Policies and

Procedures
Manual
Legacy BGCC Programs

Revised Date: Sep 2021

 A Guide to the Policies and Procedures Manual

What are policies and procedures and why should we use them?

Policies are written statements that inform employees, volunteers and students of our
obligations and guidelines in the delivery of services to children, youth and families as
well as the operations of the Agency. Policies provide us with information, guidance and
parameters as well as special considerations and approvals that are needed in our day-
to-day responsibilities.

Policies are developed for several purposes:

Operational needs – to ensure that our processes in the Agency are performed in a
consistent way to meet the needs of our clients and employees. For example, there are
policies on how an employee requests vacation. This request needs to be approved by
the Program Supervisor so they in turn can ensure that there is enough coverage at the
program while you are away.

Risk management needs – to ensure that we manage activities and situations by

providing the necessary safeguards to reduce risk and promote safety in our programs.
For example, we ensure that all programs have pre-approved and written Out of City
Trip plans that analyze potential risks associated with traveling with clients. This plan
would then incorporate our plan on how we would deal with unexpected or emergency
events while away from a program.

Compliance and regulatory needs – to ensure that we have well defined and
documented processes to demonstrate competence for our various accrediting bodies,
funders, financial obligations, relevant legislation and laws. An example of this is our
policy on Occupational Health and Safety that outlines each employee’s role as well as
the role of the Agency in ensuring that programs are safe and hazard free.

Continuous improvement needs – to improve the processes by which we collect

information within the Agency and utilize that information to modify our programs and
services to meet the needs of our clients. You will see in several policies (i.e.
Occupational Health and Safety, Program Outcomes, etc.) that the Agency collects
information which is then reviewed on a quarterly, bi-annual or annual basis. Feedback
from our clients, employees and stakeholders is crucial to our continual improvement.

Procedures are the steps or actions that we follow to ensure that we are in
compliance with the policy. While policies tell us what to do, procedures assist us by
telling us how to do it. They provide clarification by listing the steps involved in ensuring
we follow the policy.

Some of the policies in the manual also contain an introductory statement which assists
in providing context for why this policy is important to our Agency as well as the guiding
philosophy as it relates to the subject matter. Not all of the policies have a preamble as
the policy may clearly define the objective.
Our commitment to continuous improvement

Annually, our Agency reviews the Policies and Procedures Manual to ensure that the
information reflects current standards, legislation, law and best practices. This manual is
meant to be used as a tool and we always look for ways to improve upon policies and
structure them in such a way that they are useful for all employees, students and
volunteers of the Trellis within our Legacy TRELLIS programs. Sometimes a policy will
also bring about an unintended side effect that we need to know about. If you have a
suggestion on how to improve a policy or if you feel there is something missing or
information about the process that we need to know about, please share this feedback
with your Supervisor.
 POLICIES & PROCEDURES MANUAL
TABLE OF CONTENTS

A. ORGANIZATIONAL LEADERSHIP
A.1 Acquisitions and Mergers
A.2 After Hours Support
A.3 Client Grievances
A.4 Clients Served
A.5 Contractual and Partnership Agreements
A.6 Intellectual Property and Copy Write
A.7 Occupational Health and Safety
A.8 Outcome Evaluation
A.9 Policies and Procedures
A.10 Code of Conduct and Ethics

A.11 Board of Governance

A.11.1 Governance Style and Committee Principles
A.11.2 Code of Conduct
A.11.3 Board Policy Process
A.11.4 Board Membership Criteria, Recruitment and Structure
A.11.5 Board Member Orientation, Evaluation and Exit Process
A.11.6 Board Job Descriptions
A.11.7 Financial Governance

B. HEALTH AND SAFETY

B.1 Alcohol and Drug Free Environment
B.2 Emergency Drills
B.3 Emergency Response Manual
B.4 Fire Safety
B.5 First Aid Kits
B.6 Infectious Diseases and Universal Precautions
B.7 Smoke Free Environment
B.8 Working Alone
B.9 Violence in the Workplace
B.10 Health, Safety and Wellness Committee
B.11 Food Safety
B.12 Hazard Assessment

C. PEOPLE SERVICES AND VOLUNTEERS

C.1 Compensation and Benefits – See ADP
C.1.1 Attendance Reporting
C.1.2 Group Benefits Plan
C.1.3 Group RRSP
C.1.4 Honorariums
C.1.5 Leave of Absence
C.1.6 Disability
C.1.7 Overtime
C.1.8 Pay Advances
C.1.9 Salary Administration
C.1.10 Statutory Holidays
C.1.11 Vacation
C.1.12 Workers Compensation
C.1.13 Retirement Bonus
C.2 Employment
C.2.1 Allegations Against Employees
C.2.2 Candidate and Former Employee Reference Checks
C.2.3 Classification of Employees
C.2.4 Confidentiality Agreement
C.2.5 Conflict of Interest Disclosure
C.2.6 Discipline
C.2.7 Dress Code
C.2.8 Employee Educational Verification Requirements
C.2.9 Employee Files
C.2.10 Employee Grievance
C.2.11 Employee High Risk Activity Waiver
C.2.12 Employee Orientation and Commencement
C.2.13 Employee Recognition
C.2.14 Employee Screening and Recruitment
C.2.15 Employment Equity Diversity
C.2.16 Employment of Relatives
C.2.17 Exit Interviews
C.2.18 Harassment in the Workplace
C.2.19 Hours of Work
C.2.20 Investigation of Fraud, Abuse, Misconduct
C.2.21 Job Descriptions
C.2.22 Mandatory Employee Trainings and Professional Development
C.2.23 Performance Appraisals
C.2.24 Positive Workplace
C.2.25 First 90-Days
C.2.26 Re-Employment
C.2.27 Termination
C.2.28 Whistle Blower

C.3 Volunteer and Practicum Students

C.3.1 Volunteer and Practicum Student Definitions
C.3.2 Volunteer and Practicum Student Evaluations
C.3.3 File Management for Volunteers and Practicum Students
C.3.4 Volunteer and Practicum Student Grievances
C.3.5 Hiring of Practicum Students
C.3.6 References for Volunteers and Practicum Students
C.3.7 Screening Volunteers and Hiring Practicum Students
C.3.8 Special Events Volunteers
C.3.9 Termination of Volunteers and Practicum Students
C.3.10 Transporting Clients

D. FACILITIES AND EQUIPMENT

D.1 Cell Phones
D.2 Computer Usage
D.3 Confidentiality of Information Technology
D.4 Facility Standards
D.5 Keys
D.6 Maintenance of Facilities
D.7 Rental of Facilities
D.8 Specialized Assistive Technology
D.9 Telephone, Fax, Postage and Photocopying
E. FINANCIAL
E.1 Bank Reconciliations
E.2 Billing for Service Provided
E.3 Capital
E.4 Expenditure Authority
E.5 Financial Records
E.6 Funding Surplus
E.7 Funds Held for Client
E.8 Inventory Control
E.9 Investment Borrowing of Funds
E.10 Management of Funds
E.11 Petty Cash
E.12 Purchase of Goods and Services
E.13 Records Management
E.14 Recoverable Expenses
E.15 Signing Authority
E.16 Handling of Cash
E.17 Use of TRELLIS Credit Card
E.18 Budget Revision

F. BUSINESS DEVELOPMENT AND MARKETING

F.1 Marketing – See ADP
F.1.1 TRELLIS’s Logos
F.1.2 External Communications and Key Messages
F.1.3 Media Relations
F.1.4 Website
F.1.5 Social Media

F.2 Business Development

F.2.1 Guiding Principles
F.2.2 Corporate Partnerships and Sponsorships
F.2.3 Declining a Gift
F.2.4 Donations
F.2.5 Donor Privacy
F.2.6 Fundraising
F.2.7 Gifts of Securities
F.2.8 Program Proposals and Grant Activities

G. VEHICLES AND DRIVING – See ADP

H. AGENCY SERVICE DELIVERY

H.1 Confidentiality and Rights of Clients
H.1.1 Confidentiality
H.1.2 Client Records
H.1.3 Clients’ Access to Their Information
H.1.4 Disclosures
H.1.5 Informed Consent
H.1.6 Photographs, Art Work, Audio and/or Visual Recording of Clients
H.1.7 Reporting Client Abuse, Harassment or Neglect
H.1.8 Research Participants
 H.1.9 Responding to Search Warrants, Subpoenas and Investigations

H.2 Recreational Activities

H.2.1 Recreational Activities
H.2.2 Specialized Recreational Activities
H.2.3 Weather Outdoor Activities
H.2.4 Camp Fires
H.2.5 Camping
H.2.6 Alpine Skiing Snowboarding
H.2.7 Ice Skating
H.2.8 Tobogganing
H.2.9 Swimming
H.2.10 Indoor Climbing
H.3 Service Planning
H.3.1 Access to Clients outside Program Mandate
H.3.2 Behavior Management and Discipline
H.3.3 Clients and Infectious Disease
H.3.4 Consent of Behavior Management
H.3.5 Critical Incidents
H.3.6 Entertainment
H.3.7 Medications
H.3.8 Out of City Trip Plans
H.3.9 Suicidal Threats and Prevention
H.3.9A Suicide Threats & Suicide Prevention
H.3.9B Non-Suicidal Self-Injury (NSSI)
H.3.9 B Suicidal Threat & Non Suicidal Self-Injury (NSSI) Protocol Flow Chart
H.3.10 Cool off Periods
H.3.11 Transporting Children and Youth to Hospital
H.3.12 Unlocked and Locked Confinement
H.3.13 Narcan Nasal Spray Administration

H.4 Service Delivery

H.4.1 AWOL
H.4.2 Client Rights
H.4.3 Client Searches
H.4.4 Closure of Service
H.4.5 Delegation of Authority
H.4.6 Disbursement of Spending Money
H.4.7 Emergency Supply Kits
H.4.8 Maintenance of Client Support Networks
H.4.9 Medical Care Responsibilities
H.4.10 Portable Records
H.4.11 Use of Physical Restraints

I. PROGRAM SPECIFIC POLICIES

I.1 Recreation
I.1.1 Archery
I.1.2 Biking
I.1.3 Canoeing
I.1.4 Challenge Course and Elements
I.1.5 Evacuation
I.1.6 Fire
I.1.7 Hiking
I.1.8 Swimming
I.1.9 Water Testing
I.1.10 Weather
 I. 1.11 Wildlife

I.2 Foster Care

I.2.1 Annual Training
I.2.2 Caregiver Orientation Training
I.2.3 Client Intakes
I.2.4 Complaints, Screenings and Investigations
I.2.5 Level 1Training
I.2.6 Criminal Record Check and Child and Youth Intervention Module Check
I.2.7 Emergency Placements
I.2.8 Foster Care Support Family Ratio and Requirements
I.2.9 Foster Care Support File Management
I.2.10 Foster Care Support Services
I.2.11 Foster Home Closure
I.2.12 Foster Home Placement Criteria
I.2.13 Foster Parent Evaluations
I.2.14 Foster Parent Foster Child Matching
I.2.15 Foster Parent Selection
I.2.16 House and Auto Insurance
I.2.17 Licensing
I.2.18 Record of Client Progress
I.2.19 Respite Relief
I.2.20 Safety Requirements
I.2.21 Sleeping Arrangements
I.2.22 Unscheduled Visits

I.3 Group Care Programs

I.3.1 Screening
I.3.2 Eligibility Criteria
I.3.3 Emergency Placements
I.3.4 Individual Plans and Reviews
I.3.5 Program Services
I.3.6 Intakes
I.3.7 Employee Ratios

I.4 Hera
I.4.1 Eligibility Criteria
I.4.2 Individual Plans and Reviews
I.4.3 Program Services
I.4.4 Screening and Intakes
I.4.5 Employee Ratios

I.5 Independent Living and Community Transitions

I.5.1 Eligibility Requirements
I.5.2 Emergency Placements
I.5.3 Individual Plans and Reviews
I.5.4 Program Services
I.5.5 Employee Ratios
I.5.6 Supportive Roommates
I.5.7 Screening and Intakes
I.5.8 Working Alone

I.6 Licensed Preschool

I.6.1 Eligibility Criteria
I.6.2 Program Services and Supervision
I.6.3 Child Discipline
 I.6.4 Emergency Evacuation
I.6.5 Health and Accident Procedures
I.6.6 Off-Site Activity
I.6.7 Nutrition
I.6.8 Payment for Licensed Preschool
I.6.9 Parent/Guardian Volunteers

I.7 Community Youth Development

I.7.1 Eligibility Criteria
I.7.2 Program Services
I.7.3 Screening and Intakes

I.8 Community Clubs

I.8.1 Health, Allergy and Accident Procedures
I.8.2 Intoxicated Parent
I.8.3 Missing or Unclaimed Client
I.8.4 Sexual Health Presentations
I.8.5 Sleepovers and Awake-a-thons
I.8.6 Behaviour Management
I.8.7 Safe Arrival and Departure
I.8.8 Eligibility and Waitlist Criteria
I.8.9 Program Services
I.8.10 Employee Ratios
I.8.11 Visitors to Clubs
I.8.12 Club Opening and Closing

I.9 Shelter Services

I.9.1 Eligibility Requirements
I.9.2 Individual Goal Plans and Reviews
I.9.3 Program Services
I.9.4 Screening and Intakes
I.9.5 Employee Ratios

I.10 Building Youth Connections

I.10.1 Eligibility Criteria
I.10.2 Program Services

I.11 Stampede Work Experience

I.11.1 Eligibility Criteria
I.11.2 Recruitment
I.11.3 Supervision

I.12 Community Outreach

I.12.1 Eligibility Criteria
I.12.2 Program Services
I.13 Iiyika’kimaat
I.13.1 Eligibility and Waitlist Criteria
I.13.2 Program Services
I.13.3 Accident Prevention
I.13.4 Health and Accident Procedures
I.13.5 Client Discipline
I.13.6 Employee Ratios
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: ACQUISITIONS AND MERGERS POLICY NO.: A.1

DATE ISSUED: December 14, 2005 ASSOCIATED STANDARDS:

CARF - Leadership
DATE REVISED: May 2019

The external environment and internal needs of Trellis Society compel the Agency to give thoughtful, deliberate
consideration to opportunities with other Agencies.

POLICY:

1. The Chief Executive Officer (CEO) will ensure that acquisitions or mergers enhance Trellis’ potential to
achieve the vision, mission, and strategic direction of the organization.

2. All acquisitions and mergers must follow a rigorous due diligence process. The due diligence process must
include a review of:

a. the program: client files (open and closed), memorandums of understanding, policies and procedures,
accreditation materials, etc.
b. finances: several years of audited financial statements, Canada Revenue Agency T-3010 returns, expense
files, bank reconciliations, contracts, etc.
c. board/legal: board minutes, contracts, insurance files, etc.
d. people services: past and current personnel files and personnel policies, salary scales, written complaints,
etc.
e. technology: computer systems, hardware, software, etc.
f. facilities and equipment: inventory list, license of occupation, contracts, space, etc.
g. communications: written promotions, website, etc.
h. any other assets of the organization, including trademarks and intellectual property.

3. All mergers and acquisitions will be clearly articulated in a formal, legal contract.

4. The Board of Directors will have the final approval of all acquisitions and mergers.

PROCEDURES

1. The CEO consults with members of the Senior Leadership team to establish what resources would be required
if the potential acquisition or merge were to occur.

2. The CEO, or a representative designated by the CEO, is responsible to pursue the exploration of a potential
merge or acquisition.

3. The Board of Directors provides approval to the CEO to move forward to the due diligence stage based on the
information provided in the initial exploration.

4. The rigorous due diligence process is articulated and utilized as the basis of the recommendation to the Board
of Directors by the CEO.

5. If approval from the Board of Directors to proceed is obtained, the Agency will move forward with a legal
contract and an implementation of the merger/acquisition plan.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: AFTER-HOURS SUPPORT POLICY NO.: A.2

DATE ISSUED: May 1, 2005 ASSOCIATED STANDARDS:

CARF: Health and Safety
DATE REVISED: May 2019 CARF: Program/Service Structure

POLICY

1. Trellis programs that provide care to clients after business hours will have access to a designated supervisor
in the event of an emergency. The process for access is clearly defined by each program.

2. Program Managers will ensure that program employees are aware of the situations in which an On-Call
Coordinator should be called.

3. The emergency number of the On-Call Coordinator will be readily available to program employees.

4. Housing Support Workers, Managers and Directors will provide On-Call after-hours coverage ona rotating
basis as part of their position responsibilities.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: CLIENT GRIEVANCES POLICY NO.: A.3

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019 CAC

POLICY

1. All clients are entitled to a fair, accessible and structured grievance and appeal process. A client and/or their
guardian who believes that Trellis has been unfair or inappropriate in any aspect of our service delivery may lodge
a complaint with the Agency. All clients (or their guardian, if the client is under twelveyears of age) will be made
aware of their right to lodge a grievance and will be provided with a copy and/or access to the Agency’s client
grievance procedures upon commencement of services. Grievance procedures and information will be posted in
all programs for client access.
2. All client grievances will be received, investigated and responded according to the timelines listed in the
procedures section of this policy. In the event that a grievance is lodged, clients and employees both have the
right to be treated with respect, dignity and consideration.
3. Copies of all written grievances must be immediately forwarded to the Program Manager, Program Director and
the Chief Operating Officer.
4. Clients have the right to not be discriminated against as per the Agency’s Non-discriminationpolicy.
5. All grievances will be reviewed annually by the Senior Leadership team. Non-identifying information will be used
for purposes of analysis of trends, improvement areas and recommended enhancements to strengthen our
programs and services.
6. At any stage during the grievance process the client and/or their guardian has a right to request to have a third
party assist them (for example, Caseworker, CHF – Calgary Homeless Foundation, parent/guardian, community
member or Child and Youth Advocate’s Office).
7. Anyaction resulting for a grievance procedure will not result in retaliation or barrier to services.

PROCEDURES

1. Program employees will act promptly to satisfactorily resolve all situations with clients. Clients are encouraged to
first attempt to resolve their concern directly with the employee involved. However, if this puts the client in a
difficult situation, they may speak directly with the employee’s supervisor instead. If the issue is resolved at this
level, this will then not be classified as a grievance.
2. If the issue is not resolved to the client’s satisfaction, they may file a written or verbal grievance with the Program
Manager. In the event that the grievance is verbal, an employee will work with the client to document the
grievance. If the grievance is with the Manager, the client will file the grievance with the Program Director. The
Program Director will be immediately notified through email of all client grievances.
3. Every attempt will be made to come to a resolution of the grievance within ten (10) working days of the request.
The process by which the grievance will be resolved may entail an investigation by the Program Manager and
Dirctor which would include interviewing of clients and employees involved in the situation.
4. If the client is still not satisfied with the outcome of the grievance, after ten (10) working days the client may take
their complaint to the Program Director and the Chief Operating Officer, and then the CEO Trellis.
5. A written record of all grievances is kept on the client’s file, describing the nature of the complaint, the details of
the process and the outcome. The written documentation of the grievance will be completed by the Program
Manager and be signed off by the Manager and Director.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: CLIENTS SERVED AND NON- POLICY NO.: A.4

DISCRIMATION OF CLIENTS

DATE ISSUED: January 8, 1994 ASSOCIATED STANDARDS:

CARF
DATE REVISED: May 2019

Since 1939, Trellis has fostered resiliency in vulnerable children and youth to reduce the impact of poverty and
negative life experiences through a broad range of services and programs. We are committed to meeting the needs
of children, youth and families in an ever-changing and complex society using a strength-based approach, to promote
community-generated solutions that provide pathways to develop successful and active participants in society.

POLICY

1. Trellis programs and services are available to all vulnerable children and youth of Calgary and surrounding area.
The Agency has an established mandate which defines its intended clientele in each program. Access to and
utilization of these services by potential clients will be based on consistent and fair application of referral,
screening, and intake practices

2. The Agency does not discriminate against clients or potential clients on the basis of race, color, religion, spiritual
beliefs, socioeconomic status, language, ethnicity, gender, LGBTQ2S+, sexual orientation, age, physical or
mental condition. Clients will be admitted into Trellis programs based on the eligibility criteria forthe program and
program availability. The Agency will make every effort to accommodate clients with infectious diseases.
Decisions to provide or deny services to clients with infectious diseases, including HIV infections and A.I.D.S.,
will be made according to the following criteria:

a. the ability of the Agency to make a reasonable accommodation for the client;
b. the risk of transmission of the disease;
c. the ability of the client to exercise precautions against transmission of the disease;
d. the ability of other clients in the Agency to protect themselves from infection; and
e. the risk of infection to the infected client.

3. Decisions regarding the admission to or denial of services based on an infectious disease will be on a case by
case basis after ascertaining a client’s medical needs and the ability of the Agency to make a reasonable
accommodation for a client with an infectious disease. The reasons for the denial of services will be
documented so as to demonstrate non-discrimination.

4. Clients who do not meet eligibility criteria will be informed as to the reasons and provided with recommendations
for alternate services, whenever possible.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: CONTRACTUAL AND PARTNERSHIP POLICY NO.: A.5

AGREEMENTS

DATE ISSUED: November 1999 ASSOCIATED STANDARDS:

CARF - Leadership
DATE REVISED: May 2019

POLICY

1. To deliver its mandate to clients, TRELLIS will enter into contractual and partnership agreements. These
agreements may range from the procurement of products and services to agreements for the delivery of
services. To ensure contractual obligations are realistic, obtainable and manageable, the CEO, and/or Chief
Officer(s) and/or Director of Finance & Operations review and sign off on all contracts that have financial or
employee implications on the Agency.
2. Regardless of the type of agreement, all partnerships and collaborative work must align with the Agency’s
mandate and strategic goals.

Funding Agreements and Grants

3. All funding contracts and agreements (i.e. Alberta Government, City of Calgary, The United Way etc.) that bind
the Agency to provide services, must be approved by the CEO or their designate (i.e. COO or CFO) and others
if so required. Employees are not permitted to commit to any contracts or agreements.

Strategic Partnerships

4. Strategic partnerships typically are committee based and involve multiple service agencies convening for the
purpose of information exchange and/or advocacy efforts. Strategic partnership meetings are attended by the
Chief Officer(s), Director or Manager, unless otherwise delegated to a Program staff.

Collaborative Partnerships

5. A collaborative partnership is partners working together for an initiative that would expand current services in
specific areas or to develop a service that is not currently being offered in the community. These partnerships
are at the CEO/Chief Officer/Director level, as they typically involve implications to funding, revenue and/or
resources.

6. When entering into a Collaborative Partnership, the following must be given consideration:

a. Discussion of the potential partnership with the Program Manager, Director and ChiefOperating
Officer;
b. Development of a Partnership Agreement, contract or Memorandum of Understanding. Consideration is
given to how the clients will benefit from this agreement, roles and responsibilities of each partner, the
internal resources required to run the partnership and the risks associated with entering into the
agreement, and;
c. Any required signatures must be completed by the CEO or a Chief Officer.

Fiscal Sponsorship

7. In partnerships where TRELLIS is intended to be the Fiscal Sponsor, the documents must be submitted to the
CEO for approval. Agreements where TRELLIS is the Fiscal Sponsor must provide a clause that outlines the
cost
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: CONTRACTUAL AND PARTNERSHIP POLICY NO.: A.5

AGREEMENTS

for administrative support based on the total funding and revenue of the partnership or as approved by the
CEO. Rates for administration support costs are to be determined by the types of supports and services that
TRELLIS will provide. These may include:
• Human Resources support
• Technology support
• Mentorship support
• Leadership support
• Office space and supplies
• Staffing support
• Administrative services such as accounting and finance

In addition, the following steps must be addressed prior to TRELLIS acting as a Fiscal Sponsor:

a. The charity’s own charitable aims are carried out by TRELLIS;

In ensuring that TRELLIS’s own aims are being carried out by an Agent (aka intermediary) in a
fiscalrelationship, the CRA recommends the following steps:
i. Create a written agreement with the intermediary and implement its terms;
ii. Communicate a clear, complete and detailed description of the activity to the intermediary;
iii. Establish a governance structure which includes supervision and oversight of staff;
iv. Monitor and supervise the activity;
v. Provide clear, complete and detailed instructions to TRELLIS on an ongoing basis;
vi. Arrange for TRELLIS to keep the charity’s funds separate from its own and to keep separate
booksand records;
vii. Make periodic transfers or resources based on demonstrated performance.
b. The charity maintains demonstrable control and direction over the use of all of its resources directed
toTRELLIS,and;
c. The charity ensures it is not at risk of being found to be a conduit by the CRA.

Service Level Partnership

8. A service level partnership is defined as a partnership that fulfills program delivery and does not involve the
exchange an exchange of funds for the service. Service level partners may share space, instructors and/or
clients.

9. Program Managers have the ability to enter into service level partnerships if the partnership will enhance the
program delivery and/or individual programming provided to clients. If there is a formal agreement to be signed,
the CEO or a Chief Officer must be the signatory.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: INTELLECTUAL PROPERTY AND POLICY NO.: A.6

COPYRIGHT
DATE ISSUED: June 30, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Intellectual property is work created by an employee during paid time at the Agency. Intellectual property includes, but is
not limited to, contracts, program models, training manuals, inventions, publications, computer software, works of art,
music, industrial and artistic designs, as well as other creations that can be protected under patent, copyright, or trademark
laws. This policy also encompasses donor information and other funding information.

POLICY

1. Intellectual property developed by any employee in the course of their employment is deemed to be owned solely by
the Agency, unless otherwise approved by the CEO in writing.

2. Use and distribution of any intellectual property outside of the Agency requires the prior approval and written
permission of the CEO or a Chief Officer who will take into consideration the information being forwarded, who it is
being forwarded to, as well as the potential impact of distributing the material outside of the Agency.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP

POLICY: OCCUPATIONAL HEALTH AND POLICY NO.: A.7

SAFETY
DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:
Occupational Health and Safety
DATE REVISED: May 2019

Trellis is committed to the well being and safety of all involved with the Agency and adheres to legislation as outlined
in the Occupational Health and Safety Code for the Province of Alberta and applicable Federal Government
Legislation. The Agency is committed to ensuring that it reduces and eliminates risks whenever possible to provide
a safe work environment.
POLICY

1. All Trellis employees will receive information during program orientation on Health and Safety practices and their
responsibility in identifying and reporting hazards. Program orientations will also include a review of the hazard
assessment for the employee’s position including the employer and employees responsibility in promoting safety
in the workplace.

2. People Services is responsible to ensure that the agency is kept current on relevant legislation and codes as it
pertains to Occupational Health and Safety.

3. People Services shall organize and chair the Health, Safety, and Wellness Committee meetings and ensure
that the results of all assessments are communicated to the Senior Leadership team and the CEO including all
recommendations to promote a safe workplace.

4. The Health, Safety, and Wellness Committee, which provides Agency leadership on the reduction of hazards in
the workplace by assisting work units in identifying and eliminating hazardous situations, is open to all employees
regardless of their position within the Agency.

5. In conjunction with the Health, Safety and Wellness Committee, programs are responsible to organize and
conduct a health and safety inspection (called the HSW Check In) every six months. The completed HSW Check
Ins from all programs will result in a review of themes by the HSW Committee. Any necessary recommendations
for improvements will be reported to the Senior Leadership team.

6. In addition, programs will complete monthly lifecycle checklists for each facility. Any maintenance work required
at the facility will be reflected with the initiation of a ticket and coordinated by the Maintenance Support Worker.
This facility checklist will be stored on Sharevision.

PROCEDURES FOR HEALTH, SAFETY, AND WELLNESS COMMITTEE

1. People Services will organize and chair the Health, Safety, and Wellness Committee meetings. The Committee
will meet minimally twice per year and consist of employees from “work units” throughout the organization. For
the purpose of this policy, the minimum number of Committee members representing the Agency are:

a. Main Administrative Office – 1 representative

b. Youth Housing and Shelters Programs – 1 representative
c. Community Clubs and Experiential Learning Programs – 1 representative
d. Community Based Care and Supports Programs – 1 representative
e. Education and Employment Programs – 1 representative
f. Indigenous Initiatives – 1 representative
g. Mahmawi-Atoskiwin – 1 representative
h. Senior Leadership team – 1 representative
i. CEO – ex facto member
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POLICY: OCCUPATIONAL HEALTH AND POLICY NO.: A.7

SAFETY
2. The Chair must ensure that a designated employee from each of these work units is represented on the
Committee.

3. The mandate of the Committee is to be responsible for the monitoring of hazardous situations in the workplace
and to put forward recommendations to ensure that they are removed or reduced in order to provide a safe and
prepared workplace for all employees.

4. If new programs or facilities emerge and they do not fit into the current work site determinations, a new work site
will be established. This program will then be responsible to ensure that they have representation on the
Committee.
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ORGANIZATIONAL LEADERSHIP

POLICY: OUTCOME EVALUATION AND POLICY NO.: A.8

CONTINUOUS QUALITY IMPROVEMENT

DATE ISSUED: June 01, 2005 ASSOCIATED STANDARDS:

CARF – Input from Persons Served
DATE REVISED: May 2019 CARF – Performance Improvement

Trellis conducts evaluation research and uses the results and findings to engage employees, clients, funders and
stakeholders in the continuous improvement process to enhance the Agency’s capacity to deliver quality services.
Trellis utilizes a comprehensive data collection system to support outcome monitoring, evaluation and quality
improvement methods. These systems are consistent with requirements outlined by our core funders and provide
programs performance data and information to support a culture of continuous quality improvement.

POLICY

1. The Agency sets clear service standards that outline expectations for program outcomes. Annual reviews of
these processes are done in context of the goals identified in the program logic models and the specific clientele
served by the program.

2. During program orientation, employees are informed and trained on the evaluation process, program outcomes
and the specific tools used in their programs. Training on outcomes and data collection is reviewed annually and
any changes to outcome measures and tools are reviewed with program employees.

3. Under the supervision of the Chief Operating Officer, Managers and Directors are responsible fordata collection,
input and analysis for program improvements.

PROCEDURES

1. Annually, each program reviews its program model in context of the evaluation results. Managers will include
program employees in this review process to better understand the value of evaluation research and ensure
program goals, objectives, activities and outcome measures are relevant and effective. During the evaluation,
the following elements are addressed:

a. Outcomes that achieve the intended target;

b. Outcomes that do not achieve the intended target, and;
c. Unanticipated outcomes which are either positive or negative.

2. The collection of demographic information of the clients served ensures that diverse needs of clients are being
met.

3. The Agency regularly collects feedback and satisfaction surveys from clients and key stakeholders.

4. Programs will review the outcomes achieved against the identified intended outcomes annually. This information
will allow the evaluation of program effectiveness against current best practices and research as well as review
of the tools being used to monitor service delivery. This review of program outcomes will also allow for adaptation
and enhancement of program models and practices to ensure effective program delivery ofservices.
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ORGANIZATIONAL LEADERSHIP

POLICY: POLICIES AND PROCEDURES POLICY NO.: A.9

DATE ISSUED: August 21, 2001 ASSOCIATED STANDARDS:

CARF – Leadership
DATE REVISED: May 2019

POLICY

1. Trellis will maintain a current Policy and Procedures Manual, the contents of which are legal and binding and will
guide all Agency employees in their day-to-day practice. The Agency will ensure that all employees are familiar
with and have access to current and revised policies and procedures of the Agency.

2. Matters of policy are binding on all Agency employees. Supervisors will ensure their direct reports are aware of
all policies. All employees will review the Policy and Procedures Manual within their orientation period and know
how to access the manual. This will be documented during orientation and placed on the employee’s personnel
file.
3. The Senior Leadership team will be responsible for the overall development and implementation of policies and
procedures.

4. In absence of a policy to guide decisions, consultation with the CEO and the Chief Officers will be sought. It will
be determined by the Senior Leadership team if a policy then should be developed or revised to guide future
decision making in this area.

5. Annually, the Policy and Procedure Manual will be reviewed. This review will ensure that new laws, legislation,
standards and practices are reflected in the manual and that it reflects the diversity of the clients that the Agency
serves. These changes will be submitted for approval to the CEO prior to implementation. Any changes to the
manual will be given a designated administrative staff who will ensure the changes are made in the policy,posted
in the online manual, and communicated through email.

6. Agency employees may propose changes to the Policy and Procedures Manual in writing to their Program
Manager, Director or People Services at any time throughout the year. These proposals will be presented to the
Senior Leadership team. Once approved, these policies may be immediately implemented.

7. The Agency will have the Policy and Procedures Manual available online for TRELLIS employees and Foster
Parents.

8. All employees/contracted Foster Parents are expected to stay current with new and revised policies that are
developed by the Agency.
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ORGANIZATIONAL LEADERSHIP

POLICY: CODE OF CONDUCT AND ETHICS POLICY NO.: A.10

DATE ISSUED: September 3, 2001 ASSOCIATED STANDARDS:

CARF – Leadership
DATE REVISED: September 2021

The purpose of Trellis is to promote an ethical culturethat reflects the Agency’s mission, vision and values, which
are the principles governing our behaviour, the standards expected of us, and our commitment to choosing the best
course of action when resolving ethical issues. All individuals who represent, and who owe a responsibility to the
Agency and the children, youth and families we serve, must adhere to the Code of Conduct and Ethics. This
includes employees, board members, volunteers, practicum students and contractors.

Our Vision
Everyone reaches their full potential.
Our Purpose
We support growth across generations.

Our Core Values

Courage
We willingly embrace growth and don’t see it as optional.
Empathy
We relentlessly care about the growth of others and won’t let anyone go unsupported.
Learning
We choose to growth through uncertainty even when the status quo feel easier.
Impact
We go beyond what seems doable and prove that growth is possible.

