Practice Matters is an occasional posting about timely, clinical topics of interest to psychotherapy service. Topics are generated by the Practice Advisory service, provides information for registrants on various topics that emerge as key trends. Got a question or an idea for us to cover? Email qa@crpo.ca with your thoughts.

Contingency Planning

Question:

What happens to my clients and clinical records if I’m suddenly no longer able to practise?

Answer:

Planning for the unexpected will help you and your clients should you ever find yourself in a position where you are unable to practise. Indeed, Professional Practice Standard 6.4: Closing, Selling, or Relocating a Practice requires that CRPO registrants have a contingency plan in place that will:

  • ensure the standards of the profession are met, even if you are not providing the services yourself;
  • link your clients with other qualified professionals who can address their needs; and
  • assure that your clients and/or their new providers have timely access to relevant information about the client’s care.

While the particular details of a contingency plan will depend on your practice, it is likely to include:

  • the contact information for one or more individuals (designates) who have agreed to carry out specific tasks on your behalf in the event you are suddenly unable to practise;
  • a list of contacts, including clients and colleagues and others with whom you have significant professional relationships;
  • directions for the designate(s), including those that relate to contacting clients or their substitute decision-makers to inform them of the situation, provide referral information, and discuss maintenance or transfer of clinical records.

Below are some considerations that will help as you shape your contingency plan. Your own research and discussion with colleagues will also be helpful in your planning process.

Identifying an appropriate designate

In the event you were unexpectedly unable to practise, how would your clients learn that you are no longer available to provide services?

  • If you are self-employed in a private practice, you will need to identify an appropriate designate who can carry out specific aspects of your contingency plan.
  • If you work in an agency or hospital setting, it’s possible that a contingency plan already exists to address such a situation – you might find it helpful to speak with your manager for more information.
  • If you provide services under contract to a third party, it will be helpful to carefully consider any existing contracts, policies set by the third party, and your overall role in order to understand what responsibilities would fall to a designate.

When selecting a designate, ensure they have the competence necessary to fulfill the duties set out in the contingency plan. Standard 6.4 does not indicate that a designate must be a fellow RP; however, it would be helpful for the designate to at least be a member of a regulated health profession in Ontario, as these individuals are likely to be familiar with the framework of health care law and regulation.

Understanding the needs of the clients you serve is also important, as this is likely to influence your selection of the designate who will carry out specific duties described in the plan, in addition to your plans for referral of clients to other suitably qualified professionals.

Referral to Alternate Service Providers

Professional Practice Standard 1.9: Referral identifies that registrants must refer their clients to other qualified, competent professionals when they are not available to provide services. In light of this, your contingency plan must take into account referral to other professionals where applicable, as would be the case if you had active clinical files. The reasons for the referral must be explained to the client, and, if the referral process requires disclosure of the client’s personal health information, the client’s consent must be obtained before their information is disclosed.

See Standard 1.9 for more information.

Clinical Records

According to the Personal Health Information Protection Act, individuals who have received health care services in Ontario have a right to access to the personal health information that is contained in clinical records. Health information custodians are responsible for ensuring that clients have access their personal health information in a timely manner.

Health information custodians are individuals or organizations who have custody or control over a client’s personal health information. For example, an RP in private practice is responsible for storing and maintaining client clinical records, and would likely be considered the health information custodian; an RP who is an employee at a hospital or agency, on the other hand, is likely to be considered an agent working on behalf of a health information custodian, i.e. the hospital or agency.

Professional Practice Standard 5.1: Clinical Records identifies that CRPO registrants must maintain clinical records “for at least 10 years from the date of the last interaction with the client, or for 10 years from the client’s 18th birthday, whichever is later.”

If you are the health information custodian, your contingency plan must:

  • account for the maintenance of clinical records in a manner that accords with relevant laws and the Professional Practice Standards; and
  • include measures that will facilitate client access to their personal health information, or transfer of the client’s personal health information to another health provider, for the period defined in the Professional Practice Standards.

See Standards 5.1 and 5.6 on record-keeping for more information.

Instruction to Designate to Notify CRPO

As you prepare your contingency plan, consider adding an instruction for your designate to contact CRPO in the event of your death or incapacity to provide the following information:

  • relevant information about the circumstances; and
  • the name and contact information of the health information custodian designated in the contingency plan.

