standardization of Municipal Bylaws
Currently municipal bylaws govern the operation of approved homes, Homes for Special Care and hostels. This has led to various standards being in place and an uneven application of rules across the province. Some municipalities are very proactive and supportive of these homes while others are not as receptive. Provincial standards which harmonize the municipal bylaws and allow for uniform enforcement would be beneficial, if this program is to be successful.

The PPAO recommends that provincial standards be set which harmonize municipal bylaws and allow for uniform enforcement of the standards.
Community Treatment Orders
Home operators should not be involved in any way in community treatment orders. Treatment teams must be responsible for such matters as involving the housing provider would clearly create either a real or perceived conflict of interest. Tenants may find any involvement by their landlord in a CTO process to be intrusive and a breach of trust which could potentially impact on the individuals quality of life and comfort level of remaining in that home.

The PPAO recommends that home operators should not be involved in the Community Treatment Order process.

Safeguards/Accountability

Safety
There are a few ways to look at safety. One aspect of safety is the physical standard to which buildings and care services are maintained and delivered. However, in order to truly increase an individuals= safety, they must be well connected to the community around them, be well aware of what their rights are, and know what to do if those rights are violated. Tenants have the right to live in an environment that is free of fear, harassment, intimidation or coercion. If these rights are violated then they must know what recourse is available to them and who to approach for assistance. Each home operator should be required to display a poster which would let tenants know where to go for help and contain other contact information.

There must be an articulated complaints process by which tenants or family members may make complaints about the home, operators or staff. This process must be easily accessible to all tenants and family members. The complaint resolution process should involve a neutral party. The tenant should be able to access a person of their choice for assistance or representation when making a complaint.

The PPAO recommends that tenants be provided with information and education on their rights, community resources available to assist them if their rights have been violated and have access to information on how to make a complaint.
Bill of Rights/TPA
A Tenants Bill of Rights should articulate all of the rights of a tenant and be posted in each home. Information must also be posted on where to go for help if your rights have been violated. This would provide tenants with information on their rights and serve as a reminder that in addition to the rights and entitlements afforded in the TPA that tenants could expect a certain level of standards as enshrined in the Bill of Rights. A Bill of Rights similar to that in Appendix 1 would be appropriate. A widely distributed and enforced Bill of Rights, along with education provided to tenants and operators on the Tenant Protection Act and monitoring of TPA compliance, will make a large impact on the lives of these tenants and will increase their safety and the accountability of landlords.

The PPAO recommends that tenants and operators be provided with regular education sessions on the Tenant Protection Act.

The PPAO recommends that compliance with the Tenant Protection Act be monitored.

The PPAO recommends that a Tenants' Bill of Rights be adopted that would clearly articulate tenant rights and that would be posted in each home. The Bill of Rights must also have a 1-800 number for tenants to call if their rights have been violated and if they require information and/or assistance.
Third party administrators
Third party administrators should have an advisory committee comprised of tenants, family members, community providers and other interested parties to advise them on issues and to provide advice. They should most definitely have the right to remove the license of an operator, however this would hopefully be a last resort. This agency should be prepared to visit the homes frequently, and at times unannounced, as opposed to simply taking the word of tenants or operators. Some have suggested that third party administrators should be a non-profit agency that is accountable to both a board of directors and to the Ministry. When a tenant has a complaint with the third party administrator a neutral third party must be available to assist the tenant in resolving the complaint. Complaint processes must be transparent, clearly articulated and easy to use so that they do not pose a barrier to tenants.

The PPAO recommends that when a tenant has a complaint about the third party administrator that a neutral party be available to assist with the resolution of the complaint, which might include the Ministry appointing such a person or an independent office.

The PPAO recommends that the complaints process be transparent, accessible and clearly articulated so that tenants know what the process is and how to access it.
Independent advocacy services
During the consultation many stakeholders identified a need for an independent advocate or an individual who could act in the capacity of an ombudsman to assist tenants with resolving complaints. Many individuals felt that such a service should be provided by someone independent from the service provider so that there is no perceived conflict of interest. It is recognized that at times tenants may require the assistance of a third party in resolving complaints and that by assisting with problem resolution some tenants may be able to maintain their housing. The PPAO suggests that tenants and operators be made aware of independent advocacy services in the community that may be available to assist them.

The PPAO recommends that independent advocacy services be available to tenants.
Education for home operators
Ongoing education should be offered to home operators in the areas of harm reduction, quality of care, sexuality, accessing community supports, understanding mental illness, tenant rights, conflict resolution and other topics of interest. It would be helpful if local consumer/survivor groups were involved in providing the education sessions so that the information provided had a client perspective.

The PPAO recommends that ongoing education sessions be provided to home operators on topics such as harm reduction, understanding mental illness, sexual abuse, harassment, discrimination, quality of care issues and other topics of interest.
Satisfaction surveys conducted by neutral third party
To further enhance accountability mechanisms, annual tenant satisfaction surveys should be administered by a neutral third party, ideally a consumer survivor group and forwarded to the appropriate governing body. Local consumer survivor groups could assist tenants in completing the survey and ensuring that all responses were anonymous. Tenants may be more likely to participate in the process if they were assured that their involvement would not jeopardize their housing. Tenant involvement must be on a voluntary basis and with the consent of the individual.