POLICY

1. Trellis service delivery will be characterized by integrity in decision-making, freedom of choice for program
participants and the priority of professional responsibilities over personal interests. As employees and volunteers
of Trellis, we play a critical role in the lives of individuals, families and the community. Through performing this
role, we will encounter situations that have ethical dimensions and implications. Each of us has a responsibility
to strive to meet high standards of ethical conduct and is expected to act in a manner that will represent and
promote Trellis’ mission, vision and values. Although the various matters dealt with in this Code of Conduct and
Ethics do not cover the full spectrum of activities, they are indicative of Trellis’ commitment to the maintenance
of high standards of conduct and are to be considered descriptive of the type of behaviour expected from
employees and volunteers in all circumstances. Employees and volunteers are expected to comply with all
aspects of the Trellis Code of Conduct and Ethics policy as well
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ORGANIZATIONAL LEADERSHIP

POLICY: CODE OF CONDUCT AND ETHICS POLICY NO.: A.10

as the codes of ethics of their respective professions. Opportunities for learning about the Agency’s ethical
code of conduct shall include:

a. Review of the Ethical Code of Conduct during orientation of new employees;

b. Inclusion of the Ethical Code of Conduct in the Orientation Manual;
c. Inclusion of the Ethical Code of Conduct in the Board Orientation Package.

2. What follows is a decision making process and a set of principles intended to guide employees and volunteers
in achieving that high standard. In any situation you are involved in as an employee or volunteer of this Agency,
the course of action you choose is expected to be consistent with the spirit and intent of decision making process
and principles outlined below.

PROCESS

1. When a situation or course of action presents an ethical dilemma that cannot be easily resolved by reference to
the principles outlined below, employees and volunteers will first consult with their supervisor. The use of the
following decision-making model is recommended for resolving the dilemma:

a. Identification of the ethical issues and the principles that might apply.
b. Development of alternative courses of action.
c. Analysis of likely short-term, ongoing, and long-term risks and benefits of each course of action on the
individual(s)/group(s) involved or likely to be affected.
d. Choice of a course of action.
e. Action, with a commitment to assume responsibility for the consequences of the action.
f. Evaluation of the course of action.
g. Assumption of responsibility for consequences of the action, including correction of negative consequences
(if any and if possible) or re-engaging in the decision making process if the ethical issue is not resolved.

PRINCIPLES

1. Respect for the uniqueness of the children and families we serve, including their values and beliefs as
well as their potential for growth and development.

a. Provide a positive and valued experience for those receiving service within and outside TRELLIS through
an attachment-based, strength focused and solution oriented trauma-informed lens consistent with our
service delivery philosophy.

i. Ensure that individual differences including values and beliefs are respected.
ii. Assist children and families to develop to their full potential.

2. Respect for, honouring of, and upholding of the rights of children and families.

a. Adhere to a strict code of confidentiality to protect the rights of the clients receiving services in the Agency.
All representatives of TRELLIS, including employees who have limited access to confidential information,
shall be made aware of the confidentiality and related employee policies through the New Hire Orientation
process, Declaration of Confidentiality and annual Performance Management process.

i. Protect and promote legal and human rights of children and families.
ii. Ensure that client self-determination is respected to the greatest extent possible.
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ORGANIZATIONAL LEADERSHIP

POLICY: CODE OF CONDUCT AND ETHICS POLICY NO.: A.10

iii. Engage in actions that prevent the abuse, neglect, or exploitation of individuals.
iv. Ensure that all individuals have the opportunity to provide informed consent to services to the
greatest extent possible.
v. Protect proprietary and confidential information from improper or inadvertent disclosure as such
disclosure may harm the Agency’s practice or violate the interests of clients, employees, volunteers,
or board members

3. Promoting the health, safety and well-being of the children we serve, their families and support
networks, and the communities they live in.

a. Promote the physical, mental, social, emotional, and spiritual health of the children and families we serve.

i. Ensure that safety is a priority in the delivery of all Agency programs consistent with our Health and
Safety policy.
ii. Where possible and appropriate, to participate in activities that promote the health and safety of the
community consistent with our mission and values.

4. Caring, support, and striving to enhance the dignity of the children and families we serve.

a. Respect the privacy, dignity, and worth of children and their property.

i. Show compassion and empathy in the services we provide.

ii. Refrain from any activity that might embarrass, belittle or demoralize children or their family
members.
iii. In no way abuse or misuse the position of power or exploit any relationship with a client, funder or
any member of the community for personal benefit or for the benefit of the Agency.

5. Practice that emphasizes partnerships with the children we serve, their families and support networks,
and the community including other community agencies.

a. Where possible, take a collaborative approach to service delivery that emphasizes shared responsibility
endeavoring to include and consult families and support networks of the children we serve while respecting
their wishes and confidentiality.
b. Establishing and maintaining effective working relationships with community partners and referring
sources.

i. Develop and promote the expectations and choices of children.

6. Respect for diversity, cultural heritage, and spiritual beliefs.

a. Respect the opinions of others and treat all with equality and dignity without regard to race, color, religion,
spiritual beliefs, socioeconomic status, language, ethnicity, gender, gender minorities, sexual orientation,
age, mental or physical ability, political beliefs or marital status.
b. Show sensitivity to the impact of cultural heritage and spiritual belief in the delivery of services.

i. Accommodate cultural and spiritual practices and beliefs where possible and reasonable within the
context of the service we provide.
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ORGANIZATIONAL LEADERSHIP

POLICY: CODE OF CONDUCT AND ETHICS POLICY NO.: A.10

7. Commitment to competent and accountable practice that is both ethical and responsible.

a. Act with fairness, honesty, integrity and openness in accordance with any professional standards and/or
governing laws and legislation that have application to the responsibilities performed for or on behalf of
TRELLIS;
b. Adhere to the policies and procedures of TRELLIS;

i. Identify and avoid all conflicts of interest.

ii. Promote ethical conduct within the Agency and in the community, ensuring that personal biases,
values and experiences do not inhibit or negatively influence relationships with clients or colleagues.
iii. Ensure adherence to work schedules on a regular and consistent basis. The Agency has policies in
place such as sick leave and leave of absence, to recognize when an employee is not able to adhere
to their scheduled work due to extenuating circumstances.
iv. Recognize when personal problems or needs can interfere with professional effectiveness and act
to eliminate or minimize the impact through setting firm professional boundaries.
v. Treat all TRELLIS property, including cell phones, laptops, computers, furniture and vehicles with
careand respect.
vi. Demonstrate integrity in all professional relationships, including ensuring that professional
boundaries are established with all clients. It is the responsibility of all employees, students and
volunteers to be aware of what the professional boundaries with clients are and understand that
relationships made through a client’s involvement with TRELLIS are professional and not personal.
vii. Act with diligence, efficiency, and conscientiousness.
viii. Abstain from activities that might result in the actual or perceived exploitation of participants for
advantage or personal gain, including accepting or exchanging gifts, money, and gratuities or
engaging in personal fund raising while at work.
ix. Maintain accountable reporting practices including reporting all incidents of abuse or neglect and all
instances where harm or the potential for harm to children, families, employees or members of the
community at large occurs or is present.
x. Ensure that any situations involving the witnessing of documents is consistent with Agency policy
(including Informed Consent) and in the best interest of the children and families served. In order to
witness a document, employees must observe the actual signing of the document.

8. Commitment to professional and organizational excellence through an accountable, transparent and

results oriented approach to delivering services.

a. Strive to provide the most effective service possible by participating in activities designed to improve the
services we deliver.
b. Continuously pursue improvement in our ability to provide services through seeking out and implementing
best practices, taking actions to enhance the knowledge, skills, and self-awareness necessary to be
competent, and evaluating our efforts.

c. Value participant input to the greatest extent possible.

d. Ensure that human resource practices are fair, transparent, respect equality and are conducted in the best
interests of the children and families served.
e. Ensure the honest representation of the organization in any business, marketing or promotional efforts.
f. Ensure that all contracts entered into by the Agency are consistent with the best interests of the children
and families served and that contractual relationships avoid conflicts of interest.
g. Abstain from any act of professional misconduct, including activity or practices that involve intentionally
wasting or misusing our resources, committing fraud or engaging in intimidating or abusive behaviour.
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ORGANIZATIONAL LEADERSHIP

POLICY: CODE OF CONDUCT AND ETHICS POLICY NO.: A.10

CONFLICT OF INTEREST

1. A conflict of interest is defined as a situation in which an employee’s or directors personal interests may affect
their judgment in acting on behalf of TRELLIS. Sometimes appearances can be as damaging as actions.
Therefore, employees should not only refrain from becoming involved in actual conflict situations, they should
also avoid placing themselves in positions that may be perceived as conflicts. All employees are required to
immediately declare any conflict situation or perceived situation to their supervisor and when requested by the
CEO or designate, promptly terminate any relationship or position which gives rise to either an actual or a
perceived conflict of interest.

There are many situations which can be classified as conflict of interest, but the following illustrate some of the
most common ones that may be encountered in Agency business:

a. Private Business Benefit – Situations where an employee and/or their immediate relatives have a
personal financial interest in organizations supplying property, goods or services to Trellis.
b. Gifts and Entertainment – Employees will not receive for personal use any portion of donations acquired
under the name of TRELLIS and/or received by the organization. Employees who are given gifts (as thank
you) must review the type of gift that they have received with the CEO to determine if the gift is appropriate
for the employee to accept or if it needs to be dispersed in a manner that is fair and reasonable for the
Agency.
c. Personal Fundraising – Employees will not solicit clients, including children, youth and family members,
for personal fundraising endeavors.
d. Personal Property – TRELLIS will not be responsible for the personal property of employees, students or
volunteers and it is up to the individual to safeguard their personal belongings.
e. Suppliers – All suppliers and independent contractors purchasing or furnishing goods and services to
TRELLIS will be dealt with in a fair and lawful manner. TRELLIS will award contracts based on total cost,
qualityand reliability. TRELLIS and its suppliers and contractors will have mutual respect for each other’s
property.
f. Outside Employment or Directorships – Outside business interests should not adversely affect an
employee’s job by absorbing time and concentration while at work.
g. Self-dealing, Private Business or Personal Services - There must be no self-dealing or any conduct of
private business or personal services between employees and the Agency, except as procedurally
controlled to assure openness, competitive opportunity, and equal access to otherwise “inside” information.

i. All individuals who represent the Agency may not use Agency information for their own direct benefit
or advantage. This requires that the information be kept confidential whenever required in the best
interest of the organization.

REPORTING

1. All allegations related to a breach of the Code of Conduct and Ethics will be investigated. Persons making the
allegation will not face reprisal for doing so unless the allegation/complaint is found to be malicious or knowingly
false. The procedure for investigation will follow the process as set out in the Employee Grievance Policy.

PROCEDURES

1. New employees will read and sign the Code of Conduct and Ethics at the time of hire.
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ORGANIZATIONAL LEADERSHIP

POLICY: CODE OF CONDUCT AND ETHICS POLICY NO.: A.10

2. Employees will review the Code of Conduct and Ethics annually and will sign indicating that they understand
and agree to abide by the terms of the code. This sign off will be done as part of the Annual Compliance Form.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: GOVERNANCE STYLE AND COMMITTEE POLICY NO.: A.11.1

PRINCIPLES

DATE ISSUED: September 2010 ASSOCIATED STANDARDS:

CARF – Board Governance
DATE REVISED: May 2019

POLICY

1. The governing style of the Board of Directors’ will focus on strategic leadership that will emphasize:

a. Future goals rather than the past and present activities;

b. A clear distinction of the role of the Board of Directors and employees, and;
c. Pro-activity rather than reactivity.

2. In this spirit the Board of Directors will:

a. Be accountable to the community for competent, conscientious, and effective accomplishment of its
obligations in accordance with the Agency mission and core values;
b. Keep its major focus on the long term goals of the organization and the administrative or
programmatic means of attaining these goals;
c. Direct, control, and inspire the organization through the careful deliberation and establishment of
proactive policies;
d. Enforce upon itself whatever discipline is needed to operate effectively. Discipline will apply to
attendance, the treatment of other Board Members with dignity and respect and strict adherence to
the principle that the Board shall speak with one voice. The Board will allow no other, individual or
committee of the Board to usurp its role in maintaining discipline, and;
e. Monitor and regularly discuss the Board’s own process and performance. Ensure the continuity of
improvements through some systemic review and updating of governance policies.

3. The Board of Directors will establish Committees to help carry out its responsibilities. Board Committees
will be used to support the Board policy development function.

4. Board of Directors’ Committees may not speak on behalf of the Board except when formally given such
authority for specific and time-limited purposes. Such authority will be carefully stated in order not to conflict
with authority delegated to the CEO.

5. Board Committees are not to be created by the Board to advise the CEO.

6. Board Committees cannot exercise authority over employees, and in keeping with the Board’s focus on the
future, Board Committees will ordinarily not have direct dealings with current employee operations, except for
the purpose of receiving information. Further, the Board will not impede its direct delegation to the CEO by
requiring approval of a Board Committee before any CEO action. The CEO works for the Board, never for a
Board Committee or individual member.

7. The Board will use ad hoc Committees, as required from time to time, for the purpose of gathering information
related to policy issues and outlining various options, and the implications of optional course of action and
making recommendations. Ad hoc Committees of the Board:

a. Shall be chaired by a member of the Board;

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ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: GOVERNANCE STYLE AND COMMITTEE POLICY NO.: A.11.1

PRINCIPLES

i. May include in their composition, members of the community who are not on the Board;
ii. Will receive written terms of reference from the Board, and;
iii. Will be disbanded once they have completed the specific tasks assigned to them.

Board Annual Review

8. The Board of Directors will discuss and evaluate its own process annually at the Board Retreat. Responsibility
for ensuring a fair and balanced discussion of during this regular monitoring process will rest with the Board.

9. New members of the Board may also consult with the Board Chair to assess their performance. This process
is not part of the annual self-assessment conducted by the Board.

Relations With the Media

10. Relations with the media in matters relating to policy and major political issues is the purview of the Board and
relations with the media in relating to program the purview of the CEO.

11. Other than in specifically authorized instances, the Board Chair and the CEO or designate, are the only person’s
authorized to speak for the organization. Each has the authority to issue press releases and respond to the media
on behalf of Trellis.

Role in Revenue Generation

12. The Board’s primary function is to define results, not to raise money. Most of the activities related to the raising of
money are done by volunteers and employees hired to carry out this function. However, the needs of Trellis for
fundraising go beyond the scope of available employee resources, and the Board recognizes it has a role to
assist and support fundraising activities.

13. Board Members will support the fund development efforts of the organization by lobbying and networking to
position the association for successful fund development.

14. Board Members may contribute in other areas (donation, bingos, casinos, sale of memberships, and tickets to
event) in accordance with ability and time available.
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ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: CODE OF CONDUCT POLICY NO.: A.11.2

DATE ISSUED: September 2010 ASSOCIATED STANDARDS:

CARF – Board Governance
DATE REVISED: May 2019

Board members are expected to conduct themselves in an ethical and professional manner.

POLICY

1. Board Members must be loyal to the interests of the public and membership and must disclose any conflict of
interest to the Board Chair and seek direction from the Board. This loyalty supersedes the personal interest of
any Board Member acting as an individual client of the Agency’s services.

2. The Board must avoid any conflict of interest with respect to their fiduciary responsibility:

a. There must be no self-dealing or any conduct of private business or personal services between any
directors and the Agency, except as procedurally controlled to assure openness, competitive opportunity,
and equal access to otherwise “inside” information;
b. The Board must not use their positions to obtain for themselves, or for their family members, employment
within the Agency;
c. Should a Board Member be considered for employment, they must temporarily withdraw from Board
deliberation, voting, and access to applicable Board information, and;
d. Having disclosed a conflict of interest, the Board Member must not vote on the resolution relating to the
conflict of interest.

3. Board Members may not attempt to exercise individual authority over the organization except as explicitly set forth
in Board Policy:

a. Board Member interaction with the CEO or with employees must recognize the lack of authority in any
individual Board Members or group of Members;
b. Except for the authority granted to the Board Chair, Board Members’ interaction with the public, press, or
other entities must recognize the same limitation and the similar inability of any directors to speak for the
Board, and;
c. Board Members will make no judgments of the CEO or employee performance unless that performance is
assessed against explicit Board policies by the official process.

4. Board Members may not use Board information for their own direct benefit or advantage. This requires that the
information be kept confidential whenever required in the best interest of the organization.

5. That part of a meeting when financial information, negotiation strategies, or intimate personnel matters may be
disclosed shall be kept confidential. The proceedings of any meeting of the Board or any part of a meeting of
the Board or of any Committee thereof which is conducted in camera, including the minutes or any records,
shall be kept in confidence by every member of any committee or other person invited or permitted to attend
the meeting.

6. Board Members will deal with outside entities or individuals, with employees, and with each other in a manner
reflecting fair play, ethics and straightforward communication.

7. All Board Members will sign an oath of confidentiality, code of ethics and conflict of interest upon commencement
with the Board and every year thereafter.
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ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: CODE OF CONDUCT POLICY NO.: A.11.2

8. Board Members must carry out duties in good faith with a reasonable degree of diligence, care, and skill. If a
Board Member is deemed to be negligent in carrying out their duties, then given that the Board has the right to
make and enforce its own laws and punish an offender, the following guidelines will be followed:

a. Offending Board Members may be censured by the Board Chair with a letter being sent to the member
outlining the circumstances and corrective actions;
b. Continued offence will result in a motion of censure being brought to the Board Chair. This motion may result
in a voluntary withdrawal or up on a vote of the majority, the member shall be removed from all Committee
membership;
c. Continued offence by a member of the Board of Directors will result in removal from office by a resolution as
prescribed in the laws of the Agency, and;
d. In circumstances of an extreme nature the offending member will be removed from office immediately in
accordance with the by-laws.
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ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: POLICY PROCESS POLICY NO.: A.11.3

DATE ISSUED: September 2010 ASSOCIATED STANDARDS:

CARF – Board Governance
DATE REVISED: May 2019

The Board of Directors sees the development of policy as providing effective parameters and broad guidelines
for the Board of Directors and the CEO.

POLICY

1. In fulfilling its responsibility for policy-making, the Board of Directors will be directed by the following
considerations:

a. The Board of Directors will ensure that they are in compliance with relevant legislation or regulation,
the Agency’s Constitution and Bylaws, and with existing Agency policies or agreements;
b. The Board will also strive to ensure that all policies operate in harmony, and;
c. Policies will be statements of values or approaches which will address:

i. Outcomes – statement written in results language which describes what benefits are to be
delivered to which groups of people at what cost.
ii. HR and Finance and Audit Policies– policies which outlines the CEO’s authority and
responsibilities
iii. Governance process – how the Board conceives, carries out and monitors its own tasks. The
manner in which the Board represents the community and provides strategic leadership to the
organization.
iv. Board/CEO relationship – the delegation of authority and the monitoring of accountabilities

2. In setting policy, the Board of Directors will always work from the broadest, most general statement of
policy, and will proceed to develop progressively more specific policies until it is satisfied that it has
achieved the degree of definition necessary in that area.

3. The CEO is responsible for the implementation of policy with the exception of policies governing the
Board itself. This area is the responsibility of the Board Chair.

4. In shaping policy, the Board will become highly visible in seeking outcomes input. Input will be sought from
a variety of sources, including community leaders, other boards, volunteers, employees and clients.
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ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: BOARD MEMBERSHIP CRITERIA, POLICY NO.: A.11.4

RECRUITMENT AND STRUCTURE

DATE ISSUED: September 2010 ASSOCIATED STANDARDS:

CARF – Board Governance
DATE REVISED: May 2019

POLICY

Membership Criteria

1. The Board composition is based on current board by-laws which take into consideration the number of
members required for effectiveness, diversity and based on time commitment. The Board values diversity and
does not discriminate against potential members on the basis of race, color, religion, spiritual beliefs,
socioeconomic status, language, national origin, gender, sexual orientation, age, handicap or mental condition.

2. The Board will consist of:

a. elected members
b. ex-officio member – CEO

3. The Board may, at its discretion, appoint ex-officio honorary board members if it is determined necessary during
review of the Board Skills Matrix.

4. A Board Member cannot be related to any member of the Executive Leadership team, ensuring that all members
can carry out their responsibilities without undue influence from management.

5. Board Members are required to ensure that their Police and Child Intervention Checks with Vulnerable Sector
Search are current and in good standing and to review and sign off annually on a Confidentiality Waiver and the
Ethical Code of Conduct.

6. The Board shall maintain the Board Skills Matrix and annually review skills required based on the changing needs
of the organization.

Recruiting and Selection of Board Members

7. When a vacancy occurs on the Board of Directors, the HR Committee refers to the Board Skills Matrix and
actively recruits potential Board member based on the skill vacancies of the Matrix.

8. Names of potential Board Members are forwarded to the Chair and HR Committee, who then review the resume
and invite applicant to discuss the position and the Governance role and commitment required.

9. A recommendation to invite the applicant is forwarded to the Board of Directors and majority approval is required
prior to offering a position on the Board.

Board Chair and Committee Chair Selection

10. The Board Chair is often selected from the Vice Chair position. If this is not possible, the Board identifies from the
current members whom has the skills, time availability, expertise and willingness to accept more responsibility to
commit to the role. Board Members then vote for the individual and if the majority of the Board approves, the
member is asked if they willstand.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: BOARD MEMBERSHIP CRITERIA, POLICY NO.: A.11.4

RECRUITMENT AND STRUCTURE

11. Committee Chairs are invited to Standing Committees by the Board Chair. This is based on qualifications, interest
and the skill level required by the Committee. For example, the Chair of the HR Committee must have a strong
background and expertise in the HR field.

Standing Committee Structure

12. A Committee is a Board Committee only if its existence and charge come from the Board, regardless of
whether Board Members sit on the Committee. The only Board Committees are those nominated by the Chair,
which are set forth in this policy, and which are approved by the Board. The Standing Committees of the Board
are:

a. HR Committee, and;
b. Finance & Audit Committee.

13. Officers of the Board are:

a. Chair;
b. Vice Chair;
c. Secretary, and;
d. Treasurer.

External Advisors

14. Occasionally consultants and/or advisors may be required to provide guidance to the Board in relation to
support strategic planning, role definition and risk analysis. These external advisors are called upon for their
specific expertise and will not serve on the Board on an on-going basis. These individuals must operate in an
arms- length manner and will not have personal or professional relationships with any Board member or Senior
Leadership positions.

15. External Advisors may be hired to facilitate the yearly Board retreat.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: BOARD MEMBER ORIENTATION, POLICY NO.: A.11.5

EVALUATION AND EXIT PROCESS

DATE ISSUED: September 2010 ASSOCIATED STANDARDS:

CARF – Board Governance
DATE REVISED: May 2019

POLICY

Board Member Orientation

1. Orientations will be held as required to acquaint new Board Members with Trellis, the Board of Directors and
the role of individual Board Members. While orientation is an ongoing process, threeformal orientation activities
will be provided to all new Board Members:

a. Orientation to the Agency;

b. Orientation to the Board of Directors, and;
c. Orientation to the individual role of the Board Member.

2. The orientation to the Agency will cover:

a. The general scope of the Agency including its mission, principles, values, history andservices;
b. The structure of the Agency;
c. A meeting with the CEO, and;
d. Legislation affecting the Agency, the Agency’s Constitution and Bylaws.

3. The Orientation to the Board of Directors should be done as soon as possible once the new member has
been formally invited to join the Board. Supporting documentation such as Board Governance policies will
be made available immediately. Discussion will focus on the following areas:

a. The role of the Board of Directors’ as a governance unit. The importance of the Board and its
contribution to meeting community needs;
b. A review of the Board of Directions’ governance model and governance policies and the basic values
underlying the work of the Board of Directors;
c. An introduction to the Boards’ calendar, and;
d. The Board of Directors’ relationship with other groups and organizations.

4. An orientation to the individual role of the Board Member will include the following written documents:

a. An outline of specific responsibilities, expectations and benefits, including:

i. Their role with the Board is voluntary and no compensation will occur for their time and
performed duties as a member of the Board;
ii. Board Members are not permitted to apply for any form of loan on behalf of the Agency, and;
iii. Board Members may be reimbursed for their mileage, conference registrations and other
Agency related expenses.

b. The Board Member’s level of authority and accountability;

c. Role of Committees and resource available to Committee members
d. Methods of reporting and communicating, and;
e. Performance expectations for individual Board Members.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: BOARD MEMBER ORIENTATION, POLICY NO.: A.11.5

EVALUATION AND EXIT PROCESS

5. The Board Chair is responsible for ensuring that the orientation of new Board Members is undertaken in
accordance with this policy.

6. Board Members are required to attend meetings, annual retreats and planning sessions in their role on
the Board. Board Members will also be invited to visit sites, programs, and celebrations of Trellis.
Annual Board Member Evaluation

7. Individual self-assessments will be conducted annually by the Board Chair. This evaluation will assess the
performance, effectiveness and ability to adapt to the evolving context of the organization of the individual
Board Member specific to their role on the Board and the Standing Committees.

8. Confirmation of these evaluations will be documented in Board meeting minutes.

9. The Board Chair will also conduct an annual Board evaluation to assess the performance of the Board as
a whole. This evaluation will be documented in meeting minutes and/or as part of the Board annual
retreat.

Board Member Exit Process

10. Board Members leaving their positions with the Board will have the opportunity to have an exit interview with the
Board Chair and/or CEO. Information from the exit interview shall be documented on the Exit Interview form.

11. A Board Member may request that the information from the exit interview be kept confidential.

12. The Board Chair will prepare a confidential summary report from the exit interview that may be shared with the
Board if permission is granted by the exiting Board Member. This summary will be used in the context of continual
improvement of the Board, its policies, processes and governance style.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: JOB DESCRIPTIONS POLICY NO.: A.11.6

DATE ISSUED: September 2010 ASSOCIATED STANDARDS:

CARF – Board Governance
DATE REVISED: May 2019

The Board of Directors is required to make certain contributions which assure that Trellis performance conforms to
the mission of the Agency. These contributions flow from the Board’s role as the steward to the proper governance
of the Agency. The Board is also responsible for yearly review of the CEO’s performance and compensation.

POLICY

1. The functions of the Board shall be to:

a. Regularly revisit and define Trellis’ reason for existence;

b. Write directional policies which address:

i. HR;
ii. Board Governance;
iii. Board-CEO relationship, and;
iv. Finances and Audits.

c. Provide accountability and linkage to the community;

i. The Board is the linkage between the Agency and the Community and is accountable for
monitoring the allocation of organizational resources and the effectiveness of organizational
outcomes.

d. Board Members will endeavor to be informed about issues and trends affecting the ownership and
the Agency through a process of continuous education involving:

i. Self-directed research;
ii. Board briefs presented by ownership representatives;
iii. Attend relevant workshops and the National Conference;
iv. Regular inter-agency dialogue, and;
v. Specific research projects initiated to acquire statistical data on ownership concerns, needs,
demands and trends.

e. Board members must have an attitude consistent with their stewardship over owner resources.
f. To define how the Board will organize itself to get its work done. This requires a policy on Board
Resource and definition of:

i. The officer positions,

ii. Committee structure,
iii. Legislated responsibilities of the Board.

g. To ensure that organization is adequately funded and is worth funding.

 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: JOB DESCRIPTIONS POLICY NO.: A.11.6

CEO’s Performance and Compensation

h. To assess the CEO’s yearly performance, ensuring the following criteria will be met:

i. The CEO’s performance is assessed based on the overall performance of the agency, strategic
plan and their compliance with human resource and finance & audit policies as well as progress
of the individual work plan for the position;
ii. This written evaluation will document professional development and opportunities available to
the CEO;
iii. In consultation with the HR Standing Committee, the yearly evaluation will consist of a review of
the CEO’s compensation by utilizing information from the most current Boland Study as a
guideline. The philosophy of the CEO’s compensation is also based on skill, experience and
number of years in the position. The compensation mix is based on a base pay and benefits
plan. Any change in compensation will be brought to the Board for full approval prior to
implementation with a document outlining the terms of the compensation, approval date, names
of Board Members who approved the decision, data used in determining the change disclosure
of any conflicts of interest and confirmation of an annual review of the CEO’s compensation
records to be signed by the Board Chair. Any changes to compensation will be communicated
to the People Services Manager who will prepare a letter to be signed by the Board Chair. The
yearly evaluation review is completed as per the Board perpetual calendar timelines;
iv. The review will include information on succession planning for the Senior Leadership team, and;
v. Results of the assessment of the performance of the CEO are communicated to the Board.

Board Chair’s Role

2. The Board Chair’s role is to ensure the integrity of the Board of Directors’ governance process. The Chair
or their designate is the only person authorized to speak for the Board.

3. The Board Chair shall ensure that the Board of Directors’ behavior is consistent with its own rules and
those legitimately imposed upon it from outside the organization.

a. The Board Chair is empowered to chair Board of Directors’ meetings with all the commonly accepted
power of that position (e.g., ruling, recognizing).
b. Meeting discussion content will only be those issues which, according to Board policy, clearly belong to the
Board to decide, not the Executive Director.
c. Robert’s Rules of order are observed except where the Board’s Bylaws have supersededthem.

4. The Board Chair shall act consistently with Agency Policies on Governance process and on the Board-CEO
relationship.

a. Board Chair authority does not extend to making implementation decisions within the Strategic Plan or
Operational Policy areas, each of which are the purview of the CEO.
b. Board Chair authority does not extend to supervising, interpreting Board of Directors policies to, or
otherwise directing the CEO.

5. The Board Chair will ensure the Board is in compliance will licensing and accreditation requirements including
yearly review of Board policies and bylaws.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: JOB DESCRIPTIONS POLICY NO.: A.11.6

6. The Board Chair shall represent Trellis within the community.

7. The Board President shall report to the Board, any written representation when the following conditions are
met:

a. Internal procedures have been exhausted; and

b. The employee alleges that:
i. Board Policy has been violated to their detriment; or
ii. Board Policy does not adequately protect their human rights.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: FINANCIAL GOVERNANCE POLICY NO.: A.11.7

DATE ISSUED: February 2009 ASSOCIATED STANDARDS:

CARF – Board Governance
DATE REVISED: May 2019

Trellis seeks to ensure the long term stability of the organization, plan for timely growth, protect itself against
unforeseen loss of income or unanticipated expense, and still maintain the flexibility to respondto opportunities of
new revenue for new initiatives. The Board of Directors will ensure that the Agency is operating in a fiscally
responsible manner, that assets are protected and that the disposal of assets are completed based on market
value. Accordingly, the Board of Directors shall:

POLICY

Financial Planning

1. The Board will be responsible to appoint members to the Audit and Finance Committee.

2. The Board will review and approve the annual budget prepared by TRELLIS. This will include ensuring
thatplanned expenditures in any current or future fiscal year are conservativelyprojected.

3. Board member expenses shall be signed by the Board Chair.

4. TRELLIS will not expend more funds in a fiscal year except as authorized by the Board.

5. The Agency will provide a monthly variance analysis report to the Audit and Finance Committee which will
reconcile actual results with budgeted amounts.

6. The Financial Committee will act within generally accepted accounting principles as per Canadian Accounting
Standards for Not for Profits.

7. The Board will be responsible to appoint auditors for TRELLIS and ensure that the costs associated with the
auditare of fair market value. The Board Finance Committee will ensure an arms-length relationship exists
with TRELLIS and the Auditors: Board approval must be obtained prior to the Auditors engaging in any other
work onbehalf of or for TRELLIS (i.e. other contracted work, donations, etc.).

Financial Assets

8. TRELLIS will not purchase unbudgeted capital expenses of $100,000 or more without Board written
approval.This policy shall not apply to donations received by TRELLIS which are subject to be expended in
accordancewith the donor’s wishes.

9. TRELLIS will not enter into any long term obligations exceeding $75,000 per year except as authorized
anddocumented by the Board. This limitation does not include programs.

10. The disposal of assets shall be the responsibility of the CEO. Disposal of equipment or property in excess of a
market value of $50,000 shall receive prior approval from the Board. The disposal of a significant asset will be
documented in the monthly variance report presented to the Audit and Finance Committee.

Asset Protection

11. The Board will ensure that TRELLIS has adequate insurance levels in place to protect the Agency against
theftand casualty losses to a cost-effective prudent level.
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: FINANCIAL GOVERNANCE POLICY NO.: A.11.7

12. The Board will ensure that there is adequate insurance coverage in place to protect the Directors, employees,
volunteers, practicum students and clients of the organization.

13. The Board will ensure that there is no misuse or abuse of assets of the organization.

Investments

14. TRELLIS has a low risk tolerance with respect to the investment of operational funds. As such, the priority is
on protection of capital and not the maximization of investment returns. The organization shall ensure that
investments in instruments can be modified within a reasonable period of time to other instruments in order for
TRELLIS to meets its cash flow requirements. Accordingly, TRELLIS shall adopt the following principles
which will be implemented and monitored by the Audit and Finance Committee:

Eligible Investments
• Government obligations (i.e., Treasury Bill Notes, Strip Coupons, Debentures and/or Bonds) issued
directly or indirectly by the Federal government or an agency (Canadian and US) or any of the provinces,
which hold appropriate credit ratings.
• Canadian Chartered Bank Securities, bearing Bearer Discount Notes, Deposit Receipts, Term Notes,
Certificates of Deposit, Bankers Acceptance and short term bonds and strip coupons.
• Securities of foreign banks or the Canadian affiliates of foreign banks provided that the obligations are
guaranteed or carry separate appropriate ratings.
• Bonds and strip coupons of Canadian industrial companies, affiliates, financial institutions, consumer
loan companies.
• Loans to investment dealers (call loan) providing that full collateral value plus applicable margins are
held at a banking institution.
Investment Limitations

• The purchase of securities carrying a credit rating below A or AA for bonds or suggest A1/R1 for
commercial paper must compromise less than 15% of portfolio.
• Junk bonds are strictly prohibited.
• Investments of appropriate credit quality may be subject to the following limitations:
INVESTMENT VEHICLE MAXIMUM % OF PORTFOLIO
Federal Governments 100%
Provincial Governments 25%
Canadian Chartered Banks carrying a rating of A or 25%
better
Commercial paper and obligations of Canadian 10%
affiliates of foreign banks with a rating of A or A1 or
higher
 TRELLIS SOCIETY – LBGCC PROGRAMS

ORGANIZATIONAL LEADERSHIP
BOARD GOVERNANCE

POLICY: FINANCIAL GOVERNANCE POLICY NO.: A.11.7

15. Subject to prior written approval of the Audit and Finance Committee, investments can be made in third party
managed funds which co-mingle all participant investments provided that the safety, liquidity, and yield
characteristics of the fund are consistent with or better than alternative money market strategies approved
pursuant to these guidelines.