This information would be retained in CRPO’s records and used only to facilitate a client’s access to their clinical records. Only the name and contact information of the designated health information custodian would be shared.

By including this instruction in your contingency plan, you would be increasing the likelihood that a client would be able to access their clinical records in the event you are not available to provide access yourself.

Have questions about this or other topics? Contact our Practice Advisory Service at practice@crpo.ca.

Custody and Informed Consent

Question:

I’m working with a young child whose parents are going through a divorce. What do I need to know about consent in this situation?

Answer:

According to Professional Practice Standards Section 3: Client-Therapist Relationship, registrants have a duty to place the well-being of the client at the forefront of the therapeutic relationship. With this in mind, consider the following:

The client’s ability to provide consent

In Ontario, there is no “age of consent” with respect to personal health care decisions. In general, clients of any age are considered capable of refusing or providing consent to their own treatment as long as they possess the maturity to reasonably understand the information provided and can appreciate the consequences of their decisions. Where a client is a minor (e.g. under the age of 16 for health care decisions, or under the age of 18 for decisions involving contracts), their capacity to provide consent must be determined on a case-by-case basis.

Every health practitioner who proposes a treatment to a client may perform this type of capacity assessment. Registrants are advised to use their professional judgement and to exercise appropriate care in determining whether a child is capable of consenting to treatment. Where a registrant determines that a child is incapable, treatment may not be carried out unless consent has been obtained from an appropriate substitute decision maker (SDM). Review Standard 3.2: Consent, to see the hierarchy of SDMs.

Keep in mind that a client may be capable of giving consent for some aspects of care, but not others. It is registrants’ responsibility to identify the points where consent is possible and to engage the client in an appropriate informed consent process.

Custody orders and parental agreements

Where a client is not capable of providing consent, it is important to know information about the custody arrangements and whether a custody order or parental agreement exists, as these will inform who may make health care decisions on behalf of the child. For example, even when parents have joint custody, there may only be one parent who, under the custody order, may make decisions relating to the health care of the child.

This document provides information about the differences in custodial arrangements and the implications for health care decisions. See the section entitled “Caring for your children” where these concepts are explained:

Sharing personal health information

In situations where the client is a minor who is capable of providing consent, be advised that you will require the client’s informed consent in order to share their personal health information with parent(s) or guardian(s). Sensitivity to the issues that can arise in cases of separation and divorce, along with an awareness of the client’s particular concerns, will help you provide the information the client needs to make informed decisions about the sharing of their personal health information.

For more information, see our Informed Consent Workbook.

Dual Practice

Question:

I’m registered with CRPO and another college. As a dually-registered practitioner, what do I need to know?

Answer:

Practice Standards
As a starting point, dually-registered professionals are encouraged to review the standards and policies of the colleges with which they are registered. Many colleges have specific standards that apply to dually-registered professionals, though CRPO does not have such resources at this time. Until a standard or guideline on this subject exists, CRPO registrants are encouraged to carefully review CRPO’s Professional Practice Standards in light of their dual practice, in particular Standards 1.2: Use of Terms, Titles and Designations, 1.6: Conflict-of-Interest, 1.7: Dual or Multiple Relationships, 3.1: Confidentiality, 3.2: Consent, 5.3: Issuing Accurate Documents and 6.2: Advertising and Representing Yourself and Your Services.

Administrative Matters
There are a number of administrative matters that a dually registered professional should be aware of. An obvious example is the annual registration process – the dually-registered practitioner is required to complete the annual registration requirements, including any forms and payment of fees, of each college they are registered with. In addition, the dually-registered practitioner is required to engage in the quality assurance programs of any colleges they are registered with; this includes meeting the QA requirements and deadlines of each college.

Complaints
Dually registered professionals should be aware of the possibility that a concern or complaint against them can be received by one or both colleges. While each college independently investigates complaints filed against its registrants, it is possible that in some cases a complaint filed against a registrant with one college could prompt an investigation by the other college, even if the complaint was not originally filed with that college.

Considerations
Being dually registered also has implications for clinical practice – a few examples will be covered off here. For more information, registrants are encouraged to connect with CRPO’s Practice Advisory Service.

The nature of your dual-practice – Depending on the nature of your dual practice, there may be some overlap in the work you do as an RP and the work you do in your other professional capacity. Dually-registered professionals are encouraged to think carefully about where any overlap may or may not occur in their practice. If your other profession does not overlap with psychotherapy, consider whether it is appropriate to refer or treat the same client in the other role.

