Information from the Practice Advice Service

QUERIES

During the 2021-2022 year (June 1, 2021 – May 31, 2022), the College’s Practice Advice Service addressed 1255 inquiries. The five most common topics queried during this period, in descending order, were:

1. Mobility and Practice in Other Jurisdictions; mostly relating to member practice outside of Ontario
2. Supervision, primarily concerning the supervision of non-members
3. Release of and Access to Information, mostly relating to the client’s right of access and substitute decision-making, particularly with respect to childrens’ records
4. Records, mainly related to retention and destruction of records, file contents, Health Information Custodians and electronic record keeping
5. Fees and Billing, the most common queries relating to the setting of fees

Answers to many of these queries can be found on the Professional Practice FAQ page of the College website  which includes the following recent additions.

Fee Increases

Q: What are the College’s requirements concerning raising fees for service with existing clients and is there a necessary notice period for fee increases?

A: The Standards of Professional Conduct, 2017 state that:

11.1 Fees and Billing Arrangements

Members must reach an agreement with an individual, group or organization concerning the psychological services to be provided, the fees to be charged and the billing arrangements prior to providing psychological services.  Any changes in the services to be provided must be agreed to by the client before service is delivered or fees are changed.  Fees must be based on amount of time spent and complexity of the services rendered.

Practical Application: Fees for services should be determined on a consistent basis, regardless of the payer. A member may, however, offer pro bono services or apply a sliding scale to ensure access to services and affordability.

While this Standard is most often thought of in the context of initiating services with a new client, it also can be read to apply with respect to the ongoing provision of services. That is, “providing psychological services” could be read to mean each instance of providinga psychological service.

t would be inappropriate for a client to learn that their fees had been increased when they receive a bill for a service that had already occurred.  Increased fees may be an important consideration for clients in the ongoing informed consent to service process and some clients may need to reconsider whether they are able, or prepared, to continue at the new proposed rate.  

There is no specific period of notice for a fee change set out in any Regulations or in the Standards as this is a matter of professional judgment. Adequate notice of the change however, is important and there may be clients who experience a fee increase as akin to indirect termination of therapy.

In cases where the client may not agree to an increased fee, and a member is not prepared to continue to provide services at the existing rate, guidance regarding the termination of services can be found in section 8 of O. Reg. 801/93: Professional Misconduct. This section of the Regulation states that termination of service that is needed is an act of professional misconduct unless:

i. the client requests the discontinuation,

ii. the client withdraws from the service,

iii. reasonable efforts are made to arrange alternative services,

iv. the client is given a reasonable opportunity to arrange alternative services, or

v. continuing to provide the services would place the member at serious personal risk.

Although there are informal ‘rules of thumb’ with respect to ‘winding down of therapy’, often based upon the length of time a person has been receiving treatment, the College does not set any particulars in this regard.   If the client requires additional services but can not or will not pay the increased rate, it would be reasonable and appropriate to work with them for a time period that, in the member’s professional judgment, is sufficient to arrange for a transfer of care to another service provider and avoid any harm due to a disruption of treatment.

Maintenance of Records, Post Supervision

Q:  I am supervising non-members who are providing services at a clinic that is not my own. The supervision is only schedule to occur for a limited period of time. When the supervision is concluded, who keeps the patient files? Is it the clinic that the patient has been going to or am I required to maintain the file?

A: The answer to this question depends upon who has been identified as the Health Information Custodian.  Under the Personal Health Information Protection Act, 2004 (PHIPA), it is possible that either a health care practitioner or a person who operates a group practice of health care practitioners can act as the Health Information Custodian (HIC). While either is possible, only one must be established at the onset of services. Generally, this will be the particular individual or entity they authorize to collect their Personal Health Information.

If, in this scenario, the operator of a group practice is not the HIC, then, the following Standard is applicable:

4.1 Responsibility of Supervisors of Psychological Service Providers

If members are supervising psychological services provided by a member holding a certificate for supervised practice or any other unregulated or regulated service provider who is not an autonomous practice member of the College, the clients are considered to be clients of the supervisor…

It then follows that the records are considered to be the records of the supervising member.  This is supported by the following additional Standard:

9.1.2 Members Responsible for Supervising Supervised Practice Members and Non-Members

Members supervising Supervised Practice members and non-members are responsible for the security, accessibility, maintenance, and retention of records.

If the organization is not the HIC, at the end of the engagement, in most case it is the supervising member who is the HIC and the records must remain with them for the required retention period.

Professional Obligations; Consultation vs. Direct Service

Q:  When consulting to an organization, such as a foster agency, about children in their care, what are my obligations with respect to the client? For example, who is required to obtain informed consent or to collect and maintain the records containing personal health information?

A: In order to answer this question, it is important to consider what is meant by “consulting” as it can be understood to mean different things in different contexts. Consultation is defined in the Standards of Professional Conduct, 2017 as:

the provision of information, within a relationship of professionals of relatively equal status, generally based upon a limited amount of information that offers a point of view that is not binding with respect to the subsequent professional behaviour of the recipient of the information.

If this describes the nature of the relationship with the agency, then the organization is generally considered to be the client. In the case of an organizational client, the member providing consultation is required to maintain records in accordance with the following Standard:

9.3 Organizational Client Records

1. Members must keep a record related to the services provided to each organizational client.
2.  The record must include the following:
   1. the name and contact information of the organizational client;
   1. the name(s) and title(s) of the person(s) who can release confidential information about the organizational client;
   1. the date and nature of each material service provided to the organizational client;
   1. a copy of all agreements and correspondence with the organizational client; and
   1. a copy of each report that is prepared for the organizational client.

The “nature of each material service provided to the organizational client” in c) above, should likely include sufficient information to address queries about the quality of the particular consultation, should that information ever be needed.

An organizational client record must be retained for at least ten years following the organizational client’s last contact.  If the organizational client has been receiving service for more than ten years, information contained in a record that is more than ten years old may be destroyed, if the information is not relevant to services currently being provided.

It is the responsibility of the individual providing services to ensure that proper client consent is obtain for the service being providing. A person acting as a consultant to a service provider would not likely be in a position to seek consent from the person receiving services from the consultee. The consultant may, in fact, never come into contact with the person receiving services from the consultee. In some cases they may not even know their name.

If a member is identified as a “consultant” but they are personally providing the psychological assessment, diagnosis, opinion or intervention, as opposed to “consulting” to or supervising another service provider, this would likely be considered a direct service.  In this case, all of the Standards relevant to direct service provision, including those pertaining to consent and record-keeping, would be applicable.  

In circumstances where it is unclear whether one is providing direct service or consultation, it may be useful to ask: Is this a service I would provide autonomously to an individual or family in a clinical practice, or is it providing advice to another autonomous service provider who is simply looking for the input with respect to clinical decisions they must make themselves?