16. Quarterly investment reports shallbe prepared for and distributed to the Audit and Finance Committee.

17. Under certain circumstances, the Chief Financial Officer may conclude that though an investment may not
meet the criteria outlined above, the investment may be within keeping of the spirit of the policy. In such
circumstances, TRELLIS may deviate from the policy provided that the Audit and Finance Committee
approvalthe investment, there is documented written disclosure of the investment made to the Board of
Directors andthat any such investment will not exceed 5% of the portfolio and the total of such investments
will not exceed 10% of the overall portfolio.

Cash Reserves

18. The cash reserve to be established and maintained is defined as the finds held in bank accounts and term
deposits, other than those specifically designated for non-operational purposes, less the excess of any of
accounts payable over accounts receivable. The minimum fiscally prudent cash reserve shall be $750,000 or
5% of the current fiscal year’s projected expenditures, whichever is greater.

19. When in any given year the cash reserve is projected to drop below the minimum, the Board can approve
additional fundraising activities and expense reductions to restore the reserved back to the minimum level on a
timely basis.

Budget Revisions

20. The Board of Directors must be notified if a potential revision to the budget results in any of the following
conditions:

a. A change of $250,000 or more for a new fully funded program;

b. A change of $100,000 or more for a new unfunded program, and;
c. A change greater than $1,250,000 in aggregate budget changes within a three month period.

21. The Chief Financial Officer must track changes to the approved budget, and include in the financial package
distributed to the board.

22. Proposed revisions to the budget that meet the above criteria must be submitted to the Board of Directors for
approval prior to the submission of the proposal for the program(s).
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: ALCOHOL AND DRUG FREE POLICY NO.: B.1

ENVIRONMENT

DATE ISSUED: January 10, 2000 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

POLICY

1. Trellis is strongly committed to ensuring the safety and well being of all associated with Trellis; therefore, alcohol
and illicit drug use is strictly prohibited in program facilities and vehicles.

2. All employees are expected to be unimpaired at all times while on shift. Working under the influence of illicit drugs
or alcohol is prohibited. Prescription drugs causing impairment must be discussed with the direct Supervisor and
in conjunction with People Services so that an appropriate safety plan can be developed. Employees who are
using prescription or over the counter medications that can cause impairment must not work alone with children
or drive a vehicle, or otherwise endanger the health and safety of themselves or others while impaired. On-call
employees are expected to abstain from any substance causing impairment for the duration of their On-call shift.

3. TRELLIS-sanctioned events (e.g., celebrations, conferences, fundraisers, third party events) that include the
useof alcohol require specific and explicit permission from the CEO. All events that are planned by the Agency
where alcohol will be served will be held at licensed establishments whenever possible.

4. For TRELLIS-sanctioned events that serve alcohol, the Agency will develop a plan for reducing risks associated
with alcohol use, including the arrangement of safe transportation for employee’s home after the event. TRELLIS
employees are reminded that although they may be attending agency events outside of work hours, employees
are expected to adhere to the Code of Conduct and Ethics.

5. Any after work event held off premises and not planned, promoted or sanctioned by the Agency is not deemed
to be the responsibility of the organization.

6. As part of the Orientation process an explanation of the Alcohol and Drug Free Smoke-Free Environment policy
will be reviewed and documented by the appropriate supervisor.

7. It will be the responsibility of all employees to monitor the requirements for an Alcohol and Drug-Free workplace
and ensure compliance by employees and clients of the Agency. Observance of an employee or member of the
public contravening policy should be reported to the immediate supervisor or alternate appropriate level of
supervisory authority.

8. If in the event, an employee is not in compliance with the Alcohol and Drug-Free workplace requirements, an
investigation to determine the appropriate action will be completed, which may involve steps in the disciplinary
process.

PROCEDURES

1. It is expected best judgment will be used in planning events, especially if the event includes alcohol and involves
peers, former clients who are now employees, or seasonal term positions with the Agency such as junior leaders
or stampede employees.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: ALCOHOL AND DRUG FREE POLICY NO.: B.1

ENVIRONMENT

2. Employees being compensated to work at an Agency social event, must abstain from consuming alcohol while
they are completing their duties.

3. All parties renting facilities owned by Trellis must abide by the alcohol, drug and smoke free policies. Individual
exceptions may be made at the discretion and written approval of the CEO.

4. It is expected that various events, for example fundraising events, will serve alcohol to the guests. If there are
Trellis youth present, the organizing employees must ensure that the parents/guardians of the client understand
that there may be alcohol present. Employees who are supervising clients shall not partake in any alcohol
consumption. Employees who are working at the event and not supervising clients are expected to exercise
discretion and moderation as they are ambassadors of the Agency.

5. Employees who wear TRELLIS logo’ed clothing are representing the Agency and are expected to exercise
discretion and moderation.

6. Youth participating in work experience programs (i.e. Stampede, Pursuit, practicums, paid work experiences)
are considered clients of Trellis and relevant polices apply.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: EMERGENCY DRILLS POLICY NO.: B.2

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

To protect employees and clients in the Agency, Trellis will promote health and safety at the workplace by practicing
drills for emergency procedures and evacuations.

POLICY

1. All employees and clients will be orientated to the procedures for emergency drills and evacuations during
program orientation/registration. Emergency drill procedures are outlined in the Agency Emergency Response
manual.

2. Programs will practice unannounced emergency drills with clients monthly, ensuring that all emergency
procedures as outlined in procedure section below are practiced yearly on each shift.

3. Each program will have a designated muster point. Programs will have evacuation plans posted in common
areas. Programs will also have a portable record of contact information for both employees and clients that is
easily accessible in case of evacuation or emergency.

4. All clients and guardians will be advised of the drills, evacuation plan and muster point at intake or during program
registration.

5. Should evacuation be necessary, Trellis has access to numerous sites for temporary shelter. This may include
any one of our residential programs, community clubs, shelters or the Hangar. Once temporary shelter has been
established, parents and guardians (as applicable) will be contacted and provided with information as to the
whereabouts of their children and youth.

PROCEDURES

1. The Manager will ensure that the following drills are executed annually for each shift in the program:

a. Evacuation drill for fire, utility failure (gas leak) and bomb threats;
b. Evacuation drills must also include a test of the panic buttons and alarms, which require a notification to
the alarm company prior to the drill. This is required annually;
c. Lockdown procedures for armed intruders and violent/threatening situations;
d. Natural disaster – tornadoes, lightning and severe weather;
e. Natural disaster – floods;
f. Medical emergency.

2. All programs will document the drill including information on the type of drill, the shift it was performed on, the
outcome of the drill including time count and any follow up that is required to enhance the Agency’s emergency
response.
 TRELLIS SOCIETY – LBGCCPROGRAMS

HEALTH AND SAFETY

POLICY: EMERGENCY RESPONSE MANUAL POLICY NO.: B.3

DATE ISSUED: November 2, 2004 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

Terllis promotes the safety and health of its employees and clients by practicing emergency procedures in the
workplace.

POLICY

1. All employees will review the Emergency Response Manual during orientation and on an annual basis. This manual
will be reviewed by the Agency on a yearly basis to update information and enhance procedures for emergency
response.

PROCEDURE

1. The Agency will provide all new employees with a copy of the Emergency Response Manual during orientation.
This manual will also be kept online for employees through ADP and will be updated yearly. The manual will
contain information about, but not limited to:

a. Infectious Disease and Universal Precautions;

b. Crisis and Emergency Situations;
c. Safety and Security;
d. Critical Incidents;
e. Confidentiality;
f. Responding to Media.

2. The Emergency Response Manual minimally outlines procedures for the following scenarios:

a. Fire, hazards and suppression;

b. Bomb threats;
c. Natural disasters;
d. Utility failures;
e. Program evacuation;
f. Medical emergencies, and;
g. Violent situations.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: FIRE SAFETY POLICY NO.: B.4

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARD:

CARF – Health and Safety
DATE REVISED: May 2019

POLICY

1. All employees will have access to information and be trained in how to manage fire hazards, how to suppress
fires, program evacuation procedures and how to operate the safety equipment and alarm system in their facility.

2. The Agency will ensure that each program site and its equipment have current and appropriate licensing and
conform to all codes, bylaws, regulations and legislation as dictated by health, safety, building and fire authorities.
All licenses will be prominently displayed and available for public inspection

3. Fire extinguishers and fire detection systems will comply with regulations as per the Fire Code. All Agency sites
will have documented monthly reviews of fire extinguishers, smoke detectors and fire safety systems by
employees and an annual review by an external authority unless otherwise required by the licensing body.

4. Fire extinguishers found in each program will be accessible to employees and clients. Programs will have the
correct number of extinguishers to conform to the Fire Code, including all units owned or leased by the Agency
in Independent Living programs.

5. All programs must have documented procedures outlining:

a. implementation of regular evacuation drills;

b. clearly identified posted evacuation routes (primary and secondary);
c. notification of emergency services, police, fire station, ambulance;
d. Emergency Response Manual.

6. All Agency sites will have a documented monthly Lifecycle Checklist and will conform to all codes in use and
maintenance of premises and equipment.

7. All employees will possess knowledge of the security and/or alarm system in their program. The Program
Manager will be the contact person for related fire, safety and security authorities and will distribute all information
and directives from these authorities to the program. As part of a new employee and client’s orientation, the
employee/client will be provided with key information about the safety procedures in effect in the premises.

8. Agency Program Manager will arrange for required ongoing inspections with the assistance from the Business
Operations Manager. To ensure all licensing remains current, licensing of all Agency sites will be kept current
through completing an annual inspection minimally, unless otherwise required by the licensing body.

9. In the event that a program does not pass its annual inspection, the Business Operations Manager, Program
Manager and Director will be notified to ensure the necessary actions are put into place to immediately rectify the
situation.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: FIRST AID KITS POLICY NO.: B.5

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

POLICY

1. To ensure that programs are equipped to deal with non life-threatening medical emergencies, Trellis will have
available the appropriate first aid supplies. These supplies will be accessible to employees, volunteers, students
and clients.
2. The Program Manager will ensure that the contents of the first aid kit remains complete both in programs and in
Agency vehicles.
3. Employees who transport youth must ensure that they have a first aid kit in their personal vehicles.
PROCEDURES
1. All programs will have first aid kits containing, but not limited to:
a. 25 – sterile adhesive dressings (i.e. Band-Aids)
b. 5 – anti-septic cleansing towelettes, individually packaged
c. 5 – 10 cm x 10 cm sterile gauze pads, individually packaged
d. 5 – safety pins
e. 2 – pairs of disposable latex gloves
f. 1 – pair latex-free gloves
g. 1 – pair sharpe resistant gloves
h. 1 – pair of scissors
i. 1 – pair of tweezers
j. 1 – 25 mm x 4.5 m roll of adhesive tape
k. 1 – crepe (tensor) bandage 75 mm
l. 1 – pair goggles
m. 1 – disposable artificial resuscitation barrier with a one-way valve
n. 1 – first aid instruction manual (condensed)
o. 1 – waterproof waste bag
p. 1 – cotton triangular bandage
q. 1 – inventory list
r. 1 – Disposable Apron
2. All Agency vehicles must carry first aid kits. The contents of these kits will be the same as the program kits, but
will also include:
a. Instant ice packs
3. It is the responsibility of the programs to ensure that contents of the first aid kits, both at programs and in Agency
vehicles, are reviewed and documented at the facility, on the Lifecycle Checklist and Vehicle Checklistson a
monthly basis.
4. In the event that an item from a first aid kit is used, the employee will ensure that the item is re-stocked
immediately.
5. Programs travelling outside the city and for overnight trips must ensure that they have adequate first aid supplies
for the duration and location of their trip.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: INFECTIOUS DISEASES AND POLICY NO.: B.6

UNIVERSAL PRECAUTIONS

DATE ISSUED: June 2005 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

The practice of Universal Precautions is to be employed when there is or may be potential contact with blood and
other body fluids. Body fluids include blood, semen, vaginal secretions, sputum, nasal secretions, vomit, urine,
feces and any other body fluid containing visible blood. Contact with blood and body fluids must always be
minimized and fluids treated as if they contain a contagious or infectious disease.

POLICY

1. In order to control the transmission of infectious disease, Trellis will ensure that allemployees and clients adhere
to Universal Precaution measures. Universal blood and body fluid precautions will be adhered to in order to
prevent the spread of infectious diseases, including those caused by blood- borne pathogens such as hepatitis
and HIV. All employees will complete Agency Universal Precautions Training.

2. All employees will be oriented to the procedures to ensure the prevention of the spread of infectious diseases
and blood-borne pathogens. Such training shall be updated yearly and as necessary, with a record of the
training being placed on the employee’s personnel file. Developmentally appropriate information on infectious
diseases will be provided in the orientation of new clients.

3. Anyone who is exposed to blood and/or body fluids will immediately seek medical attention for the purpose of
assessment, testing and counseling. A follow up appointment for future testing should also be set at this time.
This will be reported to the appropriate On-Call Coordinator, Manager and Director and documented on a
Critical Incident Report. In the event that employees come into contact with blood and/or bodily fluids, they will
be relieved of their duties as soon as possible (i.e., as soon as a replacement for the program has arrived) to
seek medical attention but will continue to be paid until they have been assessed by amedical professional.
Injuries must also be reported to the People Services Manager within 72 hours in order to complete the
necessary Worker’s Compensation Forms.

4. Every Agency site will post the Infection Control procedures, which outline the appropriate use of Universal
Precautions. These written procedures will be readily available to all employees and all clients when
appropriate.

5. Precautions for the control of transmission of infectious disease will include but are not limited to:

a. the use of disposable latex or vinyl gloves when handling body fluids or materials contaminated by body
fluids;
b. appropriate disposal of materials contaminated by body fluids;
c. soiled materials, which need to be disposed of (i.e., bandages, paper towels, gloves, rags, etc), will be
placed in a sealed plastic garbage bag marked “Blood and Body Fluid - Precautions”, and then placed in a
garbage container located “outside” of the building. Clothing that is soiled must be sealed in a plastic bag
until they are cleaned;
d. the use of acceptable solutions (9:1 Bleach Solution) for disinfecting surfaces contaminated with body
fluids; and
e. the prohibition of sharing toothbrushes, needles, razors and body piercing jewelry.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: SMOKE FREE ENVIRONMENT POLICY NO.: B.7

DATE ISSUED: January 10, 2000 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019 Licensed Care

POLICY

1. To ensure the safety and well being of all associated with Trellis , and to ensure thatthe right to work in an
environment free of the hazards of tobacco smoke, smoking is not permitted in Agency facilities, buildings
and vehicles.

2. E-cigarettes and vaping is included in the Trellis’ definition of smoking.

3. Trellis will adhere to City of Calgary Bylaw 57M92 ensuring that no smoking will be permitted within 5 meters
of an entrance way to any of the Agency’s facilities or buildings. Postings of non smoking symbols should be
posted and maintained by employees at every facility and building owned and operated by Trellis.

4. It will be the responsibility of all employees to monitor the requirements for a Smoke-Free environment and
ensure compliance by employees, students, volunteers and clients of the Agency. Observance of an
employee, student, volunteer or member of the public contravening policy should be reported to the
immediate Supervisor or alternate appropriate level of supervisory authority.

5. Failure to follow this policy may involve disciplinary procedures.

 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: WORKING ALONE POLICY NO.: B.8

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

Some programs require that employees work alone with clients, as part of the program model (i.e., outreach) or as
part of a program procedure (i.e., an employee accompanies a client to the hospital). In these instances procedures
are put in place to ensure the safety and security of both the client and the employee.

POLICY

1. All employees and volunteers will go through an orientation and training of emergency responses, alarm systems
and afterhours support systems available to them when working alone.

2. Employees and volunteers will ensure that all mandatory trainings are completed prior to working alone, unless
otherwise approved by the Chief Operating Officer.

3. When working alone, employees will have a means to call for support in the event of a serious incident.
Employees and volunteers are responsible for ensuring that they are in possession of a cordless phone, program
cell phone or panic button when working alone.

4. In the event of a serious incident where external support is required, employees should press the panic button
AND dial 911.

5. Programs who have employees who work alone with clients in the community have specific procedures in place
to ensure the safety of employees and clients. Employees will refer to their program specific policies and adhere
to the processes in place for check-ins and/or risk assessments for new and existing clients.

6. All employees and volunteers will have knowledge of client issues and past behaviors that may be indicative of
risk to either the client or the employee.

7. Volunteers and practicum students will only work alone with clients with permission from Program Manager or
designate.

8. Each employee, student or volunteer will have access to a cell phone when they go out into the community with
clients. The cell phone should be on at all times when employees/volunteers are away from the program, but
cannot be used when driving clients in Agency or their own vehicles. In the event that an employee is gone for
an extensive period of time with a client, regular check-ins with the program or On-Call must occur.

9. Programs providing 24 hour care will participate in nightly safety calls between programs. Should one facility not
be able to reach another during the night, the On-Call Coordinator is contacted and Calgary Police will be called
to the program.

10. Hazard assessments are completed in programs every six months and will review the risks of working alone to
make recommendations for enhancements for safety. In the event that there is a change (i.e., move to a new
facility or changes in the community that may impact the safety of clients and employees), the Agency will conduct
a hazard assessment at the time of change.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: VIOLENCE IN THE WORKPLACE POLICY NO.: B.9

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019 CARF – Nonviolent Practices

Situations occur where employees and clients may be involved in escalated situations. Procedures are put in
place to ensure the safety and security of both the clients and the employees. This policy is intended to be used in
conjunction with Nonviolent Crisis Intervention training.

POLICY

1. All employees will go through an orientation and training relating to emergency responses, de-escalation of
situations, alarm and on-call systems and supports for the program.

Violence against Clients

2. Employees must always be diligent in ensuring programs are safe for all clients. Any incident of violence
against clients will be dealt with as outlined:

a. Employee will ensure the safety of the client by removing them from the situation. If unable to do so ina
safe manner, the Police may be called in. In the event the situation is unsafe for clients or employees,
employees should press the panic button AND dial 911;
b. Seek medical attention if necessary;
c. Managers/On-Call Coordinator must be contacted, as well as parents/guardians and Caseworkers/
SACIS. If SACIS gives a specific direction, the Manager/On-Call Coordinator must be notified of
direction given;
d. All clients have the right to contact the Police, write a witness statement and/or press charges. If clients
are unsure, they will be supported in documenting the incident in a witness statement and can speak to the
police and or their parent/guardian about the situation;
e. Employees will make safe arrangements for the client if the matter cannot be immediately dealt with, and;
f. Employees are bound by the confidentiality agreement and must be familiar with the Media Protocol before
speaking with any external callers.

Violence Against Employees

3. Employees will prevent themselves from engaging with escalated clients whenever possible. Employees will
have access to other employees or a means of communicating with others as per the Working Alone policy.
Any violence against employees will be dealt with as outlined:

a. Remove yourself from the situation and get assistance. In the event the situation is unsafe, employees
should press the panic button AND dial 911;
b. Seek medical attention and/or call the Police;
c. Ensure that other clients in the program are safe;
d. Contact the Manager/On-Call Coordinator for further direction;
e. When the Police arrive, employees have the right to make a statement or press charges;
f. If a client in the program is involved, Caseworker/SACIS and guardians must be contacted;
g. Employees are bound by confidentiality and must be familiar with the Media Protocol before speaking with
external callers, and;
h. Any employee injury must be reported to the Supervisor and People Services within 72 hours of injury in
order to complete the necessary Worker’s Compensation forms.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: HEALTH, SAFETY AND WELLNESS POLICY NO.: B.10

COMMITTEE

DATE ISSUED: March 2015 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019 OHS Legislation

Trellis is committed to ensuring that all programs and services promote Health, Safety and Wellness in the
workplace.

POLICY

1. TRELLIS supports the Health, Safety and Wellness Committee comprised of members from all areas of
service and operations. Each division of the organization will have members on the Committee that will serve
a minimum of a one year term. These HSW representatives will be a mix of front line employees, Managers
and Senior Leadership. Divisions in the agency are defined as follows:

• Indigenous Initiatives
• Education and Employment
• Community Based-Care and Supports
• Shelters and Housing
• Community Clubs and Experiential Learning
• Administration
• Mahmawi-atoskiwin
• People Services Manager

Each year, the Committee will renew its membership. With the exception of People Services, a Committee
member can sit on the HSW Committee for a maximum of two years unless otherwise approved by the Chair
and Co-Chair.

2. Committee members are responsible to be advocates for health, safety and wellness across the organization
and to educate employees on the importance of workplace safety.

3. The HSW Committee will have terms of reference that will be updated on a yearly basis.

4. The HSW Committee will be responsible for creating a yearly work plan that will address and mitigate risks
within the agency and will be presented to Senior Leadership. If new risks are identified that require immediate
action, the work plan may be adapted to ensure that the focus is continually on activities and actions that
create safe working environments.

5. The HSW Committee will be responsible to organize two program safety audits per year, one lead by the
program employee and the other lead by a member of the HSW Committee.

6. The minutes and action plans from the Committee will be stored on the common drive and will be accessible
to all employees.

7. All employees have an ethical responsibility to inform their Supervisor should they be aware of a health or
safety concern that poses a threat to the well-being of employees, students, volunteers, children, youth and
families. In the event that a potential hazard is identified, the person is responsible to inform their immediate
Supervisor in writing. In the event that the person does not feel that the risk has been addressed or mitigated
within a reasonable time frame, the person can email the HSW Committee at [email protected]. This email
will be classified as confidential and will follow all guidelines as identified in the Whistleblower
policy.
 TRELLIS SOCIETY – LBGCCPROGRAMS

HEALTH AND SAFETY

POLICY: FOOD SAFETY POLICY NO.: B.11

DATE ISSUED: July 2015 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

Trellis promotes health and safety of employees and clients by practicing food safety in the workplace.

POLICY:

1. All programs that serve, handle or provide food within programs must hold a current and valid Food Safety
Permit, which must be displayed in the common area of the program/facility.

2. Food Safety Training is mandatory for employees working in programs where food is served, handled or
provided. To ensure all employees are familiar with appropriate food safety practices all program employees will
complete Food Safety Training.

PROCEDURES:

1. Food Safety Permit:

One employee, typically the Program Manager unless otherwise delegated, will complete a One Day Food
Safety Certification Training through Alberta Health Services. A FOOD SAFETY PERMIT will be granted to
programs where one employee in the program has completed the One Day Food Safety Certification Training
and therefore holds a Food Safety Certificate.

2. General Food Safety:

To ensure employees are familiar with appropriate food safety practices, all program employees are required to
complete an On-Line Food Safety Training during their program orientation training. Upon completion of the
training, employees will complete a test and receive immediate certification via email.

3. Certificates:

All employees are responsible to ensure that a copy of their certificate is on file with People Services.
 TRELLIS SOCIETY – LBGCC PROGRAMS

HEALTH AND SAFETY

POLICY: Hazard Assessment POLICY NO.: B.12

DATE ISSUED: Sep 17, 2020 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED:

POLICY

It is the intent of our Agency to provide a healthy and safe work environment for all job tasks that are to be performed.
Proper hazard identification and controls will provide employees with proper direction in the safe performance of their
duties.

Before beginning any task or action, employees are to assess the possible danger to themselves and to other persons
and are to act appropriately.

It is our policy and practice to:

• assess the hazards of the workplace, job tasks, environment where the job tasks are being completed;

• eliminate or minimize the dangers of these hazards;

• ensure all employees understand the nature of the workplace hazards and use safe work practices;

• ensure employees required to perform hazardous tasks receive appropriate instruction and training. Written
copies of safe work procedures will be accessible and available to all employees.

The Senior Leadership Team must be aware of the hazards within the agency, particularly the high-risk hazards, in
order to ensure appropriate controls are considered and implemented.

Managers and Team Leaders are responsible for ensuring they are involved in the completion of positional hazard
assessments within their program areas of responsibility and enforcing the use of controls.

Employees need to be aware and understand the hazards within their job tasks and are to assist their leaders in
completing positional hazard assessments. Employees are expected to follow all applicable procedures and advise
their leaders if they have a concern about the tasks they have been asked to perform.

Positional hazard assessments are to be reviewed:

• on an annual basis

• when a new work process is introduced, or tasks change

• incident reports indicate change

• incident investigations indicate changes

• when new regulations are implemented that affect a specific written procedure

• new specifications are implemented

 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: ATTENDANCE REPORTING POLICY NO.: C.1.1

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

DATE REVISED: May 2019 Alberta Employment Standards Code

Employees shall ensure that they adhere to their work schedules on a regular and consistent basis. The Agency
has policies in place, such as sick leave and leave of absence, to support an employee who is required to be
absent from work for any reason. POLICY
1. All employees shall register for ADP Workforce Now at www.workforcenow.adp.com Instructions for registration
will be provided by the program manager at time of hire.
2. All employees are required to log in to ADP Workforce Now and complete their timecards on or before the cut-
off day.
3. Timecards shall detail the hours worked for the payroll period including overtime banked and taken, statutory
holidays banked and taken, leaves of absence, vacation banked and taken, and sick leave banked and taken.
4. The supervisor is responsible for verifying and approving the time cards by 4:30pm on the cut-off day (Thursday)
to ensure accurate and timely pay. Approvals for shifts worked overnight on a cut-off Thursday, must be approved
by 9:00am the following day (Friday). Timecards are the official attendance records of the Agency.
5. An employee who will be absent from work or a scheduled shift shall contact their supervisor prior to the start
of work with a reason for absence, providing as much notice as reasonably possible given the circumstance.
6. An employee who is absent for more than one day, shall contact their supervisor each day they are scheduled
to work and are absent.
7. When an employee fails to report to work without prior authorization or fails to provide an acceptable reason
substantiating the absence, they will be considered absent without leave and may not be eligible to be paid for
that shift. Employees abandoning their shift without prior consent will be subject to disciplinary action, up to and
including termination.
8. An employee who does not report to work for three (3) consecutive scheduled work days and does not notify
their supervisor in any way, shall be deemed to have abandoned their position which is equivalent to a voluntary
resignation. A written notice will be mailed to their home address currently on file with the Agency.Any outstanding
payments, less applicable deductions will be paid within 3 business days.
9. The employee’s supervisor/manager shall notify People Services and/or the Director of unauthorized work
absences, for appropriate action.
10. Any exceptions to this policy or procedure shall be at the sole discretion of the CEO.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: GROUP BENEFITS PLAN Please see Trellis’ Benefits Policy on ADP

POLICY: GROUP RRSP Please see the Trellis RRSP Policy on ADP
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: HONORARIUMS POLICY NO.: C.1.4

DATE ISSUED: March 1, 2006 ASSOCIATED STANDARDS:

CARF - Leadership
DATE REVISED: May 2019

It is the policy of Trellis that all Board members, employees, practicum students andvolunteers may accept
honorariums only under specific guidelines.

POLICY

1. Board members, employees, volunteers, and practicum students shall not accept gifts, monetary or other
payment in addition to their normal salary or expenses for duties or assignments to which they perform
in the course of their regular employment duties with Trellis.

2. A payment may be made to a Non-Employee for which fees are not legally or traditionally required. As
Indigenous Program Elders may come into the Agency to provide support or counseling, they may
receive an honorarium.

3. To be classified as an honorarium, no service should have been provided by the individual. When actual
services are being provided, the payment will be a payment for service. Also, it may be a payment or
money or anything of value for any appearances, speeches, or articles if the subject matteris directly
related to the individual’s official duties or the payment is made because of the individual’s status with
an organization.

4. This is generally a voluntary, non-obligatory payment or gift and may only be bestowed for contributions
outside of the parameter of the individual’s job duties.

5. All honorariums must be approved in writing by a Chief Officer, Director of Finance or theCEO.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: LEAVE OF ABSENCE Please see Trellis Policy on ADP

POLICY: DISABILITY Please see Trellis Policy on ADP

POLICY: OVERTIME Please see Trellis Policy on ADP

 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: PAY ADVANCES POLICY NO.: C.1.8

DATE ISSUED: November 1, 1997 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. TRELLIS may issue pay advances to its employees in emergency situations. The maximum allowable advance
is 75% of gross earned income in the pay period that the advance is requested. Advances will be evaluated on
a case by case basis.

2. The Employee will submit a Pay Advance Request Form to their supervisor. Supervisor and Finance will authorize
the advance and forward the form to People Services and payroll for processing.

3. The Payroll Administrator will process the advance on the next scheduled pay and will withhold any applicable
deductions. Exceptions may be granted but must be approved by a Chief Officer or the CEO. Payroll will keep
a record of the advance and a copy of the authorized form will be in the employee file.

4. Although it is preferred that advances are paid back in the next pay period, the employee can apply to have the
payback period extended to 4 pay periods. Any extension past 4 pay periods must be approved by a Chief Officer
or the CEO.

5. Should the employee terminate their employment for voluntary or involuntary reasons, the entire outstanding
amount will be deducted from their final pay. Any outstanding amount that cannot be reclaimed remains the
personal responsibility of the employee to repay immediately upon the end of employment.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: SALARY ADMINISTRATION Please see Trellis Compensation Philosophy and

Guidelines on ADP

POLICY: STATUTORY HOLIDAYS Please see Leaves & Absences from Work Policy
on ADP

POLICY: VACATION Please see Trellis Vacation Policy on ADP

 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: WORKER’S COMPENSATION POLICY NO.: C.1.12

DATE ISSUED: January 10, 2000 ASSOCIATED STANDARDS:

Workers Compensation Board Alberta
DATE REVISED: May 2019

Trellis believe in providing a safe environment for employees, volunteers and clients. In the event of an accident/injury
occurring while the employee is conducting duties as part of their job responsibilities, the Agency will support the
employee to apply for Workers Compensation and make every effort to support their return to work.

POLICY

1. Trellis will follow all applicable legislation.

2. It is the responsibility of all employees to report injury occurrences at work within 24 hours to their immediate
Supervisor, who will notify People Services within 48 hours of the injury occurring.

3. Employees must complete the WCB Workers Report in consultation with their Supervisor within 24 hours of the
injury. The Supervisor has the responsibility of escalating any pertinent information to their Manager and Director.

4. Upon receipt of the WCB Workers Report, People Services will complete the WCB Employers Report within 72
hours of the injury and ensure all claims are managed in a timely fashion working in conjunction with the WCB
to resolve the situation and manage the return to work process.

5. When the employee seeks medical attention for the injury, the employee must let the attending physician know
that the injury occurred at work and therefore a WCB Physician’s Report, completed by the physician, is required.

6. Trellis will work with the employee to file their claim in accordance with WCB Policies and Procedures and ensure
the employee returns to work healthy once the claim has been adjudicated by the WCB and approval is given
by a Licensed Physician.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
COMPENSATION AND BENEFITS

POLICY: RETIREMENT BONUS POLICY POLICY NO.: C.1.13

DATE ISSUED: December 2012 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

To acknowledge service to Trellis, retiring employees will be eligible to receive additional vacation credits that are
equivalent to their annual entitlement in the year of retirement.

POLICY

1. For example, if a retiring employee is entitled to four weeks of vacation in the year of their retirement, they will
receive an additional four weeks on top of their normal entitlement.

2. Employees will have the option to:

b. Use the time as paid vacation to extend their retirement date;

c. Receive the bonus as cash with applicable income tax deducted;
d. Transfer to an RRSP (providing the payment is eligible and they have the RRSP room);
e. Transfer to a TFSA Account

3. For the purpose of this policy, retiring employees will have to be full-time and at least 55 years of age and
have worked at Trellis for at least 10 years.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: ALLEGATIONS AGAINST EMPLOYEES POLICY NO.: C.2.1

DATE ISSUED: AUGUST 7, 2014

DATE REVISED: May 2019

Trellis shall treat all allegations, investigations and charges leveled against an employee by another employee,
student, client, or volunteer in a fair and consistent manner that meets or exceeds the requirements of Alberta’s
Employment Standards Code.

The Agency requires the reporting of any allegations, investigations and charges be reported to a Director, On-Call
Manager and People Services immediately.

POLICY

1. If a client makes an allegation against an employee, volunteer, or student, this person is to be

immediately taken off the floor from the program. This is not only done to protect the client but also to protect
the employee, volunteer or student from any further allegations.

2. Manager On-Call must be immediately notified and will then assist On-Call in identifying shiftsthat will need
to be covered for employee/volunteer/student. It will be at the On-Call Coordinator’s discretion as to who
should be sent in to replace the employee and this should be done as quickly as possible.

3. If the implicated employee is working alone, they should not put themselves in a situation where they will
be alone with clients until another employee arrives. The Coordinator On-Call will be immediately deployed
if another employee with sufficient skill and experience is not available to cover.

4. Employees involved will complete a CIR. This must be done on a CIR that is not in Sharevision due to
reasons of confidentiality.

5. Manager On-Call will also consult with Coordinator On-Call about what necessary notifications need to
occur (i.e. SACIS, Police). If the client has Intervention status, the case worker must also be contacted.

6. A copy of the CIR must be forwarded to People Services, the Director, and the Program Manager no later
than the next business day.

PROCESS FOR INVESTIGATIONS

1. Employees who have had an allegation levelled against them will be on immediate leave with pay until the
investigation is complete. As indicated above this is done to protect all parties involved from any further
escalation of the allegation.

2. Every effort will be made to find alternative work arrangements that do not involve direct client, outside of the
program for the duration of the investigation. It is expected that the employee will work with their supervisor
to fulfill these alternative arrangements.

3. There may be multiple investigations by outside agencies in addition to internal investigations depending on
the clients and their status. Investigations will be conducted as quickly and efficiently as possible.

4. An Internal investigation will be conducted by the Program Manager, Director, and People Services. All
employees who were witness to or connected to the allegation will be interviewed separately as well as the
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: ALLEGATIONS AGAINST EMPLOYEES POLICY NO.: C.2.1

client who made the allegation. Other clients who may be witnesses to the incident may also be interviewed.

5. External investigations may be conducted by SACIS, Police, CHF, or other connected parties and will be at
their discretion.

6. If the employee is cleared of the allegation, the employee will return to their program and their work schedule.
Depending on the situation with the allegation, it is possible that the employee will be reassigned to another
program at the same level and rate of pay.

7. If the employee is found to be guilty of the allegation, they will be subject to disciplinary action up to and
including termination and will not be eligible for rehire.