Providing information for informed consent – Clients are entitled to provide informed consent prior to any treatment. In order for a client’s consent to be considered informed, they must be provided with all the information that one would need in order to make such a decision. Because of potential confusion, it is important that dually-registered practitioners describe their practice and services as accurately as possible, taking care to clarify to the client when the dually-registered practitioner is working in their capacity as a psychotherapist, or when they are working in their other professional capacity.

Maintaining clinical records – The dually-registered practitioner should be mindful that they will be expected to maintain clinical records in a manner that meets the standards of each college with which they are registered.

Billing – CRPO registrants are required to issue clear, accurate documents to third-parties. This means that receipts and invoices should include an accurate description of the services provided to the client, and it should be clear in all financial records in which professional capacity the rgistrant was working in when those services were provided to the client.

This FAQ does not address registrants who practise in unregulated fields in addition to the regulated profession of psychotherapy. This will be addressed in a future article.

HST & Tax Credits

Question:

Are CRPO registrants required to charge HST?

Answer:

Whether or not a registrant is required to charge HST is largely determined by the Excise Tax Act, which is federal law. It includes a list of exemptions that exempt services that are provided by specific professionals. RPs do not appear on the list of professionals whose services are exempt from HST. There may be some situations in which an RPs services can be exempt from HST; however, your accountant or a Canada Revenue Agency representative would be in the best position to provide guidance that is specific to your situation. See Schedule V, Part 11 of the Excise Tax Act.

Are the services provided by a CRPO registrant eligible for a tax credit?

A Government of Canada website identifies that Registered Psychotherapists appear on the list of “Authorized medical practitioners for the purposes of the medical expense tax credit.” We also understand that “therapy plan” and “therapy” appear on the “List of common medical expenses” that are eligible for a tax credit. These services are only eligible for the tax credit when specific conditions are met – please visit the Government of Canada’s website or contact your tax advisor or accountant to explore how this information could impact your practice.​

Fees & Billing

Question:

I am an RP and I am opening a private practice. I’m confused about fees and billing. How much should I be charging my clients? What should my receipts look like? What needs to be included? What are CRPO’s guidelines? I want to make sure I am doing this correctly for CRPO and also for my clients.

Answer:

Setting Fees
According to Professional Practice & Jurisprudence for Registered Psychotherapists, “Establishing professional fees charged by members is not within the mandate of the College, and the College does not set the fees for members’ services. In fact, the college does not regulate the amount a member may charge a client, unless the fee is excessive. A fee is considered excessive if it takes advantage of a vulnerable client or is so high that the profession would conclude that the RP is exploiting a client.” For additional information regarding fees, consult the Professional Practice Standards, Standard 6.1: Fees.

Billing and Receipts
Many registrants, especially those in private practice, collect payment after each psychotherapy session and issue a receipt to the client. The College has information on financial record-keeping, including billing and receipts, in the Professional Practice Standards, Standard 5.3: Issuing Accurate Documents and Standard 5.5: Record-keeping – Financial Records. Members must provide clients with accurate records and other documents, including invoices, bills and receipts.

In short, receipts should include:

  • the registrant’s legal name (and any alternate name used in practice);
  • title conferred by the College and registration number;
  • amount paid;
  • date the service was provided;
  • type of services provided; and
  • full name of the client.

Members are expected to be accurate, transparent and reasonable in their fee and billing practices. For example, if a member works with associates, it should be clear which psychotherapist saw the client.

Practising Out of Province

Question:

I am an RP and I received a request for e-therapy from a person who does not live in Ontario. I am only registered in Ontario. Am I permitted to provide psychotherapy electronically or by phone to someone who does not reside in Ontario? Also, what if I am outside of Ontario and my clients in Ontario would like to continue therapy with me via the telephone or e-therapy, is that ok?

Answer:

Client is Out-of-Province
With regards to providing psychotherapy to clients outside Ontario, the general rule is that the location of the client is what governs. A Registered Psychotherapist may provide services to clients who reside outside of the province; however, you would need to contact the psychotherapy or counselling regulator in the location (state, province or country) where your client lives to make yourself aware of their regulations, if any. You should also ensure that your professional liability insurance covers you providing telephone or e-therapy to clients outside of province or country.