The PPAO recommends that annual tenant satisfaction surveys be completed by a neutral third party, ideally a consumer survivor group, who could forward the information to the appropriate governing body.

Appendix 1

Tenants' Bill of Rights
If we are to provide a strong, clear vision, that will effect real change, it is fundamental to implement a Bill of Rights for tenants of these homes. This Bill of Rights should be posted in each home, made part of each written tenancy agreement ^[1]. This is what can be used to set certain standards and what should be used as a guiding principle for enforcement by a third party.

In 1992, in his report ^[2], Ernie Lightman provided a clear vision. It may require some minor tinkering for the purposes of this program, but would need very few revisions before it could be implemented system wide. It is as follows:

Respect for the basic human dignity of the residents;
A safe, secure, and clean living environment:
1. clean and private bathing and toilet facilities including, without additional charge, sufficient soap, toilet paper, and hygienic pads;
2. a secure and locked storage area for personal effects, and the key to it;
3. a key to the home (unless there is open twenty-four-hour access), and to one=s bedroom and bathroom, each of which must have a lock;
4. a secure locked area for storage of medications;
5. meals, as contracted, that meet the minimum standards of the Canada Food Guide, (with consideration given for the fact that persons with psychiatric histories tend to require more food, as medications increase their levels of hunger, as may anxiety, and boredom) and are served at appropriate times; operators must accommodate reasonable needs of residents (for example, with sufficiently flexible scheduling of meals to meet work or comparable needs of residents);
Personal rights:
1. the right to be treated as competent in all areas of decision-making in all personal and financial matters, the freedom to come and go, and a prohibition on operators= requiring residents to sign in and out;
2. the right to dress and to decorate one=s own living area as one wishes;
3. the right to designate someone to receive any and all information to which the residents have a right of access;
4. the right to know who owns and operates one=s residence (including the names, addresses, and phone numbers of owners and operators);^[3]
5. residents shall not be required to do work or services for or on behalf of operators;^[4]
6. residents= right to privacy shall be respected at all times; this includes prohibitions on intrusion into residents= living areas, except as provided under the Tenant Protection Act^[5], and on interference with residents= personal belongings;
7. no physical search of the residents;
8. no restrictions on communication by telephone and mail, or on access to print or broadcast media, including the right to send and receive written correspondence unopened;
9. the right to unimpeded access to independent advocates, lawyers, or physicians at any time;
10. the right to receive visitors, including staff from community-based programs;
11. the right to form a tenants= or residents= association and to meet without the presence of owners, operators, or staff;
12. the right to be addressed by name and in non-patronizing language;
Confidentiality
1. if files or records on residents are kept, the right to complete access by the residents to all information contained therein;
2. no information about residents shall be released to any third party except with the written consent of the residents; residents shall have the right to correct any misinformation held or released by operators and to attach a statement of their position on an issue to that of the operators;
Sexuality:
1. the right to engage in consensual sexual behaviour that does not interfere with the dignity and privacy of other residents;
Religion:
1. the right to engage in religious practice in any manner that does not interfere with the dignity and privacy of other residents, and the right not to engage in religious practice;
Consent to treatment:
1. the right to be considered competent to accept or refuse treatment in accordance with the law;
2. the right to be free within the premises from pressure or coercion to accept ore refuse medical treatment, including psychiatric treatment;
3. the right to self-medicate in accordance with the law;
4. if someone assists with medication, the right to one=s own medication - not another = s received from a competent person according to the prescribing doctor=s instructions;
Restraint and seclusion:
1. the right to be free from punitive restraint or detention measures. This includes a prohibition on the use of binding, tying, chemical, and/or other similar restraints, and locked rooms and enclosed spaces;
Abuse:
1. the right to freedom from physical, verbal, emotional, and sexual abuse;
Advocates and other outside supports:
1. the right to have unimpeded access to independent advocates;
2. the right to have access to community support services and the right to choose the supplier of one=s purchased goods and services;
3. no one shall impede or deny entry to a residence of any person or advocate invited into the premises by the residents.

A Bill of Rights such as this would go a long way to ensuring standard treatment and expectations in these homes, however the subject of standards needs to be addressed further as it relates to this paper.

Footnotes:

[1] TPA B 91(1) Agreement Required.CThere shall be a written tenancy agreement relating to the tenancy of every tenant in a care home.

[2] A Community of InterestsCThe Report of the Commission of Inquiry into Unregulated Residential Accommodation, Ernie S. Lightman, Ph.D., CommissionerCMay 1992

[3] This is now law B TPA 8.(1) Name and address in written agreement.CEvery written tenancy agreement entered into on or after the day this section comes into force shall set out the legal name and address of the landlord to be used for the purpose of giving notice or other documents under this Act.

[4] This would not preclude tenants doing small paid jobs for operators should they choose to do so.

[5] There are specific entry provisions in the TPA for care homes B 94.(1) Entry check condition of tenant.CDespite section 19, a landlord may enter a rental unit in a care home at regular intervals to check the condition of a tenant in accordance with the tenancy agreement if the agreement requires the landlord to do so.

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