8. Record of the allegation and investigation will be recorded separately from the employee file unless the
employee is terminated as a result of the findings in the investigation.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: CANDIDATE AND FORMER EMPLOYEE POLICY NO.: C.2.2

REFERENCE CHECKS

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

CARF – Human Resources
DATE REVISED: May 2019

POLICY

References for New Applicants

1. New applicants are required to provide two (2) references as part of the new hire process and in so doing, the
candidate is giving consent for the Agency to contact these references.

2. People Services or the hiring supervisor shall be responsible for conducting two (2) reference checks on all
candidates being considered for employment. References must be from past supervisors. Candidate personal
references shall not include relatives.

3. People Services or the hiring supervisor may also contact past employers to confirm dates of employment if the
candidate has given permission.

4. All external candidates shall have references completed as a condition of employment with Trellis.

5. When the hiring supervisor and/or manager are completing the references for a candidate, the hiring supervisor
or manager shall sign all documented references and submit them to People Services.

6. In the event that a written reference is supplied, the reference must be contacted to confirm the details provided
in the reference letter. The hiring supervisor or People Services must confirm in writing that the written reference
was contacted. Only one (1) reference letter is acceptable.

References for Departing Employees

7. Immediate supervisors can provide references if they have written permission and clear it with People Services
first. References must be provided in good faith. Consult with People Services if you are uncomfortable providing
a reference or do not feel you can offer a positive reference in good faith.

8. The CEO and/or People Services are authorized to provide verbal references for past employees to potential
employers and may authorize the appropriate supervisor to do so.

9. Managers and supervisors shall not provide written references unless they are to a specific company or
institution, and People Services has first reviewed and approved the letter. Verbal employment references for
past employees of the Agency may be provided after first consulting with People Services and obtaining written
permission from the employee for the supervisor to provide the reference.

Internal Candidate Reference Checks

10. All internal candidates shall have an internal reference from their current supervisor prior to a verbal employment
offer being presented.

11. If, for reasons of confidentiality, an offer of employment is made prior to an internal reference check, then the
offer shall be made conditional upon a satisfactory reference. If the reference check is not satisfactory, then
the offer of employment shall be withdrawn immediately.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: CLASSIFICATION OF EMPLOYEES POLICY NO.: C.2.3

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

Alberta Employment Standards Code
DATE REVISED: May 2019

The Agency, due to the nature of the business, shall have several employment classifications that best suit the
organizational business needs.

POLICY

1. The Agency shall ensure that regardless of employment classification every recruitment action shall
undergo consistent hiring procedures.

2. The CEO and People Services shall assign the employment classification of each position prior to
recruitment. The decision to tender for contract shall be determined by a Chief Officer in consultation with the
CEO and People Services.

3. The employment classification shall clearly indicate in the Offer of Employment, the associated benefits
eligibility, sick leave, vacation entitlement, Group Insurance, and RRSP eligibility.

4. Should an employee’s classification change, the supervisor shall follow the process for internal job changes
as outlined in the Employee Recruitment and Screening policy.

CLASSIFICATION OF POSITIONS

Salaried Employee Classification

5. Salaried employee classifications are positions occupied on a full-time basis where employees work a full
work week (37.5 or 40 hours) on a continuous basis.

6. After a mandatory (3) month probationary period and satisfactory completion of conditions of employment,
the employee is granted permanent status.

7. This employment classification has no expiry date for employment. However, continuance of employment
may be dependent on funding.

8. Salaried employees are entitled to employee benefits on day one of their employment with the Agency.

9. Salaried employees earn sick leave credits from the first day of employment at the rate of one sick day per
month worked and according to the Sick Leave policy.

10. Salaried employees are eligible to join the Agency’s Group RRSP after completing the mandatory (6) month
waiting period, per the Group RRSP policy.

11. Vacation for salaried employees is calculated as per the Agency’s Vacation policy.
Permanent Part-Time Employee Classification

12. Permanent part-time employee classifications are salaried positions where work hours are less than a
regular work week (37.5 or 40 hours) but at least 30 hours a week on a continual basis. Hours of work
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POLICY: CLASSIFICATION OF EMPLOYEES POLICY NO.: C.2.3

follow a regular schedule.

13. After a mandatory (3) month probationary period and satisfactory completion of conditions of employment,
the employee is granted permanent part-time status.

14. Permanent part-time employees are eligible for benefits based upon an agreed 15 scheduled hours of work
weekly. (Group Benefits policy)

15. Permanent part-time employees earn sick leave credits from the first day of employment.(Sick Leave policy)

16. Permanent part-time employees are eligible to join the Agency’s Group RRSP after completing the
mandatory (6) Month probationary period. (Group Benefits Plan policy)

17. Vacation for permanent part-time employees is calculated as per the full-time vacation schedule but is
prorated on actual salary earned. Refer to Vacation policy for further information.

Special Employment Situations (Teachers)

18. Special employment situations may include Teachers and Teacher Assistants who work 10 out of 12
months (September to June) and are generally rehired in late August of each year.

19. Salary for these positions will be based on an annual rate and pro-rated for the term worked.

20. Benefits shall continue throughout the year and are optional at the employee’s expense for the time off,
should an offer of employment be accepted in writing by the employee in June.

Hourly Employee Classification

21. Hourly employees classifications are positions worked on hourly basis. They may or may not have a regular
schedule but are required to work at least one shift per pay period unless time off is requested and
approved. Payment is calculated on an hourly basis.

22. Hourly employees shall serve a mandatory (3) month probationary period.

23. Hourly employees are not eligible for benefits or RRSP.

24. Hourly employees receive straight time rates for hours worked up to (8) hours or, in the case of programs
where there is a residential permit, overtime shall be paid after a shift of (12) hours. Any hours worked in
excess of normal daily hours is compensated at overtime rates. It is not the intent that hourly employees be
required to work full-time hours for extended periods of time.

25. Vacation pay is calculated as per Alberta’s Employment Standards Code:

a) 4% of earnings, or 6% after 5 years of employment

26. Vacation pay shall be paid out on each cheque as it is earned. Temporary/Term Employee/Contract
Classification

27. This employment classification is for a fixed period of time with an expiry date. The employment relationship
ceases unless a term extension is negotiated.
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28. Employees are generally paid on a salaried basis; however, this depends on the length of the term.

29. The length of the term and the hours worked per week shall determine if there is eligibility for benefits.

30. Generally, an employee with a term that extends one year or more shall be eligible for modified benefits that
include Sick Leave (one sick leave credit per month).

31. Temporary/term employees may be eligible to join the Agency’s Group Insurance Plan or the Group RRSP
Plan if determined prior to the offer of employment.

32. Vacation pay is calculated as per the Agency’s Vacation policy or per Alberta’s Employment Standards
Code depending on the length of the term. This is decided at the discretion of a Chief Officer prior to
recruitment.

Contract Employment

33. Contract employees shall be considered employees of the Agency for the purpose of certifications
(Criminal and Child Welfare Checks) and adherence to policy and procedure.

34. The decision to tender for contract shall be determined by a Chief Officer in consultation with the CEO and
People Services.

35. The market value for the position shall be determined in advance and a tendering process will occur to
attract interested parties.

36. The decision to hire a Contractor shall be subject to all conflict of interest policies.

37. A Contract Template shall be used for all contracts specifying the nature of the work, the time period of the
work, rate of pay, and other details as applicable.

38. The Contract shall be retained with People Services in a separate section of a secured file cabinet.
39. The level of certifications will be at the discretion of the hiring Manager/Director in consultation with People
Services.

40. A Formal Contract will be completed indicating that the Contract has a registered GST number and/or
Business number, WCB Coverage and any other legislative requirements to establish independence from
the Agency. The Director of Finance and appropriate Chief Officer signing authority will sign the contract with
the Contractor with the appropriate witnesses.

41. The Director of Finance or designated employee will set up accounts payable account.

42. Prior to a decision to hire a contractor the Director of Finance, Chief Officer and People Services shall
assess the classification of the individual based on the Canada Revenue Agency stipulation.
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POLICY: CONFIDENTIALITY AGREEMENT POLICY NO.: C.2.4

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis, at all time, shall maintain the highest professional integrity by ensuring that the strictest confidentiality be
adhered to regarding member/client information, whether this information is in written format, is audio or visually
recorded, received verbally or through observation.

POLICY

1. The CEO shall ensure that professional integrity is adhered to by all employees, volunteers, practicum
students, contractors and members of the Board of Directors.

2. The CEO shall have discretionary authority to discipline any employee or others associated with Trellos who
do not adhere to this policy.

3. The Agency shall ensure that all employees and others associated with Trellis shall not divulge any
confidential personal and sensitive information to any unauthorized persons. Employees, students,
volunteers and Board Members in breach of the confidentiality agreement will be subject to disciplinary action
up to and including termination.

4. All employees shall ensure that confidential information is collected in a timely manner and shall not be
discarded on printers, faxes or other areas open to the public viewing.

5. People Services shall ensure that a witnessed signed copy of a Declaration of Confidentiality is placed and
kept on the appropriate member employee, student, Board Member, volunteer and contractor personnel file.

PROCEDURES

1. Employees shall sign a Declaration of Confidentiality each year to confirm that they are aware of,
understand, and confirm their adherence to the requirements of confidentiality, including Intellectual
Ownership, both during and following their employment with Trellis as part of the commencement process.

2. People Services shall ensure that a witnessed signed copy of a Declaration of Confidentiality is placed and
kept on the appropriate individual personnel file. They will also ensure this same declaration is signed,
witnessed and stored in the Board Member and volunteer’s file.

3. At the time of their initial involvement with Trellis, all Agency Board Members, employees, temporary and
contract employees, students, volunteers and consultants shall be required to review the Confidentiality
Policy and sign the Declaration of Confidentiality indicating their awareness, understanding and adherence
to this policy.
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POLICY: CONFLICT OF INTEREST DISCLOSURE POLICY NO.: C.2.5

DATE ISSUED: May 1, 2003 ASSOCIATED STANDARDS

CARF – Leadership
DATE REVISED: May 2019

It is the policy of Trellis that all Board members and employees shall disclose to the Agencyany outside employment
or volunteer work with another organization or agency, as soon as an employment or volunteer relationship is
established.

POLICY

1. All Board members and/or employees regardless of volunteer/employment classification shall ensure that
their private interests do not conflict or appear to conflict with their duties and responsibilities as employees.

2. No Agency Board member, employee or volunteer shall have direct or indirect interest in the assets, leases,
business transactions or professional services of the Agency.

3. The Agency prohibits the direct referral or steering of Agency applicants, of persons served or their families,
to any private practices with which the Agency Board members, employees or volunteers may have an
interest.

4. The Agency respects the right of Board members and/or employees to be involved in volunteer activities or
outside work, due to interest or need.

5. The Agency understands that some Board members, employees and volunteers may work at other agencies.
The Agency retains the right to require the employee to come to work alert, physically and mentally able to
perform their duties in serving children, youth, and families.

6. It is the duty and responsibility of the employee to notify their immediate supervisor in writing as to the nature
of the outside employment or volunteer work, so that the impact of the supplementary employment or
volunteering may be assessed. Any employee who, individually or as part of a business or professional firm,
is involved in the business transactions of Trellis shall disclose this relationship in writing and shall not
participate in any decision or vote taken in respect to such transactions or decisions.

7. The supervisor, in consultation with People Services and the CEO, shall review the potential conflict of
interest to determine if a conflict exists.

8. As determined by the CEO, private needs and interests shall not:

a) Conflict either professionally or instrumentally with the activities of the Agency;

b) Require such expenditure of energy that the individual is not able to adequately cope with the
demands of the workloads within the Agency;
c) Result in the use of the Agency time or resources, including premises, equipment or supplies, either
in preparation for or conducting private interests; and,
d) Reflect negatively on the public image of the Agency.

9. The CEO shall have discretionary authority to ensure that an employee severs ties with any conflicting agency
or with Trellis should it be deemed that a conflict of interest exists.

10. Board Members, Employees, Volunteers, and Practicum Students shall not accept gifts, monetary or other
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POLICY: CONFLICT OF INTEREST DISCLOSURE POLICY NO.: C.2.5

payment in addition to their normal salary or expenses for duties which they perform in the course of their
employment or voluntary duties with the Trellis.

11. Employees who exercise discretionary control over others, such as clients, employees or contractors, shall
disqualify themselves from dealing with relatives, as defined in the Employment of Relatives policy.

12. Trellis prohibits the payment or receipt of any form of compensation from or to another agency or provider of
services for the referral of any persons served at the Agency.

13. It is the expectation that employees will not have dual relationships within the Agency, such as an employee
who works in a program but is also a foster parent. In rare circumstances where this has been approved, if
an employee is suspended from a program due to performance concerns, their employment and/or
involvement will also be suspended in their other role until the situation has been resolved.

14. It is an expectation that any dual relationship that exists between an employee and a client, client’s guardian
or other significant figure in a client’s personal life, be disclosed immediately upon discovery of the conflict to
the relevant supervisor. The conflict must be thoroughly documented and signed off on by the Program
Manager, People Services Manager and Chief Officer or CEO.
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POLICY: DISCIPLINE POLICY NO.: C.2.6

DATE ISSUED: January 1, 2000

DATE REVISED: May 2019

Trellis will provide every opportunity for employees to be successful in their positions’ within an environment that
provides training, personal development, effective supervision and responsive management.

POLICY

1. Through the TRELLIS Performance Engagement process it is expected that employee performance shall be
maximized so that all employees are engaged and aligned with the Agency’s vision, mission and strategic goals.

2. It is expected that employee performance problems shall be identified and corrected before disciplinary action
is considered.

3. The Manager or Supervisor of an employee who is alleged to have breached rules or have inappropriate conduct,
shall immediately conduct an investigation into the alleged incident if a third party is not involved in an
investigation, with the consultation of People Services.

4. The Supervisor shall ensure that all disciplinary documentation is provided to People Services for placement on
the employee’s personnel file.

5. In the event that discipline will be administered, this policy shall ensure that disciplinary measures occur in a
manner that is fair, equitable and consistent. Discipline for performance issues, particularly those of an ongoing
nature, shall be progressive in nature.

6. The CEO shall have the discretionary authority to remove disciplinary documentation from an employee’s
personnel file upon the employee’s written request.

7. The CEO shall have the discretionary authority to terminate employment of those employees that are deemed
undesirable or uncorrectable.

PROCEDURES

1. In the event that a performance issue is identified, the supervisor shall immediately bring it to the attention of the
employee and shall provide guidance and direction to that employee in an attempt to return that aspect of
performance to a satisfactory level.

2. The supervisor and the employee, who is identified to have performance issues, shall set specific goals with
accountable due dates and with clear documented outcomes.

3. If the performance issue is not rectified within the specified time limits then following constructive discipline steps
may be taken:

a. Verbal Warning – The warning should be recorded and a copy given to the employee and the original
placed on the employee’s personnel file.
a. Written Warning – If the performance is not corrected it shall be followed by a minimum of (1) written
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POLICY: DISCIPLINE POLICY NO.: C.2.6

warning, at the supervisor’s discretion. A copy of which will be given to the employee and the original
placed in the employee’s personnel file.
c. Suspension – If performance does not improve then the employee may be suspended, with or without pay,
depending on the nature of the offense, for a maximum period of (1) week.
d. Termination – When it is impossible or undesirable to retain an employee, the employment relationship shall
be terminated. All involuntary terminations shall be approved in consultation with the CEO as
required, Chief Officer and People Services. The extent to which various steps in the discipline
procedure will be followed will depend on the nature of the problem and the potential impact on
clients and the Agency.
e. After a period of three years and if an employee’s performance improved following disciplinary action, the
employee may make a written request to the CEO for the removal of disciplinary documentation from their
personnel file. The decision is at the discretion of the CEO.
f. Incident investigation procedure:

i. When there is an alleged breach of rules or inappropriate conduct by an employee where there is not
involvement by an external party such as Calgary Police Service or Child Welfare, the supervisor or
manager will be responsible to conduct an investigation into the matter as quickly as possible.
ii. If the incident is considered to be critical then the employee may be suspended from work with pay
while the incident is being investigated.
iii. It shall be the decision of the CEO or designate regarding whether the employee will not be paid during
the investigation.
iv. The employee shall be advised of the alleged incident and that an investigation is being conducted.
v. In conjunction with People Services, the appropriate Manager shall conduct an investigation by
interviewing the employee, any witnesses who were present, and any other employees deemed to be
appropriate.
vi. The findings of the investigation shall be documented and presented to the next higher level of
management, for appropriate action.
vii. If it is determined that there has been a breach of rules or inappropriate conduct, the employee’s
personnel file will be reviewed to determine whether there is any previous disciplinary action on file.
viii. Once the decision has been made to impose disciplinary action on an employee, a letter will be
given
to the employee with a copy being signed by the employee and returned to People Services, with
documentation arising out of the investigation, for filing in the employee’s personnel file.
ix. Payroll must be advised of any suspension without pay by Change of Status form.
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POLICY: DRESS CODE POLICY NO.: C.2.7

DATE ISSUED: December 9, 2004

DATE REVISED: May 2019

Trellis acknowledges the need for professionalism and as such, all employees shall ensuretheir clothing is
appropriate for their workplace and job function.

POLICY

1. Employees working primarily at the Renfrew Administration Building as well as Management employees
shall dress in business or business casual

2. Front line employees shall dress in business casual when they have meetings with families and
professionals, but can wear more casual clothing for programming.

3. Employees shall adhere to the dress code as specified at their location. The dress code may be enhanced
to suit individual needs of specific programs.

4. Employees arriving to work with inappropriate dress shall be directed to go home and change. Their shift
will commence once they have arrived back to the program or facility in appropriateattire.

5. Employees who have appointments with professionals are to dress minimally in casual business attire.

6. Employees are encouraged to bring appropriate clothes for those days when the activities at the program
require more casual wear.

7. Employees are encouraged to wear Trellis logo clothing where appropriate during casual wear periods.

8. The following dress code guidelines have been established for employees working directly with clients:

9. No tank tops or shirts with less than one inch shoulder straps;
a) Clothing should not be tight or see-through;
b) Appropriate swimwear, shorts and skirts;
c) Shirts must fully cover midriffs and chest and should not expose any undergarments;
d) Pants and shorts should not expose any undergarments;
e) Footwear must be appropriate for activities at locations and for safety;
f) Dress jeans with no holes or frayed cuffs are appropriate.
g) The Supervisor and/or manager shall ensure adherence to this policy at all times.

10. The Supervisor and/or manager shall have authority to discipline employees not adhering to the Dress Code
Policy
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POLICY: EMPLOYEE EDUCATIONAL POLICY NO.: C.2.8

VERIFICATION REQUIREMENTS

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis values the post-secondary education of our employees and is committed to strengthening our learning
communities and providing experiences for students in the Human Services field to practice and contribute to their
field of service.

This policy applies to all employees and contractors employed by the Agency

POLICY

1. Employees working directly with clients will be hired into salaried positions for programs based on the following
educational requirements:

a. Degree, diploma or certified child and youth care certification or have two (2) years’ experience in the
human service field, or;
b. A post-secondary degree or diploma in another area will be considered with experience in the human
service field.

2. Employees working directly with clients in an hourly capacity can be hired prior to the completion of their
degree or diploma if they are working towards education in a human service field.

3. Program Managers and Directors must have a degree or diploma, a minimum of five (5) years’ experience in a
human service field and a minimum of three (3) years supervising employees.

4. Any exceptions to the above must be made in consultation with People Services, a Chief Officer and the CEO.

PROCEDURES

1. It is the responsibility of the new employee to have official transcripts sent to the People Services department
directly from the educational institution.

2. People Services will verify, where applicable, with primary source credentials of all new employees and all
employees whose condition of employment is dependent on holding current certification.

3. The verification will be documented and placed in the employee file.

4. Any annualized credentials will be monitored through a monthly report that identifies when the credential or
certificate needs to be updated.

5. Any exceptions to this policy shall be documented in writing and solely be at the discretion of the CEO in
consultation with the appropriate Chief Officer.
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POLICY: EMPLOYEE FILES POLICY NO.: C.2.9

DATE ISSUED: March 1, 2000 ASSOCIATED STANDARDS:

CARF – Legal Requirements
DATE REVISED: September 2021 CARF – Human Resources

POLICY

1. Trellis will maintain confidential personnel records on each individual employee and practicum student and
will ensure that such information is protected from unauthorized use. All employee and practicum student
records will be considered property of the Agency.

2. Employee will be maintained in a secure and locked facility.

3. Nothing will be placed in the employee’s or practicum student’s file without them being made aware of it and
being provided with a copy.

4. All employees and practicum students are entitled to view and know the contents of their personnel files with
the exception of letters of reference or Reference Check Forms. They can be viewed at any time by
appointment. Such viewing must be in the presence of the CEO or People Services.

5. All employees and practicum students have the right to submit a written request to their supervisor to have
information changed on their personnel file.

6. Managers and supervisors will have access to records of employees and practicum students under their
supervision with approval from People Services or CEO.

7. Contractors or Employees on term employment shall not view personnel files without the express written
permission of the CEO or designate.

8. Upon termination of employment, all employee records including forms, documents and correspondence
relative to the application procedure, ongoing supervision notes, and performance appraisals, shall be
transferred to and maintained in a secure archives file cabinet. The files will be maintained for a period of a
minimum of seven (7) years following date of termination and then destroyed utilizing confidential shredding
methods.

PROCEDURES

1. Personnel files (for employees and practicum students) will contain, but are not limited to, the following
documents:

a. Resume
b. Reference Check Forms for employees
c. Letter of Employment and Signed Job Description (for employees)
d. Criminal Records Check (CRIM) with vulnerable sector search
e. Intervention Record Check (IRC)
f. Declaration of Confidentiality
g. Performance Appraisals
h. Disciplinary Memos
i. Verification of Education
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POLICY: EMPLOYEE FILES POLICY NO.: C.2.9

j. Emergency Contacts
k. Driver’s Abstract (if applicable)
l. Verification of Class 1, 2, or 4 Drivers License with S-endorsement (if applicable)
m. First Aid and CPR Certification (if applicable)
n. Letters of Commendation
o. Overtime Agreement for employees
p. Changes of Status, Lifecycle, Leave of Absence (if applicable)
q. Copies of other Training certificates
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POLICY: EMPLOYEE GRIEVANCE POLICY NO.: C.2.10

DATE ISSUED: January 1, 2000

DATE REVISED: May 2019

The Agency shall maintain a fair and open working environment in which conflict is resolved through open
communication and consultation. This policy applies to all Employees, Volunteers, Foster Parents, Agency
Caregivers and Practicum Students of Trellis.
POLICY
1. An Employee, Volunteer, Foster Parent, Agency Caregiver or Practicum Student shall first take all reasonable
actions to settle the unresolved matter through discussion with their supervisor.

2. An Employee, Volunteer, Foster Parent, Agency Caregiver or Practicum Student may submit a formal written
grievance within (10) working days if they are not satisfied with the outcome.

3. If the grievance is directed towards their supervisor, the written grievance will be submitted to the supervisor’s
manager, with a copy to People Services.

4. Upon receipt of the written grievance, the supervisor and/or Manager with People Services will meet to discuss
the grievance.

5. If the grievance is against another Employee, Volunteer, Foster Parent, Agency Caregiver or Practicum Student
that person shall be notified at this point. If further information is required, People Services will gather such
information by whatever method is feasible. It is possible that the grieving individual will also meet with this group
to supply further information.

6. The Manager and People Services will prepare a written response to the Employee, Volunteer, Foster Parent,
Agency Caregiver or Practicum Student within ten (10) working days of receipt of the grievance. The response
will be approved by the Chief Officer and/or CEO (assuming the CEO is not acting in the role of manager as
mentioned above).

7. Upon approval from the appropriate Chief Officer and/or CEO, the written decision shall be submitted to the
Employee, Volunteer, Foster Parent, Agency Caregiver or Practicum Student. The decision will be final and
binding.

8. If the grievance is lodged against the Manager or a Director, the same procedures will apply. The grievance will
be submitted to the supervisor of the Manager or Director. People Services will be advised and will follow the
same procedures as stated above.

9. In the event that the CEO is named in the grievance, People Services, and one Senior Leadership team member
shall assume the role to render final and binding decisions for employee grievances after consultation with the
Board of Directors.

10. All grievances submitted and documentation arising from the grievance shall be kept in strict confidence and shall
be kept on file with People Services. Agency grievances are analyzed on a yearly basis as a quality improvement
process. All identifying information pertaining to the specific Employee, Volunteer, Foster Parent, Agency
Caregiver or Practicum Student involved is not released and kept in the strictest of confidence.
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POLICY: EMPLOYEE HIGH RISK ACTIVITY POLICY NO.: C.2.11

WAIVER

DATE ISSUED: November 1, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis recognizes that employees will, at times, engage in challenging and specialized recreation and
therefore ensures all employees recognize the need for safety precautions

POLICY

1. All employees must wear safety equipment (i.e., helmets, lifejackets etc.) when participating in recreational
activities when there is a risk of injury.

2. Employees must sign consent and waivers for themselves from agencies providing a service, or whenever
an activity is deemed to be challenging or specialized.

3. Should an employee not wish to participate in the activity due to perceived risks, they must inform the
Program Manager, at which time alternative arrangements will be made.

4. Should employees not be able to maintain safety during a challenging or specialized activity with clients, the
activity must end as soon as it is safe to do so.

5. All high risk activities must be reviewed and approved through the Manager/Director prior to any clients or
employees taking part in the activity.
 PEOPLE SERVICES
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POLICY: EMPLOYEE ORIENTATION & POLICY NO.: C.2.12

COMMENCEMENT

DATE ISSUED: November 25, 2004

DATE REVISED: May 2019

Trellis shall provide thorough Agency and program specific orientation program at commencement to aid in
employee organization knowledge, employee job knowledge required to succeed in their position, understanding
of their contribution to Agency goals and increase employee job satisfaction.

POLICY

1. The new employee’s supervisor shall be responsible, with support from People Services, to ensure that new
employees receive commencement information and a program orientation within the first week of employment.
New employees are also required to attend the Agency Orientation within the first three (3) months of
employment, preferably within their first month.

2. People Services will meet with all salaried and hourly employees to complete commencement paperwork prior
to the 1st day of employment. Employees shall not work a shift until this has been completed.

3. Supervisors shall ensure the employee is registered for the orientation sessions (both program and Agency). The
employee shall complete and sign an Orientation Sign Off form for program orientations, to acknowledge that
they understand and shall adhere to Agency policies, procedures, and code of conduct and submit the
documentation to People Services for placement on the employee’s personnel file.

4. People Services shall ensure that the Orientation Certificate is placed in the employee’s personnel file.

5. Employees are accountable for their own role within the organization and responsible for maintaining good
standing with the Agency.

PROCEDURES

1. Every new employee shall meet with People Services prior to commencement or on the first day of employment
and complete the required paperwork to begin employment. This includes:

a. Payroll information including tax forms and direct deposit information;

b. Benefits enrolment forms (where applicable);
c. Declaration of Confidentiality;
d. Criminal Record Check (CRIM) with vulnerable sector search and Intervention Record Check (IRC); e.
Signed offer letter;
f. Job Description.

2. The hiring supervisor shall be responsible for:

a. Reviewing of appropriate policy and procedure manuals and ensuring that the new employee has
reasonable access to these manuals;
b. Reviewing the job description;
c. Introducing new employee to colleagues;
d. Answering all questions, as required; and,
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POLICY: EMPLOYEE ORIENTATION & POLICY NO.: C.2.12

COMMENCEMENT

e. Access to appropriate Agency resources though provision of keys, pass codes, phones, laptop computers
(if applicable) and written acknowledgement of receipt of said resources.
3. Supervisors shall ensure that employees complete an orientation session and training developed for his/her
specific service area. This orientation must include, but is not limited to:

a. Health and safety procedures, including identifying unsafe factors;

b. Emergency and evacuation procedures;
c. Program safety for employee and clients;
d. Identification and reporting of critical incidents;
e. Non-discrimination of clients and meeting diverse needs;
f. Professional behavior and boundaries;
g. Case management practices (advocacy, client rights and privacy);
h. Reporting of abuse and neglect;
i. Medication administration, and;
j. Behavior management strategies that reduce risks for clients and employees.

4. The supervisor is responsible to ensure that all verifications of orientations are submitted to People Servicesfor
placement on the employee’s personnel file.
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POLICY: EMPLOYEE RECOGNITION POLICY NO.: C.2.13

DATE ISSUED: November 15, 2004

DATE REVISED: May 2019

Trellis is committed to recognizing employees, on an individual basis and/or as a member of a work unit or team, on
both formal and informal basis. Recognition shall be in the areas of job performance, personal achievements, job
enrichment and length of service. POLICY

1. People Services shall track length of service for each employee and ensure that appropriate TRELLIS service
awards are received at an annual recognition event. Service awards shall be coordinated by People Services
and given for the following milestone years of service: (2) years; (5) years; (10) years; (15) years; etc.
2. Individual supervisors will recognize each employee on their service anniversary, their birthday and/or for
significant achievements with a total budget of $20.00 per year for purchase of recognition items. In the milestone
anniversary years of (2) years; (5) years; (10) years; (15) years; etc., the individual recognition budget increases
to $40.00 for that year. The Supervisor shall track and manage these expenditures for individual recognition.
PROCEDURES

1. LBGC: Employees celebrating a milestone service anniversary will be presented with an award at the annual
employee recognition event.
2. All other recognition is the responsibility of the supervisor and/or manager. Each supervisor shall have a budget
$20 per employee per year from their program budget to spend on recognition of their employees.
3. Bereavement of immediate family members (spouse, child, parents, grandparents, parents in law) shall be
acknowledged by a card sent to the employee’s family signed by the appropriate employee(s). Supervisors and
Managers are responsible for the coordination of this. Flowers or other acknowledgements may be sent at the
discretion of Director(s) or Chief Officer(s).
4. Employees leaving TRELLIS with over a year of service may be honored by the Agency with a gift appropriate
totheir length of service per the table below. Gifts will be coordinated by the individual’s supervisor. Employees
may also choose to have a goodbye gathering with a cake coordinated by their supervisor with their individual
team.
a. 1-3 years of service $20
b. 4-6 years of service $35
c. 7-10 years of service $50
d. 11 or more years of service $75
e. 15+ years of service – at the discretion of the Directors
5. Employees leaving the Agency may also choose to be honored by their colleagues outside of work time in any
non-Agency sanctioned off site event.
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DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS

CARF – Human Resources
DATE REVISED: September 2019 CARF - Program/Service Structure

The Agency, in the interest of providing a safe and secure environment for children, youth and families, shall
ensure that each and every employee be screened for employment requirements.

POLICY

1. The Agency shall ensure that as a condition of employment each new employee, salaried or hourly, receive an
offer of employment that contains the conditions of employment.

2. Trellis shall ensure that every employee be screened for Reference Checks, Criminal Record Check (CRIM),
and Children’s Services, Intervention Record Check (IRC). Other conditions ofemployment are dependent on
the position and are detailed below in the procedure section of this policy.

3. Checks must be completed at specific intervals throughout employment as per the procedure section of this
policy. The costs associated with renewal checks will be paid for by the Agency.

4. Trellis Calgary also requires all employees to provide primary source verification of their educational degrees
and diplomas. Details can be found in the Employee Education Verification Requirements Policy.

5. New applicants of the Agency must also meet the conditions of the Candidate and Former Employee
Reference Check Policy.

6. All employees hired with a Social Work Diploma or Degree from an accredited Alberta institution must be a
Registered Social Worker and provide a current and valid Practice Permit from the Alberta College of Social
Workers (ACSW). All employees who have completed a Social Work Diploma or Degree from an accredited
Alberta institution, but who do not hold a current and valid Practice Permit must be members with the ACSW,
hold provisional status with the ACSW and be actively engaged in completing the current supervision
requirement of 1500 hours. Employees are required to provide proof of membership with the ACSW to People
Services. Supervision requirements are determined by the ACSW and all provisional status members are
responsible to be knowledgeable of any changes and updates. Trellis often provides opportunities for the
supervision of provisional status social workers, and employees are welcome to take advantage of any existing
opportunities, however obtaining supervision is the responsibility of the employee. Provisional status
employees successfully completing the ACSW supervision requirement receiving ‘registered’ status, must
submit their Practice Permit to People Services, upon receipt from the ACSW. Should an employee not
successfully complete the ACSW supervision requirement and are unable to obtain a current andvalid Practice
Permit must immediately advise People Services. This may result in an unpaid suspension or termination.
Employees who are social work students are not required to be members of the ACSW. Hours worked with the
Agency as a student cannot be counted towards provisional status supervision.

7. When the Agency employs youth to participate in work experience programs (i.e., Stampede, Service Canada
programs), the youth are not expected to complete an IRC or CRIM. Employees supervising these youth will
need to complete checks as per this policy.

8. The Agency shall document efforts to recruit employees who are representatives of the cultural backgrounds of
the clients we serve.

9. The CEO has discretionary authority to not fill a vacant position if this is deemed to be in the best interest of
the Agency.
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10. People Services has delegated authority to oversee all facets of the recruitment process. In turn, People
Services may delegate all or portions of the recruitment process to hiring department managers or
supervisors, as deemed appropriate to the needs of the Agency.

11. Promotion within the Agency is based on succeeding in any position. Employees have access to all job
descriptions which include requirements and certifications. Employees wishing to be promoted may discuss
their ambitions with their supervisor. The Agency’s practice is to promote hiring from within whenever possible.
However, the Agency actively seeks external applications where necessary to ensure sufficiently qualified
applicants are available for selection.

12. The Agency bases all hiring decisions on a candidate’s skill, training, knowledge, experience and personal
suitability. These factors will be assessed based on a combination of the candidate’s resume, personal
interviews, appropriate screening and reference checks.

13. The CEO shall have exclusive signing authority for all Director-level positions.

14. The People Services Manager and Directors shall have signing authority for letters of employment offers for
salaried and hourly employees.

15. People Services shall be responsible for the preparation of all letters of employment.
16. People Services, in consultation with the hiring supervisor, shall be responsible for all recruitment of vacant or
newly created positions.