Client is in Ontario and RP is Out-of-Province
The general rule is that the location of the client governs. If you are an RP with CRPO, you may provide services to clients who reside in Ontario, even if you do not. You should ensure that your professional liability insurance covers you providing tele-therapy to clients outside of province of country. Non-members of CRPO must not use the title “psychotherapist” or hold themselves out as qualified to practice as a psychotherapist in Ontario.

Record Keeping

Question:

Is it preferable to keep paper or electronic files?

Answer:

Registrants (or the organization they work for) are free to choose whichever record-keeping system is best suited to their needs and access to technology. The same principles apply to both paper and electronic record-keeping. For example, modifications to any record need to be tracked. In other words, the originals must not be overridden or erased.

Security of paper records would include locking and storage, while for electronic records it would include encryption, virus prevention, backups, and physically restricting access to the computer and display. When using electronic record-keeping systems, an alternate process for record-keeping must be ready in case the electronic system is down or unavailable. Check out CRPO’s Professional Practice Standard 5.6: Recordkeeping – Storage, Security and Retrieval as well as the CRPO Professional Practice and Jurisprudence Manual for more detail.

Question:

I have been using paper in the past and want to switch to electronic record-keeping. Can I scan and destroy the paper copies?

Answer:

There are options when it comes to transitioning from paper to electronic record-keeping. You may either convert all existing paper records into electronic form, or retain paper records and begin entering information into an electronic format on a subsequent basis. In either case, client care and appropriate record-keeping practices must continue without interruption.

When scanning paper records, registrants are responsible for ensuring their integrity upon conversion into electronic format. This includes verifying that documents have been properly scanned and that the entire record is intact, including any attached documents and notes. You should establish specific procedures for converting files and document these procedures in writing. It may be helpful to enlist a reputable commercial organization to assist in this process[1].

The Information and Privacy Commissioner of Ontario states that old paper records should not be destroyed unless the required retention period has expired or the entire paper-based record has been duplicated in electronic format[2].

Question:

How do I determine who is the “health information custodian”?

Answer:

CRPO often receives questions about who is responsible for health information recorded by a registrant. The answer to this question depends on identifying the “health information custodian.” The term “health information custodian” is defined in the Personal Health Information Protection Act, 2004 (PHIPA) [3,4]. In short, a custodian is an individual or organization that has has custody or control of personal health information.

If practising alone, a registrant is the health information custodian of their clients’ information. If employed by another health information custodian such as a hospital, the employer is the health information custodian and the registrant is expected to follow the record management practices of their employer.

Where a registrant is employed by a non-health organization such a school, university, college or municipality, the registrant is considered to be the custodian. In these situations, the registrant cannot disclose personal health information to his or her employer without the client’s consent or another legal exception.

In other situations, the answer may not be clear, and registrants will need to speak with their employer. The Information and Privacy Commissioner of Ontario also has resources on this topic [5,6].

Question:

How do I properly destroy my client files?

Answer:

Records need to be kept for 10 years from the last interaction with the client or from the client’s 18th birthday, whichever is later. Financial records, appointment and attendance records need only be kept for five years [7].

When the time period for keeping the record has expired, the records should be destroyed. If the therapist destroys any records, they should record the names of the destroyed files and the date they were destroyed.” For paper records, destruction means cross-cut shredding, not simply continuous (single strip) shredding, which can be reconstructed. You should consider pulverization or incineration of records that are highly sensitive. You might also hire a licensed service provider to destroy your files. In doing so, look for a provider accredited by an industrial trade association, such as the National Association for Information Destruction (NAID) [8].

For questions about confidentiality and health records, contact the Information and Privacy Commissioner of Ontario.
https://www.ipc.on.ca
Toronto Area: 416-326-3333
Toll Free: 1-800-387-0073
info@ipc.on.ca