PROCEDURES
Criminal Record Check with Vulnerable Sector Search

17. The Candidate must provide the Agency with a CRIM with vulnerable sector search prior to commencing
employment.

18. New employees who have received a CRIM with vulnerable sector search within 6 months prior to being
employed by Trellis can submit these records to the Agency. It will not be necessary to undergo a new
check.

19. If the CRIM indicates that a criminal record exists, a detailed description of the charges and circumstances
surrounding the offense(s) shall be submitted to the manager.

20. While a criminal record is not necessarily a barrier to employment, it is a factor that shall be carefully reviewed,
assessed and documented.

21. People Services and/or the Manager shall ensure that the CEO receives a complete file, if a criminal record
exists for a potential employee or employee.

22. The CEO shall have exclusive authority to review all files containing a criminal record prior to any
commencement of employment and shall be responsible for rendering final and binding decision for potential
employees who have a criminal record.

23. Should an employee or volunteer be charged with a criminal offense while employed by Trellis, they are
obliged to inform the Agency. Failure to do so shall result in disciplinary action up to and including
termination.

24. People Services shall ensure that these documents submitted become a part of the employee’s personnel file.
25. CRIMs are to be updated every (3) years from the time they were first obtained. Costs associated with these
updates shall be paid by the Agency. The employee will apply for an electronic Police Information Check
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POLICY: EMPLOYEE SCREENING AND RECRUITMENT POLICY NO.: C.2.14

(ePIC) with the Calgary Police Services or with the RCMP for non-residents of the City of Calgary.

26. Our preference will always be too ensure we have completed criminal record checks with vulnerable sector
search on employees prior to their commencement in programs, however, as this is not always possible, there
are circumstances where the Agency will permit employees to work with children and youth as long as the
following conditions apply with the proviso that employees are not to work alone with clients until such time as
the Criminal Record Check is received by People Services:

a The Agency will have a BackCheck Security Clearance completed on the new employee prior to
commencement;
b A clear IRC from Children’s Services has been received;
c Proof of application of the CRIM with Vulnerable Sector Search (i.e. receipt);
d If available, the employee should also provide a copy of their most recent criminal record check from
their past employer, and;
e The new employee will sign a declaration indicating that they do not have a criminal record. This
needs to be witnessed by people Services.

Intervention Record Check (IRC)

27. People Services shall provide the necessary forms to complete an IRC.
28. New employees who have received an IRC dated within six (6) months of being employed by Trellis may
submit these records to the Agency. It shall not be necessary to undergo a new check.

29. If the IRC is returned with questionable reports, a detailed description of the charges or circumstances
surrounding the report shall be submitted to the employing manager.

30. While a questionable report is not necessarily a barrier to employment, it is a factor that shall be carefully
reviewed, assessed and documented.

31. People Services and/or the Manager shall ensure that the CEO receives a complete file if a questionable IRC
exists for a potential employee.

32. The CEO shall have exclusive authority to review all files containing a questionable IRC prior to any
commencement of employment and shall be responsible for rendering final and binding decision for potential
employees who do not receive a clear IRC.

33. Should an employee or volunteer be the subject of an investigation while employed by Trellis, they are
obliged to inform the Agency. Failure to do so shall result in disciplinary action up to and including
termination.

34. People Services shall ensure that these documents are filed in the employee’s personnel file.
35. IRC’s are to be updated every (3) years from the time they were first obtained.
Primary Source Verification
36. Per the Employee Education Verification Requirements Policy, C.3.7, employees will be advised in their written
offer of employment that they must provide primary source verification of education to the Agency within 3
months of accepting an offer, preferably on their first day of work.

37. The requirement to provide primary source verification of education shall be written into any program service
contract entered into by the Agency within accredited programs.

38. People Services shall be responsible to track adherence to this policy.

39. Responsibility for the administration of this policy rests with the individual supervisors, employees and
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contractors.

40. Employees who fail to meet these requirements may be suspended without pay until they can provide the
appropriate documentation.

Driver’s License and Abstracts

41. The job description, job posting and/or advertisement shall clearly indicate the job requirements to ensure that
all potential candidates and employees are aware of the Agency standards.

42. Where applicable to the position, new employees who will be driving children, youth and families in their
personal vehicle are required to provide a Drivers Abstract and a certificate demonstrating $1 million dollars in
personal liability insurance. Please refer to the Use of Personal Vehicles Policy for additional information.

43. Driver’s Abstracts will be completed through Aviva Canada and pulled annually on April 1st. Aviva Canada will
immediately advise HUB Insurance of any tickets, suspensions, or concerns. HUB insurance will immediately
inform the Agency of any concerns.

44. Where applicable to the position, new employees are responsible for obtaining a Class 4 Driver’s License within
three (3) months of commencing employment, providing a Drivers Abstract and paying the associated costs.
Failure to do so may result in termination of employment. Please refer to the Use of Agency Vehicles Policy for
additional information.

45. New employees who have not obtained a Class 4 Driver’s License (and are required to have one as a condition
of employment) shall not drive children, youth, and families in Agency vehicles until such time as the Class 4
License has been obtained and evidence of a satisfactory driving record has been received by the Agency.

46. New employees who are required to have a Class 1, 2, or 4 with the S-endorsement must have acquired the
license before hire and will be responsible for all costs associated with obtaining the license.

47. An updated Driver’s Abstract and certificate demonstrating $1 million dollars in personal liability insurance is
required annually for insurance purposes, with all costs associated with this update being paid by the Agency.

48. Employees with the TRELLIS shall maintain (7 or less) demerits on their driving record during employment
withthe Agency.

49. If an employee receives (more than 7) demerit points, then the employee shall complete a defensive driving
course at the employee’s expense within a (2) month period. Until they have successfully completed this
course, the employee will not be permitted to drive clients.

50. Driving infractions that are incurred due to dangerous driving, excessive speeding, etc. may result in the
employee being unable to drive clients at the Agency. This will be determined by a Chief Officer in consultation
with People Services and the CEO.

51. An employee who is not able to pass a defensive driving course, loses their driving license or driving privilege,
may be terminated by the Agency if they are not able to fulfill their job duties to the satisfaction of the Employer.

52. All Employees shall adhere to the standards outlined in the Driver’s Manual.

Prior to Recruitment
53. The hiring supervisor shall review the existing job description for the vacant or newly created position prior to
beginning the recruitment process to ensure that the job description accurately reflects the job responsibilities,
duties and requirements. When required, the hiring supervisor shall make the necessary modifications to the
job description and provide a copy to People Services
54. The hiring supervisor shall verify with the Director of Finance and Administration and/or a Chief Officer that
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POLICY: EMPLOYEE SCREENING AND RECRUITMENT POLICY NO.: C.2.14

financial resources are available before recruitment is initiated for a vacant or newly created position.

55. People Services will work with the hiring supervisor to establish the best advertising strategy to maximize
limited advertising resources.

56. People Services shall be responsible for submitting all advertisements and postings.
Internal Competition
57. Internal competitions will be advertised to employees through ADP for a period of five (5) business days.

58. Internal competitions must attach an Internal Application Notification Form along with their cover letter and
resume when applying;

59. Should an employee fail to submit a signed Internal Application Notification Form, their application will not be
considered;

60. People Services shall ensure that all job postings contain at least the following information: a. Position Title;

a Position classification (full-time, part-time, etc.);

b Reporting relationship;
c Summary of responsibilities;
d Deadline for submission of applications (closing date of competition);
e Agency contact information (i.e. [email protected]).
61. All vacancies shall be filled by competition, unless two similar vacancies occur within a short period of time of
less than one month and an eligibility list shall be utilized, if one exists.

62. When re-hiring a candidate who was alumni or a volunteer, or worked a seasonal program, People Services
shall be consulted by the hiring supervisor to ensure that the candidate is eligible to be re-hired. Please refer to
the TRELLIS Re-Employment Policy.

63. External competitions shall be open to all interested candidates from the general public including Agency
employees.

64. People Services shall ensure that all external job postings contain at least the following information: a.

Position Title;

a Position classification (full-time, part-time, etc.);

b Reporting relationship;
c Summary of responsibilities;

65. Agency contact information (i.e. [email protected]).

PROCESS
1. The hiring supervisor will create a Requisition through ADP Workforce Now and submit to People Services,
with the approval of second-level supervisor. A requisition is required for each position.

2. A job description must be submitted to People Services, if there are any revisions to an existing position or if
the requisition is for a new position.

3. Prior to interviewing, the hiring supervisor in consultation with People Services, shall prepare a set of interview
questions that shall assess and evaluate a candidate’s knowledge, skills, training, experience and personal
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POLICY: EMPLOYEE SCREENING AND RECRUITMENT POLICY NO.: C.2.14

suitability.

4. All interviews will be conducted by a minimum of two (2) employees that are at or above the Manager level
and include the position’s immediate supervisor. In some instances, a Sr. Worker can attend an interview
where a second Manager is not available.

5. People Services will create the interview packages which will include interview questions, the resume and any
pre-screen notes.

6. People Services will screen for suitable candidates and change their application status to Follow Up on ADP
Workforce Now for the hiring supervisor’s consideration. The supervisor will select those candidates they
would like to phone screen and interview by changing the Application Status to Phone Screen or Interview on
ADP Workforce Now and work with People Services to set up the interview times.

7. All candidates for the same position will be interviewed using the same standard set of questions. Questions
pertaining to individual candidate experience are the only exceptions.

8. People Services shall be responsible for conducting two (2) supervisory reference checks on candidates being
considered for employment as per the TRELLIS Reference Check Policy.

9. The results of the reference checks will be forwarded to the hiring supervisor to decide if an offer of
employment is to be initiated and make a verbal offer.

10. The offer must include details listed under Offer and Conditions of Employment.
11. The hiring supervisor must provide at least three (3) business days’ notice to People Services, prior to the
commencement of a successful candidate;

12. When the offer has been accepted by the candidate, managers will send an email to [email protected]
withthe following information:

a. Subject Line - New Hire: Candidates Name

b. Position
c. Program
d. Commencement Date
e. IT Requirements:
i. Email
ii. Sharevision
iii. Cell Phone/Blackberry
iv. Laptop (if required, based on budgetary restrictions)

13. Should the hiring supervisor decide that no offer of employment is to be made as a result of this
competition, then the candidate will be contacted by People Services via ADP, to advise the candidate that they
have been unsuccessful.

14. People Services shall conduct bi-annual audits to ensuring proper recruitment procedures are being
adhered to.

Appointments and Secondments

15. In some cases, specialized positions may be created to support the unique needs of individual programs by
the Program Director in consultation with a Chief Officer, People Services and the CEO. Chief Officers may
approve the appointment or secondments of employees to these roles and the normal internal competition
process will be waived.
16. Only current employees who have successfully completed their probation period are eligible for these
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appointments or secondments.

17. Directors will be required to complete a Change of Status form with sign off by a Chief Officer and CEO to
complete the process.

Offer and Conditions of Employment

18. The hiring supervisor can make an offer of employment to the final candidate that shall include:

a. Salary;

b. Commencement date;

c. The verbal offer shall state that the offer is subsequent to a formal written offer and fulfilling the conditions
of employment;
d. As a condition of employment, the potential employee shall present to the hiring supervisor or manager, a
Criminal Record Check (CRIM) with vulnerable sector search, dated within the past 6 months, prior to start
of employment, at their expense;
e. Should the potential employee not have a CRIM with vulnerable sector search, dated within the past 6
months, the employee shall complete an Authorization to Deduct form and complete an online e-Police
Information Check (ePIC) application with the Calgary Police Services;
f. As a condition of employment, the potential employee shall present to the hiring supervisor or manager, an
Intervention Record Check (IRC) prior to the start of employment;
g. Should the potential employee not have an IRC, dated within the past 6 months, the employee shall
complete a Consent for Release form, International Social Service form (for employees who have resided
out-of-country), and an IRC form;
h. In the event the employee has a positive record with Children’s Services, the IRC will not be returned to
Trellis. It is the responsibility of the employee to inform People
Services and discuss next steps;
i. Should the potential employee fail to present a CRIM and IRC within the three-month probationary period,
the Agency may terminate the employee and/or withdraw the offer of employment;
j. In the event that due to delays with Calgary Police Services, the RCMP, or Children’s Services that the
documentation(s) cannot be presented, the potential employee may not work alone with the clients until the
checks have been received.

19. People Services shall be responsible for the preparation of written Letters of Offer to be provided to the
potential employee that shall include:

a. Salary;
b. Commencement date;
c. Job title and employment classification;
d. Reporting relationship;
e. Work location;
f. Benefits information and eligibility;
g. Conditions of probation; and Conditions of employment to include but are not be limited to:
i Criminal Record Check with vulnerable sector search;
ii Intervention Record Check;
iii Verification of credentials (education or other);
iv Verification of Class 5 Driver’s License (if required);
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v Verification of Class 1, 2, or 4 Driver’s License with S-endorsement (if required);

vi Verification of First Aid/CPR Training (if required);
viiDriver’s Abstract (if required);
viii
Mandatory trainings and responsibility of employees to keep certifications up-to-date;
ix A Class 4 driver’s license shall be obtained within three (3) months of hire;
x A First Aid certification shall be obtained within (3) months of hire, at their expense;
xi New employees shall be responsible for payment to obtain a Class 4 Driver’s License and a
First Aid Certificate, and on their own time, and;
xii For employees with diplomas or degrees in Social Work, or provisional registration with Alberta
College of Social Work.
20. Two copies of the letter of employment shall be provided to the potential employee.
21. One signed copy of the letter of employment offer by the potential employee shall constitute acceptance of the
employment offer and shall be returned to the People Services Advisor.

22. The People Services Advisor shall ensure that new employee personnel files are developed, and employee
signed accepted letter of employment is placed on the employee’s personnel file.

23. Under no circumstances shall the potential employee begin working for Trellis until the above conditions of
employment have been met, with the possible exception of the Class 4 Driver’s License and First Aid/CPR
certification.

24. Any exceptions to the recruitment procedures shall require written approval from the CEO.

Notification to Unsuccessful Applicants

25. Notification shall be provided to unsuccessful internal applicants who received an interview or more are
entitled to receive a feedback session to provide suggestions for future success and a discussion around skill
development, training, or education.

26. Notification to unsuccessful external applicants who received one interview or more shall be notified by
email, through ADP Workforce Now, that they were not successful in obtaining the position. All other applicants
will not be notified that they were unsuccessful. The advertisement will have indicated that this would be the
case stating that although all applications were appreciated, only candidates receiving an interview would be
contacted.

27. Any exceptions to this policy shall remain at the discretion of the CEO.
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PEOPLE SERVICES
EMPLOYMENT

POLICY: EMPLOYMENT EQUITY DIVERSITY & POLICY NO.: C.2.15

DUTY TO ACCOMMODATE
DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

DATE REVISED: May 2019 Alberta Employment Standards Code

Canadian Human Rights Act

Trellis is committed to being a leader in supporting and valuing the diversity of the people,organizations, and
communities we serve.

We are committed to employment diversity with respect to all aspects of employment and make every reasonable
effort to ensure that the Agency is a representative employer of women and men, members of visible minority
groups, people with disabilities and Indigenous peoples at all the organization's operations.

Pro-active accommodation at work will be provided, where necessary and reasonably practical, to provide ways
that support the employee’s dignity, worth and productivity, or to hire or retain qualified employees disabled through
either injury or illness, or otherwise belonging to groups protected under the applicable Human Rights Code.

Employees who require accommodation will speak to their supervisors or People Services to outline the details
of their need. Each accommodation request shall be considered seriously and the Agency will, in good faith,
implement accommodations to the point of undue hardship.

POLICY

1. The following principles shall apply when implementing this policy:

a. Within Trellis, diversity is valued and recognized in our treatment of employees as well as in our dealings
with children, youth, families and community.
b. Accommodation in employment most often involves the protected grounds of physical or mental disability,
religious beliefs, gender (including pregnancy and transgender/sexual), family status, marital status and
sexual orientation.
c. Within Trellis there shall be no discrimination, interference, harassment or coercion of employees or
volunteers on the basis of race, national origin, age, gender, sexual orientation, gender identity, religion or
physical and mental disability, or any other protected category.
d. While the gender of the applicant shall not influence hiring decisions, the need for a balance of male and
female role models for children may lead to active recruitment and hiring of either male or femaleemployees,
at any given time. Moreover, some programs due to clientele require employees of a specific gender.
e. Trellis shall make every effort to make its employee and volunteer workforce representative and reflective of
the communities in which the services are provided.
f. Employee complaints under this Policy shall be handled with the utmost attention, care and confidentiality.

2. The CEO shall be responsible for ensuring workplace diversity, employment equity and duty to accommodate
is being met by the Agency. Employees who have a complaint related to any aspect of employment equity or
diversity, are encouraged to address their concern(s) by following the steps in Employee Grievance policy.

PROCEDURES

1. Accommodation of needs of employees will consider, but are not limited to:
a. purchasing or modifying tools, equipment or aids, as necessary;
b. altering the premises to make them accessible;
c. altering aspects of the job, such as job duties;
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DUTY TO ACCOMMODATE
d. offering flexible work schedules;
e. offering rehabilitation programs;
f. allowing time off for recuperation;
g. transferring employees to different jobs;
h. hiring an assistant or obtaining a volunteer;
i. using temporary employees, and;
j. Adjusting policies.
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PEOPLE SERVICES
EMPLOYMENT

POLICY: EMPLOYMENT OF RELATIVES POLICY NO.: C.2.16

DATE ISSUED: May 1, 2003 ASSOCIATED STANDARDS:

CARF – Leadership
DATE REVISED: May 2019

The Agency shall ensure that employment and/or contracting of the services of close relatives is regulated so that
the appearance or practices of favoritism and/or conflicts of interest are avoided. This applies to all Board members,
employees, and contractors of Trellis.

For the purpose of this policy, a close relative is defined as an immediate member of the family and includes;
Spouse/Partner/Significant Other, Father, Mother, Child, Brother, Sister, Son, Daughter, Grandparent, Aunt,
Uncle, In Law or First Cousin. A distant relative would be a second or greater cousin or distant in-law.

POLICY

1. The employee shall be responsible to disclose to their supervisor the nature of a close relative or existence
of distant relative relationship with another employee

2. When one or more relatives are employed by the Agency, close relatives shall not be employed within the
same department or work unit.

3. A Board member or employee shall not be in direct supervision of their spouse, partner or close relative. The
Board member or employee shall be responsible to disclose to their supervisor the nature of a close relative
or existence of distant relative relationship.

4. No Board member or employee shall be involved in a recruitment process when an applicant is related in
any way to them.

5. Contractors shall not be a close relative of any employee. Contracted arrangements should be arm’s length
from the Agency and prevent any suggestion of conflict of interest.

6. When a relative is already a contractor or employee of an agency or an organization with whom TRELLIS
doesor is planning to do business, a Board Member or employee must declare that relationship in writing to
the CEO and People Services and abide by the written response governing their further actions.

7. Should an employee begin a dating or intimate relationship with another employee with whom there is a direct
or indirect reporting relationship, this must be disclosed to their respective immediate supervisors.

8. The CEO or People Services shall be consulted for interpretation or clarification of this policy, if required.
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EMPLOYMENT

POLICY: EXIT INTERVIEWS POLICY NO.: C.2.17

DATE ISSUED: May 1, 2003 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

The Agency shall, where practicable, conduct exit interviews, or arrange to collect exit interview information, with
employees prior to their last day of work. Exit interview information is collected to increase organizational
effectiveness, increase employee retention and ensure positive employee relations.

POLICY

1. People Services shall offer an exit interview for all departing and terminating employees. Employees are
encouraged to have exit interviews.

2. The employee may choose to meet with the CEO, their direct supervisor or People Services for their exit
interview. This is voluntary.

3. Information from the exit interview shall be documented on the Exit Interview form.

4. A terminated employee may request that the information from the exit interview be keptconfidential.

5. People Services will prepare a confidential summary report on the terminating employee for the CEO.
Annual summaries of this information will be available to the Senior Leadership team.
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EMPLOYMENT

POLICY: HARASSMENT IN THE WORKPLACE POLICY NO.: C.2.18

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARD(S):

OHS Legislation
DATE REVISED: May 2019

Trellis shall not tolerate or condone any degree of harassment, workplace violence or bullying by its employees or
employees of other agencies, volunteers, contractors, clients of the Agency, or members of the Board of Directors.
The Agency shall ensure the safety of its employees, volunteers, clients, and members of the general public. Trellis
recognizes that not addressing this issue leads to employee turnover, diminishes morale and motivation, creates
stress and stress related illness, and affects the health and safety of the Agency.

For the purpose of this policy, the following definitions will apply:

Sexual Harassment

Is defined as any conduct, comment, gesture, or contact of a sexual nature such that an employee’s performance
is impaired or their dignity or respect is denied. It includes any behavior known, or which should be reasonably known
to be unwelcome. It is emotionally abusive and creates an unhealthy, unproductive atmosphere in the workplace.
Sexual harassment is usually an attempt by one person to exert power over someone else.

Sexual harassment can be expressed in many ways, from very subtle to most obvious, through any of the following:
a. suggestive remarks, sexual jokes or compromising invitations;
b. verbal abuse;
c. visual display of suggestive images;
d. leering or whistling;
e. patting, rubbing or other unwanted physical contact;
f. outright demands for sexual favours; and
g. Physical assault.

Harassment

Harassment can take the form of:

a. Verbal abuse;
b. Hurtful or humiliating comments, jokes or taunts;
c. Racist or sexually explicit comments or pictures;
d. Intimidation behaviors such as stalking or staring;
e. Unnecessary and unwelcome physical contact;
f. Refusal to serve or work with an individual on the basis of any of the grounds mentioned in this policy; and
g. Repeated unwelcome sexual invitations, or such invitations accompanied by threats of reprisal or promises
of rewards.

Violence
Is defined as the threatened, attempted, or actual conduct of a person that causes or is likely to cause physical injury.
It may be any vexatious behaviors in the form of repeated and hostile or unwanted conduct that affect an employee’s
dignity or psychological and/or physical integrity that results in a harmful work environment for the individual receiving
the behavior.
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POLICY: HARASSMENT IN THE WORKPLACE POLICY NO.: C.2.18

Bullying (Psychological Violence)

Is defined as any incident in which a person is abused, threatened or assaulted in circumstances relating to their
work. These behaviors could originate from clients, co-workers or supervisors at any level of the organization. This
unacceptable behavior includes all forms of harassment, and may include but is not limited to attacks, threats, severe
verbal abuse including humiliation criticism and trivial fault finding, intimidation, blackmail, coercion, misuse of
authority, threats upon a person including jeopardizing their employment, denying necessary information and
resources, mobbing, teasing, ridicule, and other intrusive behaviors that could hurt or isolate a person in the
workplace.

POLICY

1. The CEO is responsible to ensure that a zero tolerance policy is adhered to when it comes to any degree of
harassment, workplace violence, or bullying.

2. People Services has the responsibility to ensure adherence to this policy and to ensure that information
regarding this policy be included at commencement with the Agency.

3. Any incidence of harassment, workplace violence or bullying shall not be tolerated and the resolution of the
incident will be treated with the utmost seriousness and resolved in an expedient way to the satisfaction of
the victim and the Agency, up to and including immediate termination.

4. The Agency, as an employer, is responsible for the actions of their employees. If an employee comes forward
to a Supervisors, Managers, or Director, there is an obligation to report any incident of harassment, workplace
violence or bullying to People Services.

5. A supervisor who neglects to follow up on a complaint of sexual harassment may be liable under the Human
Rights, Citizenship and Multiculturalism Act for failing to take prompt and appropriate action.

6. It is against the law to retaliate against anyone who has made a compliant of discrimination in good faith or
who has given evidence in support of or against a complaint (see Whistleblower policy).

7. Any person who believes that they are being harassed or witnesses an act of harassment towards another
employee, volunteer or client of the Agency should immediately communicate to the other individual involved
that the behavior is unwelcome and should be stopped. The communication should include the behavior in
question, the nature of type of behavior and the impact on the individual experiencing the harassment.
Depending on the nature of the incident or concern, the individual involved may choose to document the
behavior, subsequent discussion, and any action items and responsibilities.

8. If this direct communication does not result in a satisfactory resolution, the individual should then inform a
supervisor, Manager, Director or People Services. The confidentiality of the individuals involved will be
absolutely maintained.

9. An investigation will be immediately undertaken which will include:

a. A written account of the event(s) or behavior(s) to be provided to authorities, if required;

b. Individual interviews with both the complainant and the individual in question;
c. Interviews with any witnesses to the alleged harassment.
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POLICY: HARASSMENT IN THE WORKPLACE POLICY NO.: C.2.18

10. If evidence of inappropriate behavior or harassment is determined, disciplinary action will be taken with
approval from the CEO that may include, but will not be limited to, the following:

a) Performance management counseling and monitoring;

b) Suspension without pay;
c) Termination of employment, including termination without notice or pay in lieu of notice;
d) Counseling and support for the employee affected by harassment, workplace violence or bullying,
and/or;
e) Reporting the case to appropriate justice authorities.

11. Although the details of any disciplinary action cannot be shared with another employee including the victim,
the supervisor will be responsible to follow up with the employee bringing forward the complaint to ensure
that they have the supports and processes in place after resolution.

12. No person reporting an incident of harassment, violence in the workplace of bullying will be subject to
disciplinary action (unless the allegation is found to be baseless, without merit or retaliatory) nor will any
retaliatory action be permitted against the person reporting. If retaliation does occur the person retaliating
will be subject to the disciplinary policy of the Agency.
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EMPLOYMENT

POLICY: HOURS OF WORK POLICY NO.: C.2.19

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

Alberta Employment Standards Code
DATE REVISED: May 2019

Trellis shall maintain hours of work to accommodate the needs of the Agency, employeesand its clients in
accordance with Alberta’s Employment Standards Code and Regulations.

POLICY

1. Due to varying programs and job requirements within the Agency, programs and departments will observe varied
hours of work. Hours of work will be established according to the needs of that program or department and will
be clearly communicated to all affected employees.

2. The Manager is responsible for ensuring compliance with the expectation for working hours to ensure Agency
needs are met.

3. Rest periods during the shift will meet or exceed the minimum requirements of Alberta’s Employment Standards
Code.

4. The number of hours which an employee is normally scheduled to work each week is dependent on their
employment classification and the role which they work.

5. All employees are expected to arrive for their scheduled shifts on time. If there are unforeseen circumstances
that will prevent an employee from arriving on time, the Manager is to be notified as soon as possible.

6. The Agency reserves the right to change the hours of work given a written and reasonable notice to the employee.

7. Employment permit changes the hours of work and overtime pay provisions only and does not apply to any other
provisions of the Employment Standards Code.

8. People Services shall ensure all employment permit changes are submitted for approval to Alberta Human
Resources and Employment, Employment Standards, on a timely basis.

9. The employee’s Manager and People Services shall administer an Overtime Agreement for all employees which
will allow employees to take time off, in lieu of overtime worked, on an hour-for-hour basis.

10. Any exceptions to this policy shall be at the discretion of the CEO.
Recording Time Worked and Time Off

11. All employees shall complete their timecard in ADP on or before the bi-weekly cut off deadline.
12. The employee’s supervisor shall approve timecards on or before the bi-weekly cut off deadline. Please refer to
the Salary Administration Policy C.1.9 and ADP Training Manual for additional details.

13. All working hours and conditions that do not comply with Alberta’s Employment Standards Code which include
Residential and Home Care Standards shall receive approval in writing from Alberta Human Resources and
Employment, Employment Standards. A copy of the employment permit shall be posted at all relevant work
sites
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POLICY: HOURS OF WORK POLICY NO.: C.2.19

14. Except in those cases where there is an employment permit, overtime shall be paid for hours worked in excess
of the Overtime Agreement. All employees unless exempt shall be asked to sign an Overtime Agreement which
will allow employees to take time off, in lieu of overtime worked, on an hour-for-hour basis.

Salaried Employees Working Relief in Other Programs

15. Salaried employees working hourly shifts shall have successfully met the probationary period and be in good
standing with the Agency.

16. All salaried employees working in another program must have a signed contract amendment on file. 17. Approval
to work in another program must be obtained by the Manager where the employee is working their primary role
and the Manager who is offering relief hours and confirmed via email to all parties involved. Employees shall not
work a relief shift at the disadvantage of their primary program.

17. The maximum extra hours that can be worked in another program is 44 hours per week with their full time and
relief hours, without being paid an overtime rate. 19. Salaried employees will record their relief hours in their
timecard and select the appropriate program code. Their regular supervisor must coordinate with the relief
program supervisor for time card approvals.

18. Employees shall be permitted to work relief shifts in their own program at the discretion of the Manager.

19. Overtime must be authorized in advance by the Manager.

20. As per Alberta Employment Standards no employee shall work 7 days consecutively. An Employee shall take
one day per week minimum as a day of rest. An employee must have 8 hours of rest between shifts. Agency
Committees

21. Any Committee will have a clear term Start and Finish and a General Notice of Selection of New Committee
Members shall be posted in the Insider with a deadline date.

22. The Employee must be in good standing (not on probation or with one or more current written warnings on their
file). The Supervisor must be informed of the Individual’s desire to join a committee and will consider it in
making their decision to permit the employee to service on a Committee. An employee’s seniority (years of
service), best fit to contribute, and past contribution to the Agency will also be taken into account. The decision
to permit the employee to service on the Committee is at the discretion of the direct supervisor.

23. The Employee may participate on one committee for one term per annum and must not be currently on another
internal Agency committee. Consecutive terms may not be served unless a position cannot be filled from a
particular program area.

24. The Employee will consider their ability to attend meetings, work within paid time, and attend/assist with the day
of the Event in making their decision to serve on a Committee.

25. The Agency will allow for paid committee work within an employee’s hours of work. Some voluntary aspects
may exist and this will be made clear at the initial meeting.
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POLICY: HOURS OF WORK POLICY NO.: C.2.19

26. Committees may include:

a. Workplace Health and Safety

b. Workforce Council
c. Event Committees
d. Others as determined by the Senior Leadership team.

Casinos

27. Employees shall not be paid for working at a Casino on behalf of the Agency. This must be volunteertime
as per Alberta Gaming Standards.
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POLICY: INVESTIGATING AND REPORTING POLICY NO.: C.2.20

FRAUDULENT, RESOURCE ABUSE AND OTHER
MISCONDUCT ACTIVITIES

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

CARF – Leadership
DATE REVISED: May 2019

All Employees, Volunteers and Practicum Students are responsible for the detection and prevention of fraud,
misappropriations, and other inappropriate conduct. Fraud is defined as the intentional, false representation or
concealment of a material fact for the purpose of inducing another to act. Fraud may be committed in an oral or
written form involving financial documents, program files, or any document related to the employment process. This
Policy applies to all Employees, Volunteers and Practicum Students of the Trellis and includes consultants, vendors,
contractors, outside agencies doing business with employees of such agencies, and/or any other parties with a
contractual relationship with TRELLIS.

Actions Constituting Fraud

The terms defalcation, misappropriation, and other fiscal wrongdoings refer to, but are not limited to:
a. Any dishonest or fraudulent act
b. Forgery or alteration of any document or account belonging to the TRELLIS
c. Forgery or alteration of a check, bank draft, or any other financial document
d. Misappropriation or waste of funds, securities, supplies, or other assets
e. Impropriety in the handling or reporting of money or financial transactions
f. Destruction, removal or inappropriate use of records, furniture, fixtures, and equipment; and/or
g. Any similar or related inappropriate conduct

Other Inappropriate Conduct

Suspected improprieties concerning an employee’s moral, ethical, or behavioral conduct must be investigated by
Management in concert with People Services with appropriate action resulting from that investigation.

POLICY

1. Any investigative activity required will be conducted without regard to the suspected wrongdoer’s length of
service, position/title, or relationship to the Agency.

2. Any fraud that is detected or suspected must be reported immediately to the appropriate Chief Officer, CEO, or
People Services, who coordinate all investigations with the affected areas, both internal and external.

3. If there is any question as to whether an action constitutes fraud, contact the CEO or People Services for
guidance.

Investigation Responsibilities

4. The CEO in concert with People Services has the primary responsibility for the investigation of all suspected
fraudulent acts as defined in the policy.

5. If the investigation substantiates that fraudulent activities have occurred, the CEO in concert with People
Services will issue reports to appropriate designated employees and, if appropriate, to the Board of Directors
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POLICY: INVESTIGATING AND REPORTING POLICY NO.: C.2.20

FRAUDULENT, RESOURCE ABUSE AND OTHER
MISCONDUCT ACTIVITIES
or any external Legal Agency including the Law Enforcement.

6. The CEO, in concert with the appropriate Chief Officer and/or People Services, shall be responsible for
rendering final and binding decisions.

7. In the event that the CEO is named, People Services, a Board Member, and other designated Senior
Leadership team member shall assume the role to render final and binding decisions.

8. Decisions to prosecute or refer the examination results to the appropriate law enforcement and/or regulatory
agencies for independent investigation will be made in conjunction with legal counsel and Senior Leadership,
as will final decisions on disposition of the case.

Confidentiality

9. The CEO or designate treats all information received confidentially. Any person who suspects dishonest or
fraudulent activity will notify the CEO or PEOPLE SERVICES immediately, and should not attempt to personally
conduct investigations or interviews/interrogations related to any suspected fraudulent act.

10. No person reporting a suspected fraudulent act will be subject to disciplinary action (unless the allegation is
found to be baseless, without merit or retaliatory) nor will any retaliatory action be permitted against the person
reporting. If retaliation does occur the person retaliating will be subject to the disciplinary policy of theAgency.

11. Investigation results will not be disclosed or discussed with anyone other than those who have a legitimate
need to know in order to conduct the investigation.

Authorization For Investigating Suspected Fraud

12. The CEO or designate shall have:

a. Free and unrestricted access to all Agency records and premises, whether owned or rented, and;
b. The authority to examine, copy, and/or remove all or any portion of the contents of paper and electronic
files, desks, cabinets, and other storage facilities on the premises without prior knowledge or consent of
any individual who may use or have custody of any such items or facilities when it is within the scope of
their investigation.

Participation The Investigation of An Activity

13. If an Employee is called to respond to a subpoena, search warrant, investigation, or other legal action or
instrument related to their past or present employment, the Agency shall provide the appropriate compensation in
terms of salary and time to allow the Employee to participate. The Employee will be assisted in preparation for and
attendance of the event, by the appropriate Management authority.
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EMPLOYMENT

POLICY: JOB DESCRIPTIONS POLICY NO.: C.2.21

DATE ISSUED: May 1, 2003 ASSOCIATED STANDARDS:

CARF – Human Resources
DATE REVISED: May 2019

The Agency shall ensure that every position within the organization has a current job description which clearly
indicates the position employment classification.

POLICY

1. The Agency recognizes that all employees are entitled to have a clear understanding of their position, duties,
and responsibilities to be successful in their employment.

2. The Agency recognizes that job descriptions are a key document to be used in the performance management
process and shall aid in structuring work plans and goal setting for each employee.

3. The Manager and/or immediate supervisor shall be responsible to ensure that a current job description is
available for each position within their program and is reviewed annually.

4. The Manager and/or immediate supervisor review the job description with each employee that reports to them
as part of the TRELLIS Performance Engagement Process annually.

5. People Services, in consultation with the immediate supervisor and/or manager shall approve job descriptions.

6. People Services is responsible to ensure that job descriptions exist for all positions within the organization, and
that they are consistent and available for position analysis.

PROCEDURES

1. The Manager and/or immediate supervisor shall ensure that all job descriptions include: a. Position Title;

b. Position Summary;
c. Duties and Responsibilities;
d. Knowledge and Skill Requirements;
e. Required Certifications and Trainings;
f. Reporting Relationship; and
g. Date Written or Revised.

2. All new employees shall receive a copy of their job description at the start of their employment.

3. The employee shall review and sign their job description and provide an original signed copy to their hiring
supervisor or to People Services during the commencement process. This will be placed in the employee’s
personnel file.

4. Should a job description be developed or re-written then the immediate supervisor, in consultation with the
Manager or Director shall approve the new job description.

5. Should a significant change occur in duties then the job description shall be revised at the time of the change
by the supervisor.

6. Supervisors shall review and revise job descriptions annually in conjunction with the Performance Engagement
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POLICY: JOB DESCRIPTIONS POLICY NO.: C.2.21

process, and provide the updated job description to the employee and People Services, if needed.

7. Job descriptions shall be reviewed by the Program Manager or Director in consultation with program
employees.

8. People Services shall ensure that job descriptions are available to all employees of the Agency.
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EMPLOYMENT

POLICY: MANDATORY ON-GOING EMPLOYEE POLICY NO.: C.2.22

TRAININGS, CERTIFICATIONS AND
PROFESSIONAL DEVELOPMENT

DATE ISSUED: January 10, 2000 ASSOCIATED STANDARDS:

CAC
DATE REVISED: May 2019 CARF

To ensure the safety and well-being of all young people associated with Trellis, all direct service employees will hold
the required certifications for their position as per their job description. This policy is to be used in conjunction with
the On-Going Professional Development policy.

POLICY

1. All new employees, regardless of their employment classification, are required to complete FOIP training
online preferably prior to their employment start date or, by the end of their second day of work.

2. All new employees, regardless of their employment classification are required to complete the following
trainings within the first 90 days of their employment:

TRAINING VALID FOR:

Universal Precautions Training Annual Requirement: Valid for one (1) year

New Employee Orientation One (1) Time Only Requirement

3. Many TRELLIS child and youth programs require employees to store, control and/or administer medications
regularly or on occasion. As per individual program requirements, employees may be required to complete
Medication Administration Training. If the program stores, controls and/or administers medications then, all
new program employees, who work directly with children/youth are required to complete the following training
within 30 days of their employment:

TRAINING VALID FOR:

Medication Administration Training Annual Requirement: Valid for one (1) year

IMPORTANT NOTES:
Those employees who work in programs where medications are administered must complete
Medication Administration Training before being left alone with children/youth.

All employees who work directly with children/youth must complete Universal Precautions Training
before being left alone with children/youth.

4. All employees, regardless of their employment classification, are required to complete 3 hours each of
DIVERSITY TRAINING and LGBTQ2S+ TRAINING within the first six (6) months of employment.
Employees may take trainings in the community or may take advantage of regularly offered Diversity and
LGBTQ2S+ at TRELLIS.
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POLICY: MANDATORY ON-GOING EMPLOYEE POLICY NO.: C.2.22

TRAININGS, CERTIFICATIONS AND
PROFESSIONAL DEVELOPMENT

TRAINING VALID FOR:

IMPORTANT NOTE:
Upon completion of Diversity Training and LGBTQ2S+ training, employees are required to take 3
hours of Diversity Training of their choice. Employees may choose to access community trainings or
trainings offered at TRELLIS and at TRELLIS expense.

TRAINING VALID FOR:

Three (3) hours of Diversity Training of choice Annual Requirement: Valid for one (1) year

5. All new employees, regardless of their employment classification, must complete 3 hours of Indigenous
Awareness Training within six (6) months of employment and annually each year thereafter. Employees
may take trainings in the community or may take advantage of regularly offered at TRELLIS. All employees
working in CHF funded programs must complete 6 hours of Indigenous Training within six (6) months
of employment and annually each year thereafter.

TRAINING VALID FOR:

Three (3) hours of Indigenous Awareness Training of Annual Requirement: Valid for one (1) year
choice
Six (6) hours of Indigenous Awareness Training of Annual Requirement: Valid for one (1) year
choice is required for staff in CHF funded programs

6. All new employees working directly with children/youth are required to complete the following trainings within
the first six months of their employment. Trainings will be offered by the Agency and at the Agency’s expense:

TRAINING VALID FOR:

Suicide Prevention (ASIST) 2 days (14 hours) Three (3) years AND/OR to expiry date on certification
Re-certification of ASIST-Tune Up ½ day (4 hours) A re-certification of ASIST may be taken PRIOR to the
expiration of a valid ASIST certification. Only one
Tune-Up may be taken and then it is necessary to take
the full 2 day ASIST

EXAMPLE:
February 1 & 2, 2016 ASIST (2 day) Expires: February 1, 2019
January 15, 2019 Tune-Up (1/2 day) Expires: January 14, 2021
January 1, 2, 2019 ASIST (2 day) Expires: January 1, 2023

The ½ day Tune-Up may not be taken if the current ASIST has expired. This ½ day re-certification is only
available to those who take it before expiration of the current ASIST. Tune-Up re-certifications will be offered by
the Agency at the Agency expense. If an employee allows their ASIST certification to expire and a full 2 day
ASIST is required, this will be at the EMPLOYEE expense.
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POLICY: MANDATORY ON-GOING EMPLOYEE POLICY NO.: C.2.22

TRAININGS, CERTIFICATIONS AND
PROFESSIONAL DEVELOPMENT

7. All new employees working directly with children/youth are required to complete the following training
within 30 days of employment.

TRAINING VALID FOR

To be reviewed at program Orientation and
Emotional CPR Program Video
Annually

8. All new employees working directly with children/youth must hold a valid certification and/or complete the
following training within the first six months of their employment. Trainings will be offered by the Agency and
at the Agency’s expense:

TRAINING VALID FOR:

Therapeutic Crisis Intervention (TCI) (20 hours) To remain certified staff must complete 12 hours per
(Participant must pass all TCI Tests) All staff in year of documented refresher training.
Community – Based Care and Supports programs
must be TCI certified ( Group homes, Eleanor’s
House and Foster care)

OR

Non- Violent Crisis Intervention (NVCI) (1 day) Two (2) years and/or to date on certification

9. At the time of hire, all new employees working directly with children/youth will be required to provide proof
of valid Standard First Aid & CPR Certification in their Absorb account. In the event that a newly hired direct
service employee does not hold valid Standard First Aid & CPR Certification, this requirement will be written
into their Offer of Employment as a condition of employment. The cost to obtain this certification is at the
expense of the newly hired employee. New employees are required to complete this training and submit
proof of valid Standard First Aid & CPR Certification within 30 days of their employment start date, unless
otherwise approved by the Program Manager.

TRAINING VALID FOR:

Standard First Aid & CPR Certification Three (3) years and/or to expiry date on certification

IMPORTANT NOTE:
Proof of re-certification is the responsibility of the employee. The employee must ensure proof of re-
certification is on file in their Absorb account.

10. Direct service employees who do not have proof of valid Standard First Aid & CPR Certification in their
personnel file cannot be alone with children/youth and may be suspended without pay at the discretion
of the Program Manager.

11. Employees are responsible to ensure that all required certifications are current and up to date.
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POLICY: MANDATORY ON-GOING EMPLOYEE POLICY NO.: C.2.22

TRAININGS, CERTIFICATIONS AND
PROFESSIONAL DEVELOPMENT

Employees may not work alone directly with children/youth with expired certifications, unless approved by
the Program Director.

12. Failure of employees to keep any mandatory and/or required trainings and certifications up to date will result
in disciplinary action, unpaid suspension from work until proof of completion and/or termination of
employment.

13. The Agency will incur the cost of mandatory trainings however failure to attend once an employee is
registered will result in the fee being billed to the employee unless appropriate notice and Manager approval
of nonattendance is received.

14. The costs associated with training re-certifications will be incurred by the Agency, provided that re-
certification is obtained before certification has lapsed, unless otherwise approved by the Program Manager
due to special circumstances.

15. Copies of all required and mandatory trainings must be uploaded to the employee’s Absorb account. It is the
responsibility of the employee to ensure all certificates are uploaded into their Absorb account.

16. With the exception of Universal Precautions, Diversity and Indigenous Awareness trainings, non-direct
service employees are exempt from mandatory training requirements but may attend the trainings if
approved by their supervisor.

17. Employees attending the required trainings do so on paid time. Training dates are posted in Absorb and
employees are responsible for self-registering once the training date is approved by their Manager.

18. The CEO must approve in writing any exceptions to the above.

19. All Training will be completed to enhance operational effectiveness and in conjunction with the Mandatory
Employees Training and Certification policy.

20. In order to maximize the benefit of external training and development to an employee or group of employees,
the employee will commit to share knowledge gained with other employees in the program.

21. All training materials including those developed by employees, obtained by an employee at an external
training opportunity for which the Agency has paid, will be considered the intellectual property of the Agency
and remain in the possession of the Agency.

22. Managers are expected to provide internal training to employees. This is part of their normal responsibilities
and they will not be provided extra compensation for trainings. The Trainer shall be required to be “certified”
in the training program prior to delivering the training and provide proof of such certification.

Memberships and Payment for Conferences

23. Employee attendance at Regional and National Conferences will be at the discretion of the CEO in
consultation with the Directors. Other conferences will be at the discretion of the Directors.
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POLICY: MANDATORY ON-GOING EMPLOYEE POLICY NO.: C.2.22

TRAININGS, CERTIFICATIONS AND
PROFESSIONAL DEVELOPMENT

24. Memberships and other dues will be paid for at the Executive and Directorial Level and for certain programs
such as Fund Development and People Services based on the value that the membership provides and will
be considered non-transferable for the individual upon leaving the Agency.

25. Any employee attending a conference will be paid for their normal days of work but will not be paid for any
additional days nor will overtime be accrued. If the conference falls on a day the employee would not normally
work or if the employee is required to use a travel day, time will be banked as overtime and approval is at the
discretion of the Program Director.

26. Employees may be eligible for reimbursement for meals (excluding all alcoholic beverages) during travel
or en-route. Employees must obtain permission for meal expenses prior to their travel date from the Program
Manager. The maximum reimbursement for such meals will be:

Breakfast $15.00
Lunch $20.00
Dinner $30.00
27. The employee will only be paid an allowance for the meal, if it is not offered by the conference. The employee
will need to use the conference allowance form to claim this amount. The payment will be processed by the
account payable payment deadline. In some circumstances, a request for a petty cash advance may be
approved by the Manager for these expenses

External Workshop and Training Opportunities

28. Requests for external training opportunities may be made to the employee’s direct supervisor and must be
approved by the Manager.

29. Approval for such training and development opportunities will be based on:

a. Relevance to the employee’s position in the Agency including Salaried, Hourly, or Temp Status;

b. The Employee’s standing with the Agency. Employees who are participating in Corrective Action plans to
improve performance will not be eligible;
c. Availability of training funds within the program;

d. Identification of such a training need in the employee’s Performance Engagement; and,

e. The employee’s plans to share information obtained with other Agency employees who might benefit from
it.

30. Every attempt will be made to distribute available training dollars in an equitable fashion among employees.
In general, with the exception of mandatory training, an Employee will only be eligible for discretionary training
funds including professional development once per annum during the Education Advancement Scholarship
Application process. If any exceptions are requested, the Manager and Chief Officer(s) must sign off on the
request prior to it being approved.

Internal Employee Trainers

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EMPLOYMENT

POLICY: MANDATORY ON-GOING EMPLOYEE POLICY NO.: C.2.22

TRAININGS, CERTIFICATIONS AND
PROFESSIONAL DEVELOPMENT

31. Managers are required to train employees as part of their normal responsibilities. The Agency will incur the
costs associated with the trainer’s certification and will determine the training obligations (i.e., number of
trainings to be provided, length of training service) with the Manager. Managers will not be paid separately
by the Agency for providing trainings to employees.

32. If a Manager is providing training to external Agencies as part of their normal responsibilities, the appropriate
Director will approve any costs and/or remuneration associated with the training.

33. If a Manager chooses to provide training to external Agencies, where the provision of the training is outside
of the Managers’ regular work responsibilities, the Manager must do so using personal time. Any expenses
associated with the training will be at the expense of the Manager.

34. If a Manager leaves the Agency, they may be required to fulfill their training obligations or repay a portion
of the training fee established by when the certification training was obtained and the number of trainings
already facilitated by the Manager.

35. The Chief Officers in concert with People Services shall identify all internal trainers annually and ensure that
“certification” to deliver training is maintained prior to any training being delivered to other employees.

PROCESS

When an employee has a new training certificate or other documentation to be added to their People Services file
they are to do the following:

36. Scan the training certificate or documentation you are submitting.

37. Upload the document to your Absorb account

38. Cleared Criminal Record Checks will be emailed to the employee by People Services. The employee is
responsible for uploading the Criminal Record Check to their Absorb account.

39. Cleared Intervention Record Checks will be emailed to the employee by People Services. The employee
is responsible for uploading the Intervention Record Check to their Absorb account.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: PERFORMANCE APPRAISALS See Trellis Performance Management Policy

 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: POSITIVE WORKPLACE POLICY NO.: C.2.24

DATE ISSUED: November 1, 2004

DATE REVISED: May 2019

Trellis, as a provider of community services in Calgary, has a professional responsibility to all its stakeholders
including employees, funding partners, volunteers, clients, and members of the Board of Directors. The Agency is
committed to creating and maintaining a professional and positive working environment where behavior reflects
mutual respect and is free from damaging conflict and harassment.

POLICY

1. Every employee, volunteer and members of the Board of Directors has the right to be treated with respect
and has the obligation to treat all stakeholders in the same manner.

2. Although every employee and volunteer has the ongoing responsibility to create and maintain a positive and
safe workplace, those in senior and supervisory roles have a heightened responsibility in this regard. Their
responsibility includes the obligation to use whatever authority they might have in such a way that they are
leaders by example. They should be aware of the working environment and, by their presence, positively
influence the workplace. They should be aware that any reluctance to act, when negative behaviors and/or
situations occur, can indicate approval.

3. Favoritism is prohibited in the application or receipt of Agency services and in those decisions made by
management that impact on employees and volunteers. Any evidence of favoritism shall be reported to the
CEO or People Services immediately and will be dealt with according to the Agency’s discipline policy.

4. All employees and volunteers shall conduct themselves in accordance with the Agency’s Code of Conduct
and Business Ethics policy (A.10) and Conflict of Interest policy. Moreover, employees, volunteers, and
members of the Board of Directors shall ensure that their private interests do not conflict or appear to conflict
with their duties and responsibilities or create the appearance of impropriety which can weaken morale and
the respect for the Agency and its reputation.

5. Conflict that appears in the workplace, which cannot be resolved through open communication and
consultation, will be handled in accordance with the Agency’s Employee Grievance policy.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: First 90-Days POLICY NO.: C.2.25

DATE ISSUED: May 1, 2003 ASSOCIATED STANDARDS:

Alberta Employment Standards Code
DATE REVISED: September 2021
POLICY

1. During the first 90-days, it is the responsibility of the immediate supervisor to assess all aspects of the employee's
performance, such as technical ability, attendance, relationship with others, adherence to policy, developmental
needs and overall suitability to be a contributing member of the Agency employees.

2. During the first 90-days, should a supervisor identify performance issues with a probationary employee, the
immediate supervisor shall provide feedback clarifying performance expectations. This must be documented in
writing.

3. The Agency may reinstate an employee at their request to a previous position, if one is available, should they not
meet the requirements of the new role. The reinstatement shall only take place with approval from a Chief Officer
and if there has been no breach of the policy.

4. All employees shall have a “90-Day Check In”. The immediate supervisor shall obtain all approval signatures and
ensure that a signed “Performance Engagement Review Template” is completed and submitted to People
Services for placement in the employee’s personnel file.

5. During the first 90-days, should the employee not meet job standards in the opinion of the immediate supervisor
and/or the next higher level of supervision, the employee may be terminated in accordance with Alberta’s
Employment Standards Code and with the approval from the CEO in consultation with Human Resources.

6. During the first 90-days, an employee is not eligible to apply for any other positions within the Agency unless the
direct supervisor's approval is obtained.

7. Any exception to this policy shall be at the discretion of the CEO.

 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: RE-EMPLOYMENT POLICY NO: C.2.26

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis recognize that it is possible for former employees to be re-employed with the Agency. The Agency wishes to
address those situations where employees with prior service with the Agency are re-hired and the process for
accredited service adjustments for re-employed employees.
POLICY

1. The Agency shall make necessary accredited service adjustments as required for employees during
employment that may include but are not limited to:
a. Leave of Absence;
b. Continuous Service is interrupted due to Sick Leave or Long Term Disability; and
c. Change in Classification or Status of Employee.
2. As a result to the changing dates as noted in the above situations an accredited service calculation shall be done
by People Services in concert with payroll with regards to adjusted Service Date (may relate to Anniversary or
Date of Hire); and Vacation Entitlement Date.
a. Employees who are re-employed within three (3) months of their previous termination date:
i. The employee’s original hire date is recognized and service-related benefits (such as vacation and
service awards) are based on this date. Reinstatements for Group RRSP and Life Insurance are based
on the insurer policies.
b. Employees who are re-employed after three (3) months but less than one (1) year of their previous
termination date:
i. The employee’s re-hire date shall be adjusted to recognize the break in service and service-related
benefits (such as vacation and service awards) are based on this service date. Reinstatements for Group
RRSP and Life Insurance are based on the insurer policies.
c. Employees who are re-employed after one (1) year absence:
i. Prior service shall be recognized for service awards only. Returning employees shall work one half the
period of previous service to reconnect for service awards to be considered as one continuous
employment period.
Re-Employment:
3. Candidates wishing to be re-employed by the Agency require at least one (1) satisfactory or better, reference
from their former supervisors. Should their former supervisor be no longer with the Agency, the normal reference
checking process as outlined in the Candidate and Former Employee Reference Check policy.
Employment of Former Clients
4. TRELLIS will allow clients to be employed by the Agency in certain circumstances. Clients must wait 1 (one)
yearfrom program services or participation ending before applying for employment. Once employed, the client
will be treated as any other employee and be subject to all conditions, policies, procedures, and practices of
TRELLIS.
5. The CEO shall approve in writing any exceptions to this policy.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: TERMINATION POLICY NO.: C.2.27

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

Alberta Employment Standards Code
DATE REVISED: May 2019

Trellis shall respect and treat all employment terminations in a fair and consistent mannerthat meets or exceeds
the requirements of Alberta’s Employment Standards Code.

POLICY

1. The CEO shall approve all involuntary employment terminations.

2. The Payroll Administrator or designate shall ensure that a Record of Employment is prepared and supplied
to Service Canada for all employees who have not worked in 3 months or to any person who has terminated
their employment voluntarily within (5) business days after the end of the pay cycle. Employees who have
had their employment terminated will have their ROE filed within (3) business days from their termination
date.

3. An employee who has been employed by the Agency more than once, will have their employment considered
to be continuous if not more than (3) months have elapsed between the periods of employment.

4. At the time of termination, all employees may request or may be requested to participate in an “exit interview”
with the CEO or People Services. During this interview, they are welcomed to freely express their thoughts
about the Agency.

5. With the exception of involuntary terminations for just cause, written notice of termination of employment or
pay in lieu of notice of termination, or a combination thereof, shall be given as required by the Alberta
Employment Standards Code.

6. Terminations for “just cause” require no written notice of termination, or pay in lieu of such notice.

7. Regardless of the type of termination, on the last day of employment all Agency property shall be returned,
including keys, cell phones, laptops and credit/gift cards to the supervisor of the employee. The Finance
Department will be contacted prior to the final pay being issued to determine any outstanding Petty Cash.
These outstanding amounts are to be deducted from the final pay.

8. People Services shall coordinate with Business Operations to ensure that all Agency assets, email,
Sharevision, internet access and building security codes are disabled.

9. Employees will receive

a) Final Pay cheque or pay advice (must be processed within 3 days for all involuntary terminations)
b) Record of Employment (ROE) will be filed electronically upon processing of last pay
10. If possible, any outstanding time off in lieu of overtime shall be taken prior to the termination date at a mutually
agreeable time between the employee and the supervisor.

Termination by Employee
11. If an employee resigns, theyare required to give as much notice as possible, but not less than:

a. One week if employed more than three (3) months but less than two (2) years
b. Weeks if employed two (2) years or more.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: TERMINATION POLICY NO.: C.2.27

Termination by Employer
12. People Services in consultation with the Manager and or Director shall approve all involuntary terminations
in order to maintain the highest quality of employees and to ensure the consistent and fair treatment of
employees. All potential termination actions must be documented and submitted to People Services and
reviewed by the Chief Officers.
13. The following are possible reasons for involuntary terminations, but are not limited to:
a. Elimination of position(s) caused by change to service needs and/or funding agreements;
b. Should an employee hire been conditional upon a satisfactory reference check and subsequent
references do not support the applicant’s suitability for the position;
c. Failure to recognize, work within and respect the authority and accountability structure within the Agency;
d. Incidents of repeated unsatisfactory work, attitude or conduct are cause for dismissal; however, except in
situations where “just cause” can be established, no employee will be dismissed without warning because of
unsatisfactory work, attitude or conduct;
e. Serious violation of Agency policies which may be construed as just cause such as, but not exclusively:
i. Any violation of the rights of children, youth or employees;
ii. Abuse or neglect of children;
iii. Failure to report abuse or neglect of children caused by others;
iv. Physical assault of children;
v. Theft from the Agency including unauthorized use of funds, material or equipment;
vi. Possession and/or use of illegal drugs or alcohol while on Agency business;
vii. Exposure of children, youth or employees to unnecessary risk;
viii. Failure to advise the Agency in a timely manner of a criminal charge or child welfare investigation;
ix. Violation of the Ethical Codes of Conduct;
x. Conviction of a criminal offense or serious driving offense while in the employ of theAgency;
xi. Inappropriate or unauthorized disclosure of confidential information, and;
xii. Violations of any of the Agency policies and procedures.

Vacation Pay:
14. Any vacation or vacation pay owing at the termination date shall be paid out at the time of termination.
Employees leaving voluntarily may not use vacation as part of their notice period.
Overtime
15. Every effort should be made to use accumulated overtime prior to the end of employment, however, any
overtime owing as at the date of termination shall be paid out at time and a half.
Sick Leave
16. Accumulated sick leave credits are forfeited as at the date of termination. Employees who have given notice
are not entitled to use sick leave during their notice period without the approval of a Chief Officer or the CEO.
Group Insurance
17. Group benefits coverage terminates as of the date of termination with the exception of Group Life Insurance
which remains for (31) days and during which the employee may convert to an individual policy without
evidence of good health.
Group RRSP
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: TERMINATION POLICY NO.: C.2.27

18. Contributions to the Group RRSP through TRELLIS will cease as of the date of termination.

Records of Employment

19. Will be issued in accordance with CRA regulations: after 1 week without earnings for full time employees
and 30 days without earnings for part-time employees.

Employees Moving Programs

20. Employees moving from a full time role to a part time role will have their vacation and overtime paid to them
once approved by People Services and Program Manager.

PROCESS

Voluntary Terminations (i.e. Resignations)

1. Employees must provide a written letter of intention to terminate their employment with the TRELLIS to
theirsupervisor. This letter must be forwarded to People Services along with the employee’s reason for
departure within 24 hours of receipt.

2. Upon receipt of notification of termination the Manager/Supervisor must forward an email to

[email protected] within 24 hours. The email should contain the following information: a.
SubjectLine – Name of Employee and program
b. Body of the Email
i. Last day of work
ii. Do they have an email address? Does it need to be deactivated or forwarded?
iii. Do they have a Sharevision account?
iv. Is the employee a Time and Attendance Supervisor? If yes, who should employee(s) reporting to
this individual be delegated to in ADP?
v. Is the employee using any overtime or vacation as part of their notice period? If yes please specify
their last day of vacation.
vi. Is there any outstanding petty cash? vii. Does the employee have an Agency cell phone or laptop?
Who will collect it?

3. People Services will prepare the Employee Termination Form and circulate for signatures.

4. Manager/Supervisor must approve the final timesheet in ADP as soon as possible.

Involuntary Terminations (i.e. Layoffs, Terminations with/without Cause)

1. Managers must meet with People Services to discuss all involuntary terminations.
2. People Services will prepare all the paperwork and circulate for signatures.
3. Managers approve the final timesheet and submits outstanding petty cash amounts on the dayof
termination.
 TRELLIS SOCIETY – LBGCC PROGRAMS

PEOPLE SERVICES
EMPLOYMENT

POLICY: WHISTLE BLOWER POLICY NO.: C.2.28

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARD(S):

OHS Legislation
DATE REVISED: May 2019

Trellis requires that all employees, students and volunteers adhere to high standards of business and personal ethics
in the conduct of their duties and responsibilities. All employees, students and volunteers must practice honesty and
integrity in fulfilling their responsibilities and must comply with all applicable laws, accrediting standards and
regulations.

1. Trellis does not tolerate or condone any degree of fraudulent acts, resource abuse, abuse, neglect,
harassment, workplace violence or bullying in the workplace. Employees, practicum students and volunteers
all have a responsibility to ensure that programs and services are operating in a safe, supportive and
respectful manner. Any person who believes that another person’s actions are not aligned with our Agency
core values has an ethical responsibility to reportwrong-doings.

2. No person reporting a suspected fraudulent act, resource abuse, abuse, neglect, harassment, health and
safety concerns, violence in the workplace or bullying will be subject to disciplinary action (unless the
allegation is found to be baseless, without merit or retaliatory) nor will any retaliatory action be permitted
against the person reporting. If retaliation does occur the person retaliating will be subject to the disciplinary
policy of the Agency.

3. Supporting evidence for the allegations if available is helpful but not imperative.

4. Investigation results will not be disclosed or discussed with anyone other than those who have a legitimate
need to know in order to conduct the investigation. Every attempt will be made to keep the identity of the
person coming forward both anonymous and confidential.

Associated Policies: Harassment in the Workplace, Violence in the Workplace, Reporting of Fraudulent, Resource
Abuse or Other Misconduct Activities.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: VOLUNTEER AND PRACTICUM POLICY NO.: C.3.1

STUDENT DEFINITIONS

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Volunteers are those persons who provide assistance to the Agency (on an unpaid basis, without a
third party involved) in the delivery of service of programs and services. The types of volunteers taking
part at TRELLIS are leadership (i.e. Board of Directors, committees), programs, special events and
administration.

POLICY

1. The Recruitment & Training Specialist, in conjunction with Program Managers, are responsible for
the education and placement of volunteers and practicum students into the appropriate program.

2. Each program will be given a volunteer and practicum student manual as a reference guide for the
management of these individuals. Additional support for volunteer management will be provided on
an as needed basis by People Services.

3. A volunteer must have completed their paperwork and interview process by the organization prior
to completion of the volunteer task. Volunteers come from all sectors of the community: parents
of members; post secondary students; retired persons and the community at large.

4. All employees that are responsible for volunteers will assess the ability of the volunteer to assume
unsupervised status. These assessments will be based on the continuum of risk and the
vulnerability of the clients with whom the volunteer would be working.

5. Types of Volunteers

a. Youth Volunteers – volunteers who are under the age of 18 years and are at least two years
older than the oldest client in the program. They must be supervised by employees at alltimes
and may not work alone with clients. Positions could include Counselors in Training, Keystone
or Leadership.
b. Lead Volunteers - volunteers who are 18 years or older, have a clear Criminal Record Check
(CRIM), a clear Intervention Record Check (IRC), a First Aid/CPR certificate, and have
demonstrated experience within the Agency. All documentation must be on file prior to working
alone with clients. First Aid/CPR training may be paid for by the Agency at the discretion of the
Program Manager.
c. Support Volunteers - Support volunteers do not possess first aid certification and/or may be
under the age of 18.
d. Previous Client Volunteers - volunteers who are 18 years or older and were previously clients
of TRELLIS. These volunteers must wait 1 (one) year from program services or participation
ending before becoming a volunteer. Exceptions to this are at the discretion of
the Chief Operating Officer and CEO in consultation with the Program Manager and People
Services.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: VOLUNTEER & PRACTICUM POLICY NO.: C.3.1

STUDENT DEFINITIONS

Practicum Students

6. Practicum students are those persons who are in “unpaid” positions within Trellis. These students
work for a pre-determined amount of time as dictated through their educational institution, whereby
TRELLIS provides a valuable placement for the student to gain knowledge and work experience.

7. Students are supervised by a full-time TRELLIS employee. Practicum students are not considered
part of program ratios and can at no point be left alone with clients, regardless of completed
paperwork.

8. On occasion some students from certain faculties may hold a “paid” practicum placement and shall
be subject to and treated as a TRELLIS employee.

9. Requirements for a Practicum Student placement are:

a. Available during flexible hours (days, evenings, weekends)

b. Must be at least 18 years of age;
c. Must have a general interest in working with children, youth and families;
d. Must be enrolled in an education program requiring a practicum placement, and;
e. Completed CRIM and IRC on file with People Services prior to commencement of placement.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: VOLUNTEER AND PRACTICUM POLICY NO.: C.3.2

STUDENT EVALUATIONS

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis will ensure that all Volunteers and Practicum Students have a current job description that
outlines the tasks, responsibilities, and expectations of their role.

2. Volunteers receive written evaluations after six weeks and then every May and December of eachcalendar
year.

3. All Practicum Students shall receive two written evaluations, one at the midpoint of their placement and one at
the end final, or as outlined by the educational institution the student is representing.

4. Each Volunteer and Practicum Student reports to a Program Manager or designated employee who meets
with the volunteer regularly to give feedback and conduct the evaluation process.

PROCEDURES - Volunteers

1. The volunteer evaluation process is as follows and uses the Volunteer Evaluation as provided by People
Services:

a. Six Week Experience Review: Conducted six-weeks after the start date of the volunteer.
b. Six Month Review: Completed in May of each calendar year.
c. Annual Review: Completed in November of each calendar year.

2. The Employee Supervisor complete the required Volunteer Evaluation prior to meeting with the volunteer and
conduct the review in person with the Volunteer. The Volunteer and Employee Supervisor must sign off on the
document. If the volunteer does not agree with the feedback given, please refer to the Appeals section below.

3. If concerns arise in regards to the Volunteer’s placement before the evaluation date, the evaluation can be
delivered sooner than the stated period.

4. The Employee Supervisor as well as People Services shall have the responsibility to ensure all evaluations are
completed and are up to date. All written evaluations must be forwarded to People Services and the evaluations
will be filed in the volunteer’s personnel file.

APPEALS

1. If the Volunteer disagrees with the Evaluation, the Volunteer will forward a copy of the Evaluation with awritten
description of their concerns to the Program Manager and People Services. People Services will be
responsible for conducting a mediation meeting to discuss the contents of the Evaluation and resolve the
appeal to better support the volunteer. Actions may include training, clarification on goals or objectives, or an
assignment change.

2. All communication, amendments or signed documents will be forwarded to People Services and included in the
Volunteer’s agency file.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: VOLUNTEER AND PRACTICUM POLICY NO.: C.3.2

STUDENT EVALUATIONS

3. People Services will also be responsible for communicating the results of the meeting with the applicable
Program Manager.

4. If the appeal is not resolved after the initial meeting, please proceed to the Grievance Policy in this section for
the next steps (C 4.4.)

PROCEDURES – Practicum Students

1. The Program Manager Senior Employee or designate must follow the education institutions guidelines for
performing evaluations.

2. Both the Employee Supervisor and student sign off on the evaluations, which will be forwarded to People
Services and placed on the Practicum student’s personnel file.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: FILE MANAGEMENT FOR VOLUNTEERS POLICY NO.: C.3.3

AND PRACTICUM STUDENTS

DATE ISSUED: January 1, 2000 ASSOCIATED STANDARDS:

DATE REVISED: September 2019

POLICY

1. Trellis will ensure that all Volunteer and Practicum Student forms, documents, reviews, supervision, and
correspondence shall be maintained in the Volunteer and Practicum Student files.

2. Each Volunteer or Practicum Student is responsible to provide information when requested in order to maintain
their role with the agency.

3. People Services is responsible for ensuring that all files are up to date and accurate.

4. Records are kept in a secure location, accessible only to the CEO, Chief Development Officer, People Services
and, on request, the Volunteer or Practicum Student’s supervisor.

5. All Volunteer or Practicum Student records can be accessed by the appropriate individual except for the
reference checks and letters of reference. They can be viewed at any time by appointment. Such viewing must
be in the presence of the CEO and or People Services.

6. No document shall be placed on the volunteer or student’s file without them being made aware of it and being
provided with a copy.

7. All volunteers and students have the right to submit a written request to have information changed on their file.
The request should be given to People Services and would follow the normal grievance policy and procedure.

8. Volunteer or Practicum Student records will be kept in live files until they are terminated then, the completed
files will be kept in the archives. The files will be maintained for a period of a minimum of 7 years and then
destroyed utilizing confidential shredding methods.