[1] From “Ontario Policy Statement # 4-12, Electronic Records”, 2000, College of Physicians and Surgeons, p. 5.
[2]From “Personal Health Information: A Practical Tool for Physicians Transitioning from Paper-Based Records to Electronic Health Records”, 2009, Information and Privacy Commissioner of Ontario, p. 20.
[3]From “Frequently Asked Questions Personal Health Information Protection Act”, 2015, Information and Privacy Commissioner of Ontario, p.7-9.
[4]From “Personal Health Information Protection Act”, 2004, Information and Privacy Commissioner of Ontario, Section 3(1).
[5] From “A Guide to the Personal Health Information Protection Act”, 2004, Information and Privacy Commissioner of Ontario.
[6]From “ Frequently Asked Questions Personal Health Information Protection Act”, Information and Privacy Commissioner of Ontario, 2015.
[7]From “Professional Practice Standards for Registered Psychotherapists”, 2014, The College of Registered Psychotherapists of Ontario, page 68.
[8]From “Personal Health Information: A Practical Tool for Physicians Transitioning from Paper-Based Records to Electronic Health Records”, 2009, Information and Privacy Commissioner of Ontario, p. 22.

Self-Referral

Question:

I am an RP. I work for an agency and also have a private practice. What are CRPO’s guidelines for referring a client of the agency to my private practice?

Answer:

CRPO’s Professional Practice Standard 1.9: Referral, states that a member may “self-refer” a client from one practice to another, in certain circumstances. The key is allowing the client to make an informed choice and not taking advantage of an existing professional relationship in order to secure more business. This Standard also provides a description of what a self-referral is, when a self-referral may be made, safeguards to avoid a conflict of interest as well as exceptions.

Some employers may not allow registrants to self-refer clients to their private practice. In this case, registrants should act in accordance with their employer’s policies; the College generally does not get involved in employer-employee issues.

Please consult Standard 1:9: Referral, for additional detail.

When Professional Practice Standards Clash With Employer Policies

CRPO registrant (not her real name) called our practice advisory service because she was feeling concerned that the policies at her place of employment clashed with CRPO’s professional practice standards. She explained that she provides psychotherapy to people using their employee assistance plans. The problem is that her employer does not want Jane to disclose to clients that they are only entitled to have four to five appointments with her. Jane was aware that this limitation may not support the well-being of her clients, which is at the heart of standards of practice. She felt worried that her employer’s policy was impeding her ability to meet CRPO’s standards.

Our practice advisor asked Jane if she had spoken with her employer about how this policy would be applied in situations where longer-term therapy would benefit the client. She replied that, yes, she had raised concerns about the potential for a negative impact this would have on clients, but the employer had not been moved to change the policy.

She noted that she was considering raising the matter as an informed consent issue. Jane had used the CRPO Informed Consent Workbook, and was aware that laws, such as the Health Care Consent Act (HCCA) and the Personal Health Information Protection Act (PHIPA), set the basic requirements of the informed consent process. Jane knew she was responsible for ensuring that her clients had given informed consent before any assessments or treatments are provided, and before collecting, using and disclosing the client’s personal health information. While her place of employment had an informed consent policy and process in place, it had a gap when it came to information about restrictions on the number of appointments.

The limitations to the services that Jane is able to provide to a client should be disclosed as part of informed consent. Transparency about limitations to services may help the client and their therapeutic process, particularly when establishing therapeutic goals and treatment plans that are realistic and when considering the client’s longer-term needs for self-management and/or further services.

Our practice advisors suggested that Jane had a couple of options: one was to approach the employer again and advocate on behalf of her clients’ well-being, as well as her own interests as a regulated health professional who is required to meet certain standards.

Her other option was to seriously consider whether she wanted to continue in an employment relationship that was impeding her ability to support safe practice and client well-being.

The practice advisory reminded Jane that if she needed to discontinue services in order to comply with an employer’s policy, she must do so in accordance with the Professional Practice Standards 6.3: Discontinuing Services.

Jane decided that the informed consent angle was how she would approach the matter. She decided to approach her employer and make the case that providing additional information to clients was important, as was  to checking in with clients to see whether that additional information impacted their decision to proceed with (or refuse) treatment. This felt like the safest and most ethical approach, in light of the circumstances. Jane realized that she would not be able to compel her employer to allow more therapy sessions, but she felt that the changes to support appropriate informed consent would be a reasonable compromise, that only needed a minor policy change within the organization. Jane contacted us again recently to let us know she is actively working with her employer to implement this new policy.

Understandably, these potential conflicts can be frustrating, even distressing, for a practitioner who recognizes when they have an obligation to meet standards of practice even when doing may result in friction with their employer. While CRPO regulates individuals, not employers, we encourage employers to establish policies that align with standards of practice that are relevant to the professions that work within the organization.