9. The files will include the following documents (according to the Volunteer File Checklist):

Volunteer File

a. Application Form
b. Declaration of Confidentiality
c. Risk Acknowledgement/Medial Release
d. Resume
e. Interview Questions
f. 2 Volunteer References
g. 1 photocopy of 2 Government issued ID’s, one with a photo
h. Completed IRC and CRC
i. Declaration of IRC and CRC
j. Volunteer Waiver
k. Volunteer Agreement
l. Volunteer Position Description
m. Media Release
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: FILE MANAGEMENT FOR VOLUNTEERS POLICY NO.: C.3.3

AND PRACTICUM STUDENTS

n. First Aid (Lead Volunteers)

o. Drivers Abstract (Mentor’s or Class 1, 2, or 4 Drivers only)
p. Copies of all correspondence regarding the volunteer
q. Recognition and Awards
r. All evaluations
s. Exit Interview

Optional Paperwork (specific to volunteer position requirements)

a. Proof of First Aid Certification (if delivering programs Independently)

b. Class 1, 2, or 4 Driver’s License with S-endorsement (only if driving a TRELLIS NSC vehicle)
c. Driver’s Abstract (if driving youth/families for TRELLIS/$1,000,000 liability)
d. Media Release Form

Practicum Student File

a. Application Form
b. Declaration of Confidentiality
c. Risk Acknowledgement/Medial Release
d. Resume
e. Interview Questions
f. 2 References
g. 1 photocopy of 2 Government issued ID’s, one with a photo
h. Completed IRC and CRC
i. Declaration of IRC and CRC
j. Volunteer Waiver
k. Volunteer Agreement
l. Volunteer Position Description
m. Media Release
n. Copy of Faculty Learning Contract
o. Copies of all correspondence regarding the student
p. Recognition and Awards
q. All evaluations

Optional Paperwork (according to position requirements)

a. Proof of First Aid Certification (if delivering programs Independently)

b. Driver’s Abstract (if driving youth/families for TRELLIS/$1,000,000 liability)
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: VOLUNTEER AND PRACTICUM POLICY NO.: C.3.4

STUDENT GRIEVANCES

DATE ISSUED: January 1, 2000

DATE REVISED: May 2019

The Agency shall maintain a fair and open working environment in which volunteers and practicum student’s
differences are resolved through open communication and consultation.

POLICY

1. Trellis shall provide a grievance procedure to ensure that Volunteers and Practicum Students are ensured a fair
and objective method to express and obtain a resolution to their concern(s).

2. The CEO shall be responsible for rendering final and binding decisions for Volunteers and Practicum Students
grievances.

3. In the event that the CEO is named in the grievance, the People Services Manager and other designated
management shall assume the role to render final and binding decisions for employee grievances.

4. An Employee, Volunteer or Practicum Student shall first take all reasonable actions to settle the unresolved
matter through discussion with their Employee Supervisor.

5. An Employee, Volunteer or Practicum Student can submit a formal grievance within ten (10) working days if an
individual’s concern(s) are not satisfactorily resolved. The grievance needs to be stated in writing and submitted
to their supervisor and People Services.

6. If the grievance was directed towards their supervisor, the grievance stated in writing needs to be submitted to
the supervisor’s Manager with a copy to the People Services Manager.

7. Upon receipt of the written grievance, the Supervisor, Program Manager, and People Services Manager will meet
to discuss the grievance.

8. If the grievance is against another Employee, Volunteer or Practicum Student they will be notified at this point.
If further information is required the People Services Manager will gather such information by whatever method
is feasible. It is possible that the grieving individual will also meet with this group to supply furtherinformation.

9. The Program Manager and People Services Manager will prepare a written response to the employee,Volunteer
or Practicum Student within (10) working days. The response will be approved by the appropriate Chief Officer
and/or CEO (assuming the Chief Officer/CEO is not acting in the role of Manager as mentioned above).

10. Upon approval from the CEO, the written decision will be submitted to the Employee, Volunteer or Practicum
Student. The decision will be final and binding.

11. If the grievance is lodged against the Manager or a Director, the same procedures will apply. The grievance will
be submitted to the supervisor or the Manager or Director. The People Services Manager will be advised and will
follow the same procedures as stated above.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: VOLUNTEER AND PRACTICUM POLICY NO.: C.3.4

STUDENT GRIEVANCES

12. In the event that the grievance concerns the CEO, the Employee, Volunteer or Practicum Student, will as an
initial step, consult with the People Services Manager to develop a reasonable plan to address the grievance.

13. All grievances submitted and documentation arising from the grievance shall be kept in strict confidence and
shall be kept on file with the People Services Manager.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: HIRING OF PRACTICUM STUDENTS POLICY NO.: C.3.5

DATE ISSUED: July 2010

DATE REVISED: May 2019

POLICY

1. Unpaid Practicum Students are not Employees of Trellis and are not subject to financial remuneration for the
learning-work place experiences in which they are involved. Trellis partners with learning institutions in their area
to assist in the development of potential employees for the sector.

2. When developing a Practicum Student’s learning contract it is the policy of the organization that a student must
successfully fulfill the learning contract in the area in which it was developed. For example, a Practicum Student
at Bowness Group Home should fulfill their entire practicum at that location; unless it was agreed in the learning
contract that the student could move around TRELLIS to gain other learning “work” experiences in other
departments.

3. It is the understanding of the Agency that students will not be hired prior to successfully completing their learning
work place experience.

4. Practicum Students must complete a practicum file with People Services and/or the workplace supervisor
including a valid Intervention Record Check (IRC) and a Criminal Record Check (CRIM) dated within 6 months
of the start of their placement or complete the required paperwork through the agency.

5. Practicum Students will sign a Declaration of IRC and CRC form in the interim of their checks returning to the
agency. This must be completed before the student can start in their perspective program.

6. All Practicum Student information must be kept in a locked private space at the Program.

7. Practicum Students must not be alone with children or youth unless it is agreed in their learning contract and they
have provided the Agency with a valid First Aid and CPR certificate, along with a complete Practicum Student
file.

8. Hours of practicum must be reported monthly to People Services.

9. Upon completion of the practicum, the file must be sent to People Services for archiving or to complete the hiring
process.

10. If a student demonstrates an innate ability to perform their duties above and beyond their placement requirements
and the Agency is considering the Practicum Student for a paid position prior to completing their practicum this
can only occur with the discretion of a Chief Officer and all appropriate processes of hiring must be followed in
consultation with People Services.
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PEOPLE SERVICES
VOLUNTEERS AND PRACTICUM STUDENTS

POLICY: REFERENCES FOR VOLUNTEERS AND POLICY NO.: C.3.6

PRACTICUM STUDENTS

DATE ISSUED: January 1, 2006

DATE REVISED: May 2019

POLICY

1. Trellis shall provide verbal and written references for Volunteers and Practicum Students provided that written
consent from the individual is obtained, this written consent must be kept on the individuals file.

2. When approached to provide a reference on the behalf of a Volunteer or Practicum Student, employees are to
contact the People Services Manager.

3. The People Services Manager, will then direct the employee accordingly as to the type of reference that can be
given.

4. People Services will place the individual’s written consent on their permanent agency file kept at the admin centre.

5. In the case that a written reference is requested for an educational institution or on the behalf of a Volunteer, the
People Services Manager will inform the employee as to the process which should be followed. Each request will
be handled on a case by case basis.
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PEOPLE SERVICES
VOLUNTEERS AND PRACTICUM STUDENTS

POLICY: SCREENING VOLUNTEERS AND HIRING POLICY NO.: C.3.7

PRACTICUM STUDENTS

DATE ISSUED: January 1, 2000

DATE REVISED: September 2019

POLICY

1. All Volunteers and Practicum Students who have direct contact with clients or access to documentation related
to client and agency services must successfully complete the screening process.

2. Unpaid Practicum Students are not employees of Trellis and are not subject to financialremuneration for the
learning “work” experiences they are involved in.

3. Any deviation from the process or exemption of the requirement of a clear Criminal Record Check and
Intervention Record Check must be approved through a written explanation of the exemption from the CEO.

PROCEDURE – Volunteer Placement

1. All volunteers must complete an application and Confidentiality Agreement.

2. Volunteers must submit 2 character-based references (one to be checked verbally).

3. Complete an Intervention Record Check (IRC) and Criminal Record Check (CRIM) screening. If the volunteer
presents with an approved CRC and IRC, they cannot be back dated more than 6 months previous to their
interview with TRELLIS. **All IRC and CRC will be updated every three years.

4. Provide copies of government issued photo ID and non-photo ID (i.e. SIN card, birth certificate, health care
card) to be submitted with the IRC and CRC’s. A copy of their ID will also be kept in their volunteer file.

5. Fill out a Declaration of Criminal and Child Welfare Check.

6. Fill out the volunteer waiver and agreement.

7. Fill out a position description specific to the program they will be volunteering in.

8. Be referred to a program that appears to be the best match.

9. Be interviewed and accepted by the Program Manager, Senior Employee, and/or program specific designatefor
that program.

10. Read and review the self study module orientation (if required).

11. Read and review the Volunteer Orientation book located at each facility.

12. If they will be working as a lead volunteer they must provide a copy of their First Aid/CPR certification.

13. If they are going to be driving for the agency they must provide a copy of a Class 1, 2, or 4 driver’s license with
the S-endorsement, a driver’s abstract and copies of their current insurance and registration documents. As well,
they must have completed the other necessary steps in driving non-NSC and NSC vehicles as outlined in other
policies.
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PEOPLE SERVICES
VOLUNTEERS AND PRACTICUM STUDENTS

POLICY: SCREENING VOLUNTEERS AND HIRING POLICY NO.: C.3.7

PRACTICUM STUDENTS

Points of Consideration for Volunteers

1. If the Program Manager or Employee Supervisor does not feel the volunteer is appropriate please refer to the
Volunteer Policy and Procedure Manual under, Volunteer Screening Procedures, Turning Someone Down.

2. All volunteers wishing to offer their services in residential care must be a minimum of 24 years of age or older.

3. All volunteers wishing to offer their services to Shelters and SCRIPT must be a minimum of 21 years of age or
older. These age restrictions are for specific programs to ensure there is an appropriate age differentiation
between child and youth served and volunteers.

PROCEDURES – Practicum Student Hiring and Placement

1. Practicum students must fulfill their entire practicum at their designated location; unless it was said in the learning
contract that the student could move around TRELLIS to gain other learning “work” experiences in other
departments.

2. It is the understanding of the agency that students will not be hired prior to successfully completing their learning
“work” experience.

3. If a student demonstrates an innate ability to perform their duties above and beyond their placement
requirements and the agency is considering the practicum student for a paid position prior to completing their
practicum this can only occur with the discretion of an agency director and all appropriate avenues of hiring must
be followed through the People Services department.

4. Practicum Students must successfully complete the following, prior to beginning their placement:

a. A resume must be provided.

b. Completion of a successful interview with the Program Manager or Employee Supervisor.
c. Declaration of Confidentiality
d. Completion of the Criminal Record and Intervention Record Checks with a clear record. If the IRC and CRC
are not provided by the student, TRELLIS will proceed with the process on their behalf. The student may not
start their placement until these checks have been returned, clear.
e. Complete an agency orientation with the Program Manager.
f. Attend trainings as deemed necessary by the Program Manager.
g. If the student presents with an approved CRC and IRC, they cannot be back dated more than 6 months
previous to their interview with TRELLIS.

Points of Consideration for Practicum Students

1. If the Managerof the program does not feel the practicum student is appropriate, a report will be made to the People
Services Manager and a second referral will be made within the organization pending the outcome of the report.
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PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: SPECIAL EVENTS VOLUNTEERS POLICY NO.: C.3.8

DATE ISSUED: July 2010

DATE REVISED: May 2019

This Policy applies to all adult and youth volunteers who will be volunteering in one-time TRELLIS special events.

Well planned volunteer roles and supervision help to ensure the volunteer’s experience is positive for both the
individual, employees and event participants with whom they are working.

If a volunteer will be taking part in a special project that will be offering repeat services to clients (i.e. teaching a
dance class, yoga, etc) please refer to the Special Project Policy in this manual on how to proceed.

POLICY

1. Each volunteer will be responsible to the TRELLIS employee designated supervisor of the special event.

2. The appropriate designate shall sit down with the volunteer and ensure all special event paperwork is
completed and an orientation on the event has been given (either prior to or on event day).

3. On the day of the event the employee designated supervisor will be responsible for ensuring the volunteer
receives an orientation to their role and that they are carrying out their role throughout the event.

4. All employees participating in the event has a responsibility to ensure that the volunteer receives proper
supervision.

PROCEDURES

1. The TRELLIS employee designated supervisor will be responsible for the development of all one-time
specialevent volunteer position descriptions (including roles and duties) and schedules.

2. The Employee Supervisor will complete the Special Event Forms and submit them to People Services at least a
month prior to the event so they can start recruiting volunteers.

3. People Services will then send out emails to TRELLIS’s special event volunteers, phone current volunteers
andpost the position description where applicable. (i.e. Volunteer Calgary)

4. When Volunteers are recruited, People Services will give the Employee Supervisor the volunteer’s contact
information, and/or their completed Special Event Application/Waiver.

5. As part of the supervision, the Employee Supervisor shall ensure that all screening paperwork is completed and
up-to-date as per the Volunteer Special Event procedure (found in the Employee Volunteer Manual). If they want
to be a regular volunteer, they must fill out the paperwork before volunteering again.

6. The Employee Supervisor will then phone each special event volunteer providing them with the details on the
event (i.e. date. Location and time) and their role. After the initial phone call, the supervisor will add each volunteer
to the, Special Event Volunteer Sign-in sheet.

7. On the day of the event the employee designated supervisor will provide the Volunteers an orientation to their
role, answer any questions the Volunteer may have and introduce them to other employees working at the
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PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: SPECIAL EVENTS VOLUNTEERS POLICY NO.: C.3.8

event. The supervisor will also sign each Volunteer in and out, based on the Special Event Volunteer Sign-in
Sheet.

8. Upon completion of the event, the Employee Supervisor will be responsible for filling out the, Special Event –
Volunteer Completion Form and submitting all associated forms to People Services no later than five days after
the event.

9. The employee designated supervisor will also be responsible for sending each volunteer a thank you note or
card upon the completion of the event.

10. All Special Event Volunteers will be added into Razor’s Edge for tracking purposes and will be added to the
Volunteer email list, unless otherwise specified by the Special Event Application, as per Canada Anti Spam
Legislation (CASL), as of July 01, 2014.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: TERMINATION OF VOLUNTEERS AND POLICY NO.: C.3.9

PRACTICUM STUDENTS

DATE ISSUED: January 2010 ASSOCIATED STANDARDS:

CARF – Human Resources
DATE REVISED: May 2019

POLICY

1. On occasion there will be volunteers and students who will have performance related issues and will need to be
removed from programs. This can be for a myriad of reasons, which may include, but not limited to:

a. Disrespectful attitude
b. Consistently being late
c. Not showing up
d. Disagreements with employees and volunteers
e. Safety concerns regarding clientele

It should be noted that if a volunteer engages in behaviours that in any way physically or emotionally harms a client,
employee or volunteer, the volunteer will be asked to leave the Trellis effective immediately.

2. Before recommending a volunteer or student to be terminated, there should be careful consideration toretain
the volunteer in a different capacity. This includes:

a. Defined expectations and behaviours (as per the Volunteer Agreement and Position Description)
b. Regular & consistent supervision
c. Regular & consistent attendance reporting
d. Defined & regular evaluations
e. Performance Improvement Program
f. Grievance Process (if applicable)

3. In order to complete the Termination process, People Services will document the issue capturing (in detail) the
events that occurred before and during the issue. This can be documented through a Critical Incident Report
(CIR) or an email to the Program Manager.

4. If the issue is ongoing and correctable, it should be documented in the Volunteer Evaluation with a
development plan for improving of the issue(s). This should be on file with People Services upon completion.

Termination of a Non-Performing Volunteer or Student

5. When no other course of action appears to be reasonable, the supervisor will contact the People Services
Manager to initiate the termination process.

6. The People Services Manager will then discuss the termination with the Program Manager and Director.

7. The CEO must be advised of and approve all Volunteer dismissals.

8. The People Services Manager will draft a dismissal letter, and set up a meeting with the volunteer and Program
Manager, to be conducted in person and in private.

9. If the volunteer or student refuses to come in for the meeting, please let them know that there will be no other
course of action for them and that they will be relieved of their services with Trellis effective immediately. Mail
them the termination letter, and place a copy in the file.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRATICUM STUDENTS

POLICY: TERMINATION OF VOLUNTEERS AND POLICY NO.: C.3.9

PRACTICUM STUDENTS

10. If the volunteer or student agrees to come in for the meeting, they will be presented with the dismissal letter. The
People Services Manager and Program Manager will discuss in an honest fashion the steps taken to retain the
volunteer or student, but be firm in the dismissal.

11. The People Services Manager and/or Program Manager will contact all concerned parties and advise them of
the dismissal. Documentation and informing the applicable employees, student and volunteers ends Trellis’ legal
relationship with the person.

Immediate Termination

12. If a Volunteer or Student engages in any of the following behaviours or actions they will be immediately dismissed
from their service with Trellis:

a. Not upholding an environment that is safe, supportive and protects members from the threat of emotional,
physical, mental, verbal or sexual abuse
b. Breaching the Non-Discrimination/Equity Policies
c. Engaging in alcohol or drugs when representing Trellis
d. Breaching the oath of confidentiality
e. Not adhering to our professional behavior policy

Closing a Volunteer or Student’s File

13. Once the termination process has been completed it is the responsibility of the supervisor and People Services
Manager to close the file. It will be the supervisor’s responsibility to forward any remaining paperwork to the
People Services Manager.

14. People Services will update the Volunteer Database when applicable and place the file in the inactive volunteer
filing cabinet. The file will then be archived for a seven-year period.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PEOPLE SERVICES
VOLUNTEERS AND PRACTICUM STUDENTS

POLICY: TRANSPORTING CLIENTS See Driver & Transportation Policy on ADP

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FACILITIES AND EQUIPMENT

POLICY: CELL PHONES POLICY NO.: D.1

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF - Technology
DATE REVISED: May 2019

The Agency recognizes that cell phones are required in some programs as a means to communicate as a function
of their position, for emergency situations and when employees are required to work alone in the community.

POLICY

1. When employees bring personal cellular phones to work, they must ensure that calls do not interfere with
program responsibilities. Cell phones should be turned off or silenced when working. .

2. Employees may take personal calls of importance discreetly but keep calls brief. Calls must be kept toa
minimum and should not be a daily occurrence.

3. No information about TRELLIS should be stored on personal cell phones. Information regarding clients and
allcontact information must always remain confidential and private.

4. Employees who are not provided with a cell phone as a function of their job will not be personally reimbursed
unless there is written approval by the Program Manager and Program Director.

Use of Agency Cell Phones

5. All Agency cell phones must be password protected.

6. Employees are responsible for the care of the phone and phone accessories. Should it become lost, stolen, or
damaged, employees will be held responsible for repair or replacement costs. In the event that this occurs,
employees must immediately notify their supervisor and Administration Coordinator. Reasonable arrangements
for payroll deduction will be made for reimbursement to avoid undue hardship on the employee.

7. Employees may use this phone for reasonable personal use however are fully financially responsible for
downloads (e.g., ringtones, games, etc.), any texting fees, and personal long distance charges. Please inform
your supervisor and the Administration Coordinator if you plan to incur these charges. Cell phone bills are
reviewed monthly by the Agency and employees incurring personal charges will be responsible for the full
reimbursement.

8. Employees who plan on taking their cell phone out of the country must notify their Program Supervisor and
Administration Coordinator prior to travel. It is the expectation that employees will be fully responsible for any
charges incurred as a result of travel unless usage has been pre-approved by the Program Manager and
Program Director.

9. Cell phone numbers may appear on Agency communications and on business cards.

10. Cell phone and data plans vary depending on your device and/or provider. Please check withthe
Administration Coordinator for the most up-to-date plan information for your device.

11. Employees are asked to use their discretion when connecting to internet browsers, search engines, GPS,etc.
with Agency mobile devices unless approved by TRELLIS for internal usage. Employees using these
features resulting in high data use will be charged for usage.
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POLICY: CELL PHONES POLICY NO.: D.1

12. TRELLIS employees must adhere to the Driver’s Safety Manual and cannot use cell phones while driving. In
theevent of an emergency, employees must park the vehicle prior to making or receiving a call.

13. TRELLIS employees are expected to use appropriate etiquette when using this device for work purposes
(e.g.,silencing the phone during meetings, trainings or workshops, unless previously arranged with the
facilitator).

14. Employee’s acceptance of the phone does NOT imply they are available to the Agency at all times. Regular
work schedules and expectations for availability continue to apply.

15. The cell phone must be immediately returned when an employee is no longer with the Agency or in the event of
an extended leave from the Agency. Employees are not permitted to take the Agency phone or cell number
with them unless approved by a Chief Officer. An asset return form must be completed and given to employee’s
supervisor on employee’s last day. The cell phone is considered returned when the asset return form, phone,
and all associated accessories (including charger) are given to the Administration Coordinator.

16. Agency cell phones should not be used by non-employees, except in emergency situations and under
supervision by the employee, due to confidential information stored on the devices.
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FACILITIES AND EQUIPMENT

POLICY: COMPUTER USAGE POLICY NO.: D.2

DATE ISSUED: August 2003 ASSOCIATED STANDARDS:

CARF – Technology
DATE REVISED: Oct 2019

The purpose of this policy is to provide guidance to computer users on matters relating to the usage of the
TRELLIScomputer systems, access to information stored and use of the internet.

POLICY

1. All usage of TRELLIS computer systems must be for purposes benefiting the Agency and must be used in an
ethical manner.

2. Users of the Agency’s software must respect licensing agreements and comply with purchasing agreements.

3. All software and hardware installations must be performed by an authorized person (deemed the Network
Administrator) operating on behalf of the Agency. These installations must have been approved in writing by the
Program Manager. Removal of hardware, software and computer related supplies and documentation is to be
done only with the approval of the Business Operations Manager.

4. Each user who has been assigned a log on ID and password into the Trellis network must changetheir password
and keep that password confidential. Passwords can be reset by the Network Administrator and/or the
Administration Coordinator. It is the responsibility of each user of the network to ensure their activities are
performed in such a manner as to protect the security of the computer system. Passwords must be changed
every 12 months at a minimum.
5. Use of the internet is continually monitored by the Network Administrator and inappropriate use of the internet
will be reported to the Business Operations Manager, who will then alert the appropriate Manager/Director. The
Agency Senior Leadership team can at any time request a log of the internet sites that employees are accessing.
This information can lead to disciplinary notice to the identified employee.

Software Licenses

6. Software (or the respective license) that is owned by the Agency will be installed onto Agency computers. Loaned
software, downloaded software or games are absolutely not permitted on Agency computers or servers.

7. The Agency will accept donated software that meets with the standard operating system and computer programs
that have been approved by the Network Administrator or a Director of Service. Employees are not to purchase
software without permission. Software is not to be duplicated for any purpose.

Supplies and Documentation

8. All hardware, software, computer related supplies and documentation are the sole property of the Agency. This
includes workbooks or textbooks received by employees when taking a computer course paid for by the Agency.
This property must not be removed from the Agency without approval from the Business Operations Manager,
and must be returned to the Agency in a pre-determined time.

Physical Security

9. Users of the computer systems are expected to avoid any activity around the workstations that may result in
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FACILITIES AND EQUIPMENT

POLICY: COMPUTER USAGE POLICY NO.: D.2

damage to the computer, software or information.

10. Laptop computers should be locked up when not in use. Laptop locks will be provided. All employees must use
a security cable to keep the laptop physically attached to an immovable object at all times. If possible, employees
must avoid leaving their laptops unattended in an automobile. If they must do so temporarily, the laptop must be
placed in the trunk. Laptops that will not be used for several days or longer must be locked out of sight in a
secure cabinet or safe.

Business Use

11. Usage of the computer system must be done in an efficient manner that avoids monopolizing systems and
connect time, disk space and other computer resources. It is the responsibility of each employee to keep their
files and directories current. Any outdated information should be deleted, or if requested to the Business
Operations Manager, can be archived. Only information that will be reused should be stored on the network.

12. The Agency has deemed certain web sites as undesirable and these are blocked for usage by employees. This
list is maintained by the Network Administrator who ensures tight controls.

13. Technology Training - IT related to job duties (initial and ongoing) At staff orientation (first day), new staff are
shown how to use agency wide platforms and technologies (ADP, Pingboard, Absorb, etc.). Following that
training, program Managers or other team members are responsible to train new staff on program specific
platforms (Sharevision, Certify, Freshdesk, etc.) on a need-to-use basis.

14. Cybersecurity - Staff orientation covers the basics of Cybersecurity, both through conversation and a video.
Additionally, absorb has several Cybersecurity Awareness trainings which staff are to complete at least once
(1) a year. Additionally, TRELLIS's third party IT provider will send out regular spam/phishing emails to all
TRELLIS users to test susceptibility. Users that fail the test are directed to a site to immediately preform
additional Cybersecurity training.

Personal Use

1. Personal use of Agency computers must be infrequent, of short duration and on the employee’s own time. No
personal files may be saved to the Agency’s network. Accessing inappropriate web sites (which can be tracked
by the Network Administrator or the designate) are also prohibited and may result in a loss of access as well as
other disciplinary and/or legal action.

2. Downloading of personal files or programs onto Agency computers is forbidden.

Anti-virus, Spam and Firewalls

3. Anti-virus, firewalls and spam notification software has been installed on the network. The Network
Administrator will do frequent remote checks of the computers to ensure that the anti-virus and proxy filters are
working appropriately. Employees are prohibited from disabling any of these security measures unless
approved by the Network Administrator.

Electronic Messaging/Emails

4. The Agency recognizes that the electronic mail system is a core communication tool. Users of the computer
system are prohibited from transmitting fraudulent, harassing, obscene or otherwise inappropriate messages
and files.
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POLICY: COMPUTER USAGE POLICY NO.: D.2

5. Users must not send any electronic mail or other form of electronic communication by forging an identity or
attempt to conceal the origin of the message in any way.

6. Users must ensure that their spam and junk email boxes are emptied frequently.

7. Users should ensure that emails are either archived or deleted within 3 months of receipt due to the volume of
emails and users on the exchange server.

8. Users will not use any other accounts except Agency email accounts for Agency-related business.

9. Employees, when accessing their email from a non-Agency computer, must ensure that the privacy and
confidentiality of the email is protected and that any Agency information is not downloaded.

10. Users must ensure that the privacy statement and auto signature is set as a default in keeping with Agency
practice.

11. Agency signatures are to be set up for email accounts on Agency cell phones.

Use of the Internet

12. The Internet will only be used for business, research, and/or educational purposes that are consistent with the
values and mission of TRELLIS.

13. Participation in newsgroups, discussion groups, forums and chat lines must be restricted to business, research,
and/or education related to the organization’s mission and values and must have the approval of the Program
Manager.

14. Users are not to download programs into their computer system without prior consent as these can contain
harmful actions to the computer’s operating systems.

15. Inappropriate materials must not be downloaded by any employee, volunteer or client. For research on specific
programs (e.g., sex trade and youth) permission to access certain web sites and materials must be obtained
from the Program Manager and reported to the Business Operations Manager and the Network Administrator.
Accessing and/or down loading any materials that can be considered or interpreted as inappropriate may result
in a loss of access is prohibited.

16. Employees must supervise and monitor the use of computers and Internet access by clients to ensure that the
above principles are adhered to. Clients can be very vulnerable with respect to the internet, chats, and interactive
sites and safety and wellbeing must be a priority.

17. Sites can be blocked without warning or explanation by the Network Administrator (as directed by either Directors
of Service or Managers).

18. If an inappropriate site is accidentally accessed this must reported immediately to the Program Manager.

19. Downloading of any copyrighted content is prohibited. This includes, but is not limited to, images, music, movies,
books or presentations.

Social Networking Sites

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POLICY: COMPUTER USAGE POLICY NO.: D.2

20. Programs will work directly with Communications to build and monitor their social networking site (refer to
Communications Social Media Policy).

21. All employees, students and volunteers of the Agency should ensure that networking sites set up for personal
use should not provide information about the Agency that would have a negative impact in the community.
Information about Agency clients should never be posted as per the Confidentiality policy.
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FACILITIES AND EQUIPMENT

POLICY: CONFIDENTIALITY OF INFORMATION POLICY NO.: D.3

TECHNOLOGY

DATE ISSUED: August 2003 ASSOCIATED STANDARDS:

CARF – Legal Requirements
DATE REVISED: April 2018 CARF - Technology

POLICY

1. All information researched, developed and gathered by Trellis employees and volunteers in the pursuance of
completing their job belongs in whole to the Agency. This information shall remain confidential to the Agency and
be used solely for the purposes of running the Agency’s business, unless written approval is given by the CEO to
use the information for other purposes.

2. All information stored on the computer systems, iPhones and other electronic devices should be assumed to be
private and confidential to the assigned user unless another user has been given explicit permission to access
and use the file.

3. Employees may not store or keep pictures or videos of clients on their personal devices including their cloud.

4. It is the responsibility of each employee, volunteer and contractor to ensure the information they are responsible
for is securely stored within the network and can be retrieved as required for normal business functioning.

5. Employees will store their computer files within their password protected directory unless it is a file that is shared
amongst employees (thereby saving the file on the computer’s common (or shared) directory. This includes all
memory sticks and electronic devices with Agency information stored on them.

6. All servers are backed up daily and an offsite copy is maintained.

7. Employees will be issued a password that is not to be given to volunteers, clients or other individuals who may
be using the Agency computers. The Network Administrator does not have access to passwords, instead can
only reset the password if requested.

8. When an employee leaves the Agency, the information on that employee’s directory is to be directed as per the
supervisor and the disposition of the contents must adhere to the Intellectual Property policy.

9. Contacts and donor information is the sole intellectual property of The Agency.

10. Employee intranet access (through the website) is prohibited by former employees. Access to databases will be
deleted upon termination.

11. Computer users must not engage in activities intended to circumvent computer security controls such as:
creating, modifying or executing programs designed to surreptitiously penetrate computer systems or programs;
use of a proxy server, attempting to crack passwords; trying to discover unprotected files; or attempting to decode
encrypted files. Users must not try to access the accounts of others with the intent to read, browse, modify, copy
or delete files or directories unless explicit permission to access and use the file has been given byan authorized
employee (i.e., supervisor or author of file). Users are expected to use software programs and accounts only for
the purposes for which they were intended by the Agency. Disciplinary action may occur if such activities occur.
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POLICY: CONFIDENTIALITY OF INFORMATION POLICY NO.: D.3

TECHNOLOGY

12. The destruction of any Agency document is prohibited in the event that any legal process is initiated.
Documentation is defined for the purpose of this policy as any document that contains any information regarding
a client or that of Agency operations. If the non-destruction of this information has an impact on the Agency’s
computer systems and its functioning, the Agency will work with the Network Administrator, in consultation with
legal advice, to save information using alternative methods.

Decommissioning of TRELLIS Hardware

TRELLIS is committed to the safe and secure decommissioning and disposal of hardware. When decommissioning
hardware, following standards and well-documented practices are critical in ensuring security and environmental
needs are met. Assets will not be unnecessarily wasted or given to individuals outside the organization, data stored
on hardware will be properly backed-up as needed prior to being securely purged.

Decommissioning Responsibilities
Decommissioning of hardware (whether due to obsolescence, failure, or another reason) will be the jurisdiction of the
external IT agency provider (TWT) and in coordination of the internal IT lead at TRELLIS who will work with any
related owners/stakeholders (e.g., finance, if this involves an accounting system or HR if it is a payroll).

Disposal of Hardware
Organizational hardware, such as laptops, desktop computers, keyboards, mice, computer screens and iPhones are
to be properly recycled through a third-party electronic recycling company, such as the Electronic Recycling
Association (ERA). TRELLIS is devoted to ensuring all data is removed prior to recycling devices with companies
that are performing on and off-site data destruction to prevent information being recovered. Upon request, the ERA
will provide a Certificate of Data Destruction.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FACILITIES AND EQUIPMENT

POLICY: FACILITY STANDARDS POLICY NO: D.4

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS

DATE REVISED: May 2019

Trellis and its employees strive to ensure that all programs and facilities are well maintained, in good repair and
maintain a high standard of safety and sanitation.

POLICY

1. Programs in the Agency providing 24 hour care will follow the guidelines of the current licensing body. In addition,
programs will also follow the draft guidelines as established by Alberta Health Services for Social Care Facilities.

2. Programs providing 24 hour care will minimally provide:

a. An atmosphere that is pleasant and conveys dignity and respect for the clients served;
b. Bedrooms that are furnished to meet the needs of clients;
c. Bathrooms that are conveniently located, hygienically maintained, and appropriately partitioned for privacy;
d. Areas where clients in residential programs can study, dine, play, and meet with family members and
significant others, and;
e. Private offices or rooms available for the interviewing or counseling of clients and/or families.

3. All programs will ensure compliance with the requirements of Occupational Health and Safety, Alberta Health
Services and the Emergency Response procedures.

4. Pets are not permitted in facilities that are required to follow the Social Care Facilities guidelines as part of
licensing unless specifically indicated in the approved list. Pets that are brought to a program to visit must
remain outside of the building.

First Aid Kits

5. Each program and facility will have a stocked first aid kit that is clearly identified and accessible to employees
and clients and contain the contents as outlined in the First Aid Kit policy.

6. Any medical supplies used from the first aid kit must be documented in the program communication book and
replenished. Managers will assign an employee to monitor the contents of the kit and purchase new supplies as
needed.

Food Safety

7. All employees must thoroughly wash their hands before handling any food in the program. Proper washing
dictates that hands and exposed arms should be lathered with soap for at least 20 seconds before rinsing under
clean warm water. Proper drying of hands and arms is done with a single service towel or hot air dryer.

8. Precautions will be taken to ensure that food products and household cleaning products are stored appropriately
and will include the following:

a. All perishable food products will be refrigerated. All leftovers will be sealed and labeled with a description of
food and date prepared.
b. Any products that could pose a health problem or that could be abused (e.g., vanilla extract, cleaning
supplies) will not be directly accessible to the clients.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

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POLICY: FACILITY STANDARDS POLICY NO: D.4

c. Direct service workers involved in meal preparation will be aware of proper cooking and food preparation
techniques.

9. Programs must develop cleaning schedules for such items as:

a. Refrigerator;
b. Freezer;
c. Oven and;
d. Food cupboards, etc.

Entrances and Doorways

10. All entrances, stairwells and doorways must be clear and maintained.

11. Under no circumstances should emergency exits be inaccessible.

12. Entrances should be well lit and easily accessible to employees, clients and thecommunity.

13. Employees working within different worksites may be responsible to assist in clearing and/or maintaining of
entrances, stairwells and doorways.

14. Any employee who is aware of a hazard should make every effort to rectify the situation and report it directly to
their supervisor.

Damage and Theft

15. All damage or theft to programs and vehicles must be reported immediately. Employees must notify their
immediate supervisor as well as complete an Agency Critical Incident report.

16. Any damage that results in a safetyhazard to clients or employees must be addressed immediately.

Storage

17. No combustible materials are permitted in mechanical or furnace rooms.

18. The mechanical and furnace rooms shall not be used for storage.

Hazards and Hazardous Materials

19. Each employee, student or volunteer is responsible for reporting hazards to their Manager if the situation
cannot be rectified immediately.

20. The Health, Safety, and Wellness Committee facilitates hazard assessments twice a year to ensure that all
programs are operating in a safe manner.

21. All hazard materials will be stored and disposed of in a safe manner. In the event that a specific item will not be
accepted at a disposal station, the employee will follow disposal instructions from Poison Control Center or the
Fire Department. Hazardous materials that require special disposal are, but not limited to:
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FACILITIES AND EQUIPMENT

POLICY: FACILITY STANDARDS POLICY NO: D.4

a. Biohazard substances or bodily fluids that could cause infection (refer to Universal Precautions policy);
b. Industrial and toxic cleaning supplies;
c. Paints and paint thinners;
d. Batteries;
e. Fluorescent lights bulbs;
f. Copier toner, and;
g. Computer monitors or other electronic equipment.

Program Property

22. Each Manager is responsible for ensuring that the exterior of the program is maintained, in good repair and hazard
free. This includes conformance with all City bylaws, removal of debris and snow as well as all general
maintenance of the property.
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FACILITIES AND EQUIPMENT

POLICY: KEYS POLICY NO: D.5

DATE ISSUED: April 15, 2004 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis strives to ensure that programs and confidential information are kept secured at all times. Employees will have
access to program keys and assume full responsibility for knowing their whereaboutsat all times.

POLICY

1. Program Managers are responsible for distributing keys, ensuring employees return keys uponleaving the
Agency. Supervisors are responsible for knowing which keys employees have been assigned.

2. The Business Operations Coordinator is responsible for distributing and assigning keys for the Renfrew facility
and Hangar.

3. The Administration Coordinator will maintain a copy of the front door key for all Agency facilities.

4. Full time employees will be provided their own program keys. Depending upon their role in the Agency, part- time
employees may also have keys. The request will be made by the Program Manager if this is required. Employees
must sign off on a key form when they receive the key.

5. Keys will never be given to clients. While on shift, employees should know the whereabouts of the program
keys at all times.

6. If you lose your keys, you must notify your Manager or On-Call Supervisor immediately. Do not leave the
office unattended if you cannot lock it.

7. Should an employee lose or have their keys stolen they may be expected to reimburse the Agency the cost of
re-keying. Reasonable arrangements will be made for reimbursement to avoid undue hardship on the employee.

8. Employees must return keys to their immediate supervisor (or delegate) on their last day of employment.

9. Should an employee leave the Agency and not return their keys, re-keying costs may be deducted from their
final pay.
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FACILITIES AND EQUIPMENT

POLICY: MAINTENANCE OF FACILITIES POLICY NO.: D.6

DATE ISSUED: July 8, 2003 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

In order to provide and deliver services to clients, Trellis can hold capital assets. These capital assets may range
from buildings to large and small equipment. To maintain high quality, functional assets, Trellis will institute a
maintenance program. This policy is intended to provide guidance regarding the maintenance of the assets required
in the delivery of services and applies to all TRELLIS facilities, equipment, furniture and appliances.
POLICY
1. The Business Operations Manager is responsible for maintaining a current Approved Vendor List for
maintenance.
2. The Business Operations Manager is responsible for coordinating and monitoring a maintenance request
system.
3. The Program Manager are responsible for establishing an expectation for facility cleanliness and for maintaining
the facility including the building, property, equipment and appliances. Furnaces and mechanical systems are on
regular maintenance schedules.
4. Each facility will be responsible for its own maintenance. Maintenance will include duties such as:
a. Daily cleaning and sanitizing. All employees must read the instructions for use of any cleaning products
and ensure that they are using the product for its intended use and with the correct safety equipment;
b. Washrooms, toilets, kitchens, floors, bedrooms (if applicable) offices, dusting, and vacuuming;
c. Garbage removal to the curb or bin;
d. Light repairs and maintenance;
e. Light bulbs, furnace filters, door stops, snow removal and lawn and garden maintenance;
f. Scheduling dump runs to ensure that items are not collecting in the home or the yard (these are done
through a maintenance request ticket), and;
g. Monitoring for hazards and removal of hazardous materials.
5. Employees are expected to keep program areas neat and tidy although some cleaning may be contracted in
specific facilities. Employees are expected to clean up after themselves when using the shared spaces such as
the kitchen. Wherever feasible employees will be required to perform light maintenance to assist with upkeep of
the program. When it is not possible for employees to perform the light maintenance, employees are asked to
advise the Coordinator to approve the use of an approved vendor to complete the work. When larger maintenance
issues arise due to mechanical failure of furnaces, water heaters and electrical, the Coordinator will notify the
Maintenance Support Worker. The Maintenance Support Worker will work with the Business Operations team to
coordinate the services for the project.

6. Other maintenance issues will involve submitting a maintenance request ticket and describing the problem in
detail. The maintenance worker will either do the repairs themselves, or will confer with the Business Operations
Manager to hire an outside contractor depending on the complexity of the job. When major repairs are necessary,
over $1,500.00, three estimates are required as per policy on purchasing of goods and services. This is not
necessary if deemed an emergency situation and approved by the Program Manager (furnace is not working;
water tank burst) or a business relationship has been secured through a current contract.
7. During renovations and builds are being completed, all equipment, appliances and fixtures purchased must be
approved for use in Canada. Despite any cost savings that may be available, TRELLIS will not use products
thatare not approved or pending approval/patents.
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FACILITIES AND EQUIPMENT

POLICY: RENTAL OF FACILITIES POLICY NO.: D.7

DATE ISSUED: July 8, 2003 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis will make its facilities available to its programs and outside community minded groups. Preference will
be given in the following order:

1. Trellis programs and events

2. Community child and youth serving non-profit agencies

3. Non-profit community agencies

4. Corporate bookings

POLICY

1. TRELLIS will have first right of refusal for any facility bookings.

2. Booking requests for Renfrew or the Hangar can be made in writing by e-mail, to the receptionist, who will
maintain the booking calendar. Other sites are to be booked directly through the facility’s program manager or
designate.

3. Outside community minded groups can apply to use facilities by completing a Facility Rental Agreement
application.

4. The rental fee will be determined by current market rates and equipment. This review will happen every 3 years
by the Chief Financial Officer

5. Renters cannot provide alcohol at events unless they obtain their own liquor license as well as Party Alcohol
Liability Insurance (PAL).

6. Renters must provide proof of liability insurance for their event prior to using the facility.

7. Approved applicants may be issued a distinct security access code and a key depending of which facility is
rented. Renters are responsible for payment in full for any false security alarm fees if:

a. an alarm has been accidentally set off,

b. TRELLIS’s procedures were not followed by the renter.
Alarm procedures must be explained to renters at the time of booking.

8. Damage deposit shall be a minimum of $100.00 with no exceptions. Renters will complete a pre and post event
site inspection with TRELLIS.

9. The rental fee must be paid in advance. The cancellation policy for the specific event and venue will be
included in the Rental Agreement.

10. Deposits will be refunded when the keys are returned.

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FACILITIES AND EQUIPMENT

POLICY: SPECIALIZED ASSISTIVE POLICY NO: D.8

TECHNOLOGY
DATE ISSUED: ASSOCIATED STANDARDS:
CARF
DATE REVISED: May 2019

Trellis recognizes that at times our clients require specialized assistive equipment and computer programs to enhance
their ability to integrate into the community and programs. Employees of TRELLIS may also require adaptive
technology to be able to complete the duties of their position. The Agency will make every attempt to provide these
adaptations through specialized funding requests or through the program budget.

POLICY

1. Any assistive technology programs or devices purchased by the Agency or through a funder will remain property
of TRELLIS unless otherwise previously arranged and approved.

Clients

2. When a client is identified as needing assistive technology to enhance their ability for community integration and
overall functioning, the parent/guardian will be asked to purchase the item for the client. If this is not possible due
to financial hardship or lack of funding, the Manager will evaluate if the item can be purchased through the
program budget.

3. If the purchase cannot be made through the budget, the Manager can identify and apply to other funding sources
that may be secured for the purchase.

4. Any assistive equipment bought by a parent/guardian will remain the property of the client and their
parent/guardian.

Employees and Volunteers

5. The Agency will attempt to make available the assistive technology required for employees and volunteers within
the program budget or other funding sources.

6. In the event that the Agency cannot purchase the item due to budgetary constraints, the employee or volunteer
may be asked to purchase the item for their personal use. In these instances, the item will remain the property of
the employee.
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FACILITIES AND EQUIPMENT

POLICY: TELEPHONE, FAX, POSTAGE AND POLICY NO.: D.9

PHOTOCOPYING

DATE ISSUED: August 2003 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

The purpose of this policy is to provide guidance to telephone, fax and photocopier users on matters relating to the
usage of Trellis equipment. The Agency’s telephone, fax and photocopier systems are for the sole use of the Agency
and Agency related business.

POLICY

1. All usage of Trellis telephones, fax and photocopier systems must be for purposes benefiting the Agency.

2. Adherence to privacy guidelines, as per privacy policy, must be upheld when dealing with private and
confidential material.

Telephone

3. Business long distance charges are charged against the employee’s program. Employees are responsible for
any personal long distance charges that arise.

4. All Agency phones including cell phones have a password to access voicemail. The Network Administrator has
the ability to reset all passwords.

Fax

5. Personal use of the Agency fax is not permitted.

Photocopier and Postage

6. The Photocopier and postage are to be used for Agency business only. Each program will be given a photocopier
code and all copies will be billed to the program. Programs will also be billed postage costs for all outgoing mail
from their program.

7. Administration is responsible for providing a monthly expense log to Accounting for billingpurposes.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: BANK RECONCILIATIONS POLICY NO.: E.1

DATE ISSUED: September 1999 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

The purpose of this policy is to advise management, the Director of Finance, auditors and funders of intent for the
Agency to operate in a fiscally responsible manner.

POLICY

1. Trellis will manage its cash assets prudently and will always be aware of the cashposition of the Agency.

2. All bank statements will be reconciled to the general ledger on a monthly basis.

PROCEDURE

Finance Coordinator

1. Obtains online bank statements for the immediate preceding month.

2. Reconciles the bank statement to the general ledger.

3. Forwards the reconciliation to the Director of Finance for review and approval.

Director of Finance

4. Approves the bank reconciliation and stale dated cheques for write-off and returns to the Finance Manager.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: BILLING FOR SERVICE PROVIDED POLICY NO.: E.2

DATE ISSUED: October 2004 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

Trellis will occasionally complete work that is outside of funding agreements and bill for this service

POLICY

1. The Agency will provide internal controls to ensure that accounts receivables are closely monitored.

2. The Agency will ensure adequate and complete compensation is received for services provided.

PROCEDURE

Child Maintenance

1. Relevant employees have the appropriate forms. The forms are completed and submitted to the Region and
copies are sent to accounting for record keeping on a monthly basis.

Fee for Service

2. Fee for service employee’s record the services provided. This record is delivered to the Finance Coordinator
to ensure an invoice is generated and delivered. The information is due in accounting monthly by the 6 th of the
following month.

3. All fee for service invoices must have the necessary supporting documentation, including dates of service and
the service being provided.

4. In the event that a fee for service invoice is not accurate, the Finance Department will make the necessary
amendments to the invoice. This would include returning compensation if overbilling has occurred or requesting
additional funds if extra services were provided.

Programs

5. For services provided by club employees for a fee. Document the type and value of the work at the time it is
performed. Have an authorized signing authority sign off on the work order. Submit the documents to accounting
along with the contact name, business name and address and contact phone number. Accounting will generate
an invoice and post to the appropriate accounts.

Accounting

6. Accounting will complete and mail the invoices. Every 30 days a report will be generated to identify all
outstanding invoices. Follow-up calls and letter will be made at 60 days. After 60 days, the Manager will be
notified for further action. All invoices will be written off after 12 months or when deemed uncollectible.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: CAPITAL POLICY NO.: E.3

DATE ISSUED: June 2001 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

This policy applies to expenditures of a capital nature that can not be absorbed into the operating budgets as called
for and agreed upon in the annual budget as approved by the TRELLIS Board of Directors. This policy includes capital
expenditures, purchase agreements, renovations and non-routine maintenance where the total cost of such
expenditures exceeds expenditure authorities as detailed in the Expenditure Authority policy.

POLICY

Annual Budget

1. Management will prepare an annual capital budget, which will be submitted to the Board’s Finance and Audit
Subcommittee for review and then forwarded to the Board of Directors for approval. The Board’s motion, approval,
and entry into the minutes will constitute authorization for expenditure. Spending will conform to the budget. If
required the Agency will request an amendment to the budget.

General

2. Various service contracts have differing definitions of capital. TRELLIS will comply with the definitions of each
contract for reporting purposes.

3. Capital expenditures for furniture, fixtures and equipment that individually cost less than the amounts specified
in the Expenditure Authority policy, but combined with an upgrade that is above the limits, will be the responsibility
of the CEO or their designate. All capital expenditures of this nature must receive three quotations unless a known
“best supplier” is the source of the item(s) to be purchased.

4. Capital expenditures for renovations, repairs and new construction must combine all sub-contractors to complete
the work and will follow the Expenditure Limits policy. All capital expenditures of this nature must receive three
quotations.

5. Capitalization of expenses will be determined on a case by case basis. A general guideline will be that purchases
with a value greater than $5000 and an expected life of greater than or equal to three (3) years will be capitalized.

6. Capital will be amortized within the guidelines of GAAP. Straight-line amortization will be used.

7. The Director of Finance will update the capital asset pool as purchases and improvements are made. The Finance
department will maintain a Ledger of Fixed Assets showing:

a. Description of item
b. Acquisition value
c. Date of acquisition
d. Place of acquisition
e. Model/serial number
f. Condition
g. Disposal date
h. Selling price once sold
i. Method of disposal
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FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: CAPITAL POLICY NO.: E.3

Dispositions

8. When agreed upon by the CEO, assets can and will be disposed. Losses or gains will be recorded according to
GAAP. The Director of Finance will remove the asset from the pool. The Director of Finance will make all the
relevant entries to the General Ledger to account for the reversal of the asset, record the gain or loss and the
reversal of the accrued amortization. If applicable, the bill of sale will be kept and recorded by the Director of
Finance.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: EXPENDITURE AUTHORITY POLICY NO.: E.4

DATE ISSUED: November 1999 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

This policy is intended to provide substantial internal controls so that expenditures are closely monitored.

POLICY

1. Only those identified in Schedule A shall have the authority to make purchases on behalf of the Agency.

2. When purchasing goods and services for programs, employees may use a purchase order at approved vendor
locations, complete a cheque requisition or submit a bill to Accounting for payment. In some instances Agency
credit cards may be used but requires prior approval from the Finance Coordinator as detailed in the procedure
section of this policy.

3. It is the responsibility of employees to ensure that the authorities and authorization limits by position are adhered
to for the purchase of goods and services as outlined in the following Schedule A:

Position Type of Expenditure Authorization Limit

Coordinator/Supervisor Routine budgeted expenses $750.00
Manager Routine budgeted expenses $1,500.00
Directors Routine budgeted expenses $7,500.00
Position Type of Expenditure Authorization/Signing Limit
CEO Routine budgeted Expenses $75,000.00
Chief Officers Capital items not budgeted $50,000.00
Director of Finance Long Term Obligations $75,000.00
Director if appointed Approved Capital Expenses $400,000.00
Board of Directors All items No limit – Requires approved
motion be recorded in board
minutes
Personal reimbursement Signed by board chair or treasurer

4. Regular payroll and related expenses – benefits, RRSPs, salaries, and withholdings are not subject to the above
authorization limits. However, extraordinary items are subject to the above authorization limits. These include but
are not limited to: termination payouts, vacation payouts, and garnishes’.

5. All purchases in excess of $10,000.00 will require 3 quotes

PROCEDURES FOR EXPENDITURES

Purchase Orders

1. Purchase orders are like cash and therefore every effort must be taken to secure the purchase order books.
Purchase order books must be stored in a secure location. Purchase orders turned in to accounting to vouch
purchases must have the assignee’s name and signature on them to authenticate the purchase.

2. Schedule “A” employees can request purchase order books. Accounts payable will distribute a P.O. book
recording the name and program to which the book is assigned. The employee can only spend up to their
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FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: EXPENDITURE AUTHORITY POLICY NO.: E.4

respective limit on any one P.O. Coordinators and Supervisors will have their respective Manager sign off on all
P.O.’s. The person authorizing the expenditure shall sign & print their name so that the Accounting Assistant can
see policy is being followed.

3. When making a purchase, record the amount on the P.O. print your name and program, and sign the P.O. Prior
to turning the yellow copy of the P.O. over to accounting, record the appropriate charge account code to the P.O.
for processing. Incomplete P.O.’s will be returned to the appropriate program for correction before processing.
No invoices will be paid on incomplete purchase orders.

Cheque Requisitions

4. If you need to make a purchase where a P.O. is not acceptable, you can request a cheque. You must provide
Accounting with 2 weeks’ notice for a cheque requisition.

5. Complete a cheque requisition with all the relevant details for the request. Incomplete requisitions will be returned
to the program requesting the cheque. Have your Manager sign off (also print name) on the cheque requisition
according to their respective limits. Forward the request to Accounting within the required time limit.

6. Accounting will process the cheque according to the details provided on the requisition. All cheque requisitions
must include backup. In very rare circumstances where an invoice follows after payment, the invoice must be
sent to the Accounting Department within 2 weeks of the purchase.

Direct Invoice Payment

7. Direct invoice payment will require that purchase orders are delivered to the Accounting Assistant so that the
correct accounts can be charged for the purchase and that the purchase order can vouch theinvoice.

8. Recurring payments, such as rent, leases, and contracts (Xerox, pest control, janitorial, etc.) do not require a
P.O.

Credit Cards

9. Trellis holds the following credit cards:

• Home Depot • The Bay
• Petro Canada Gas Card • Canadian Tire MasterCard
• Royal Bank VISA • Staples
• Grand & Toy • Totem
• Ikea • Kinko’s

10. To access the cards, see the Finance Coordinator. The Finance Coordinator will issue the cards to those identified
in Schedule “A”. The Finance Coordinator will record the date and signature of the person signing out the card.
The person will follow the purchase order procedure for making a purchase with a Credit Card. The
invoices/receipts will be returned to the Accounting Assistant along with the P.O. The Credit Card will be returned
to the safe and the Finance Coordinator will record the date and sign the card in.

11. Petro Canada gas receipts will be turned in monthly on the 6 th of each month along with the personal expense
claims.
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FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: EXPENDITURE AUTHORITY POLICY NO.: E.4

12. No payment will be made for charges not substantiated by receipts. The receipt must contain the list of items
bought and a payment slip is not sufficient. The person responsible for the card will also be responsible for
charges appearing on the card for which there are no receipts.

13. The Accounting Department will pay for the goods in the normal fashion.

14. No personal expenditures are allowed with or on any purchases for TRELLIS. Employees violating this procedure
will have credit card privileges suspended, repay the non-authorized amount and a $50.00 administration fee.
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FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: FINANCIAL RECORDS POLICY NO.: E.5

DATE ISSUED: November 1, 1999 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

POLICY

1. Trellis shall maintain all financial records in accordance with Generally Accepted Accounting Principles. In
addition, TRELLIS will adhere to external guidelines when applicable, such as those pronounced by Child and
Family Services, FCSS, United Way and other funders.

2. Audited Financial Statements will be produced on an annual basis within six months of the end of the fiscal year.
The auditor is recommended by the Finance and Audit Committee and appointed by the Board of Directors at the
annual general meeting.

3. The management of TRELLIS will be responsible for the preparation of each fiscal budget. The Finance and
Auditcommittee reviews the budget and makes a recommendation to the Board of Directors for approval.

4. Budgets are prepared annually to coincide with the TRELLIS fiscal year.

5. Financial Statements will be produced on a monthly basis, global statements are provided to the CEO and Chief
Officers. Financial statements will be reviewed by the Directors and Managers, and a variance analysis is
provided to accounting. Monthly statements and variance analysis are presented to the Finance and Audit
Committee and then reviewed by the Board of Directors.

6. All payroll and financial accounting records, including support documentation, will be maintained as per legislation
and policy regarding Records Management.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: FUNDING SURPLUS POLICY NO.: E.6

DATE ISSUED: November 1999 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

It is recognized that occasionally certain funding surpluses may result from the contracted funds received from
Calgary Region Child and Family Services Authority. This policy in intended for Senior Leadership purposes only.

POLICY

1. Funding surpluses are to be utilized in accordance with the Surplus Retention Reserve Agreement as negotiated
between the Trellis and Calgary Region Child and Family Services Authority.

2. Notwithstanding the above, TRELLIS may, at its discretion, apply for and negotiate with Calgary Region Child
andFamily Services Authority for a change or reallocation of the “end use” of these funded surpluses.

3. All surpluses will be handled according to funding restriction.

4. Restricted funds will be deferred to future periods for use.

5. Unrestricted surpluses will be recognized and flow through the Agency’s Net Assets of the Balance Sheet
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FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: FUNDS HELD FOR CLIENTS POLICY NO.: E.7

DATE ISSUED: May 2003 ASSOCIATED STANDARDS:

CARF – Financial Planning
DATE REVISED: May 2019

Trellis establishes a financial system in accordance with generally accepted accounting practices to account for
the receipt and disbursement of all personal clients funds held on behalf of the client by the Agency.

Personal client funds refer to any funds which the program holds for the client as well as any funds provided by
the contract which are designated specifically for the client’s personal use such as allowances, clothing money,
accommodation and living expense funds in SIL programs.

POLICY

1. Programs will ensure that all funds are kept in a safe place and available for the client toaccess.

2. Allowance funds and clothing money will be controlled by designated employees in the programs and by the
Foster Care parents. A record will be maintained of all allowance monies and clothing money allocated to
each client.

3. Any monies paid out to the client will be recorded and signed for by therecipient.

4. Funds received on a client’s behalf will be documented with a description of the nature of the transaction and
the initials of the individual receiving the funds.

5. The program will also document any monies held back for debts, restitution or from damage deposits. This
record will indicate the reason for holding back money from the client and will require the client’s initials as
their acknowledgement of the transaction.

6. If a client entrusts any money to an employee, they will be given a receipt of this transaction for their own
records. Upon requests of these funds, the client will sign, indicating their receipt of the funds and this willbe
recorded on their financial record.

7. Funds held for independent living clients, will be controlled by the Manager and a record of accommodation
and living expenses will be maintained and signed for by the client receiving the funds.

8. Damage deposits are held in a separate bank account, used only for damage deposits. A monthly bank
reconciliation will be performed on this account.

9. An accurate record of all transactions involving each client’s funds will be maintained and this record will be
available for the client to review upon their request.

10. Interest on deposits will be calculated according to the servicealberta.gov.ab.ca “security deposit interest
calculator”. As of 2016, the interest rate on security deposits is 0%. A monthly account reconciliation will not
be provided to the client. However, when the client moves out, a statement will be provided within 10 days to
the client which outlines the deposit, and interest owed, as well as deductions. If the deductions cannot be
ascertained within 10 days, a preliminary statement will be provided, with a final statement of account within
30 days of the client giving up possession. A cheque with the remainder of the security deposit will be sent
with the final statement.
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INTERNAL FINANCIAL CONTROLS

POLICY: FUNDS HELD FOR CLIENTS POLICY NO.: E.7

11. The following will be deducted from any damage deposit amounts held for the client: money owed for rent,
damage to the property, cleaning of the property, unreturned keys, money owed forfees.

12. Clients can access the records of their funds held by emailing us at [email protected]
with the subject line “Deposit information request” and including the client name, and date of deposit in the
email.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: INVENTORY CONTROL POLICY NO.: E.8

DATE ISSUED: November 2004 ASSOCIATED STANDARDS

CARF – Financial Planning and Management
DATE REVISED: May 2019

The Agency will purchase, rent, and lease equipment and materials at times to aid in the delivery of services and
programs to its clients.

POLICY

1. Any equipment and materials purchased, rented or leased becomes the property of TRELLIS.

2. All employees must ensure that materials and supplies are used appropriately and in alignment with the
intended use.

3. Inventory must be maintained in the best working condition. Defective property must not be used to deliver
programs or services. Deficiencies must be reported to the appropriate supervisor.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: INVESTMENT BORROWING OF FUNDS POLICY NO.: E.9

DATE ISSUED: November 1999 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

The purpose of this policy is to establish guidelines governing the investment of funds in the operations account.

POLICY

1. This policy is for Management purposes only.

The Investment Policy Statement

2. The Investment Policy Statement is an attempt to express the investment objectives Trellis in a document that
can help guide the content of the investment portfolio. The Investment Policy Statement provides a useful
framework for managing the investment portfolio and provides a useful process for making decisions, reporting
on progress and reviewing the objectives in a timely and regular manner. (See attached Investment Policy and
Investment Guidelines).

The Borrowing Policy Statement

3. Trellis may borrow or raise or secure the payment of money as it aligns with the purpose of carrying out
its Mission. See policy on expenditure authority for limits.

4. Trellis shall maintain a line of credit sufficient to cover one payroll period’s costs. This line of credit may be
secured by the general assignment of book debts (i.e., what funds are owed to Trellis).

5. Issuance of additional collateral security must be approved by the Board of Directors.

Investment Guidelines

Portfolio Objectives

6. The primary objective of the portfolio will be to maximize safety of principal. Subject to these constraints, the
portfolio will be managed with a secondary objective of maximizing the overall return.

Asset Mix and Implementation

7. The portfolio shall consist entirely of debt instruments with a term of not longer than the expected termination
date of the portfolio. Investments will be made with the intention of holding the security to maturity. However,
the portfolio will maintain a degree of liquidity for emergency purposes. The investment policy strictly prohibits
the portfolio manager from engaging in any activity that would be considered speculative or that would
jeopardize the ability of the portfolio to meet its potential cash flow obligations.

Eligible Investments
8. Investments may be made in:

a. Government obligations (i.e. Treasury Bills, Notes, Strip Coupons, Debentures and/or Bonds) issued
directly or indirectly by the Federal government or an agency (Canadian and U.S.) or any of the Provinces,
which hold appropriate credit ratings.
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INTERNAL FINANCIAL CONTROLS

POLICY: INVESTMENT BORROWING OF FUNDS POLICY NO.: E.9

b. Canadian Chartered Bank Securities, being Bearer Discount Notes, Deposit Receipts, Term Notes,
Certificates of Deposit, Bankers Acceptances, and short term bonds and strip coupons.
c. Securities of foreign banks or the Canadian affiliates of foreign banks provided that the obligations are
guaranteed or carry separate appropriate ratings.
d. Commercial paper and other obligations including bonds and strip coupons of Canadian industrial
companies, utilities, financial institutions, consumer loan companies. Rated A or better.
e. Loans to investment dealers (call loan) providing that full collateral value plus applicable margin are heldat
a banking institution.

Investment Limits

9. The purchase of any securities carrying a credit rating below A or AA for bonds or suggest A1/R1 for
commercial paper is strictly prohibited. Investments of appropriate credit quality may be made subject tothe
following limits:

Maximum % of Maximum Dollar Value

Investment Vehicle Portfolio Per Issuer
Federal Governments 100% unlimited
Provincial Governments 100% $5,000,000
GIC’s and money market funds 100% $3,000,000
issued by Canadian chartered
banks rated A or better
Obligations of Canadian 25% $1,000,000
affiliates of foreign banks with
a rating of A or A1 or higher
Commercial paper of Canadian 25% $100,000
affiliates of foreign banks with
a rating of A or A2 or higher
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: MANAGEMENT OF FUNDS POLICY NO.: E.10

DATE ISSUED: January 01, 1998 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

The purpose of this policy is to guide the Agency in managing its financial affairs in accordance with generally
accepted accounting practices and applicable contractual and statutory requirements. Several financial tools and
procedures will be utilized to ensure this compliance.

POLICY

1. All financial activity will be recorded in compliance with generally accepted accounting principles.

Budgets

2. Agency budgets will be prepared in the fall for the following fiscal year. This will allow time for review by the
Senior Leadership team and approval by the Board of Directors.

3. If there are new programs starting mid year that will substantially change the financial picture of the Agency, an
amended Budget will be prepared for approval by the Board of Directors for the fall meeting.

Monthly Financial Statements

4. Agency financial statements will be prepared monthly and will be reported to the CEO and the Board of Directors.
Departmental Revenue and Expenditure statements will be prepared and distributed monthly to Program
Managers and will compare actual activity to approved budget amounts. This will ensure financial information is
available for responsible fiscal management of the Agency.

Audits

5. The Agency will be audited annually or as required by contractual obligations by an accounting firm of Chartered
Accountants, Certified General Accountants or Certified Management Accountants. The audit firm will be
recommended by the Board of Directors and appointed at the Annual General Meeting. Audited statements will
be prepared according to Audit Guidelines within the terms of each individual contractual agreement and
according to generally accepted accounting principles.

Contracts

6. All Agency expenditures pertaining to a program which is funded through a contract will be in line with the terms
of the contract. If exceptions need to be made for any reason, one of the Chief Officers of the Agency will discuss
the change with the funder prior to any expenditure being made. All funding contracts must be signedby the
CEO and the original copy of the contract filed with the Director of Finance.

PROCEDURE

1. The Agency’s fiscal year runs from January 1 to December 31.

2. The Director of Finance will arrange the dates of the audit with the external auditors. The audit should occur by
mid February to provide timely information.
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INTERNAL FINANCIAL CONTROLS
POLICY: MANAGEMENT OF FUNDS POLICY NO.: E.10

3. The Agency will assist the auditors in all ways possible to achieve a comprehensive, accurateaudit.

4. The Draft audited Financial Statements will be reviewed by the Audit and Finance Committee of the Board of
Directors and approved by the Board. Two Board Members will sign the audited financial statements.

5. Audited statements and reports will be sent to all stakeholders and donors who require such information as part
of the funding agreement. Additional copies of the audited financial statements will be distributed at the discretion
of the CEO and or the Fund Development department.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: PETTY CASH POLICY NO.: E.11

DATE ISSUED: November 1, 1997 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

The purpose of this policy is to provide guidance to employees who are eligible for Petty Cash funds.

POLICY

1. Funds will only be given to employees who are responsible for running programs. Employees receiving petty
cash are responsible for the security and prudent management of such funds.

2. Employees receiving petty cash must be aware of the purchasing policies regarding expenditures.

3. Petty cash funds will be given out with the following limits:

Program Maximum Limits:

4. $600 for each program. If the petty cash balance goes over the program limit of $600, a Petty Cash
Requisition Form must be approved and signed by the program Manager/Director and the Director of
Finance.

Employee Maximum Limits:

5. Employee maximum limit is $300. Anything over $300, should be approved and signed by the program
Manager/Director and the Director of Finance.

6. It is the Program Manager’s responsibility regarding the allocation of funds to meet the needs of the program in
consideration of the maximum limits set out in this policy

Spending Maximum Limits

7. Petty cash funds should be used to purchase items and services under $75 each. Any expenses over $75 must
be pre-approved & authorized by the Program Manager. The Agency does have a credit card and can facilitate
a quick pay for higher expensed items or events. The Finance department must be notified in these instances
and arrangements will be made.

8. Disbursement of allowances in Child Welfare programs are not subject to the $75 limit.

PROCEDURES

1. If a Manager determines that an employee requires Petty Cash, they shall provide Accounting with a completed
Petty Cash Authorization Form stating the amount required. The Manager shall also ensure the employee
receiving the funds is aware of the policy and procedures with respect to Petty Cash. The employee will be
required to sign this form acknowledging the amount received and authorizing the Agency to recover this money
upon termination or change of status where petty cash is no longer required.

2. Any employee taking unpaid leave longer than four (4) weeks shall reimburse the Agency the amount of petty
cash outstanding.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: PETTY CASH POLICY NO.: E.11

3. The Petty Cash fund should be used to purchase items under $75 each. When purchasing items with Petty Cash,
the employee shall:

a. Keep all receipts

b. Submit an Expense/Petty Cash Reimbursement Form to their supervisor. The form must be properly
coded, signed by the employee, and authorized by the supervisor. All receipts must be attached.
c. When disbursing client allowances, the employee shall ensure the individual receiving the money sign and
date the appropriate allowance form. This form is the acceptable receipt needed for reimbursement.
d. Reimbursement claims can be made twice a month. No claims shall be outstanding past 3 months.

4. If funds are lost or stolen, the employee is responsible for replacing it.

5. The supervisor of an employee shall:

a. Review the purchases for appropriateness

b. Check the coding & completeness of the reimbursement form
c. Authorize reimbursement by signing the form
d. Forward the Petty Cash form with attached receipts to the Accounting Assistant for payment.

6. Accounting will track the frequency and amount of Petty Cash Reimbursements claimed, and will revise the
amount of the fund based on usage.

7. Annually, confirmations of outstanding amounts will be sent out by the accounting department. The employee
will confirm the amount, sign the form, and return it to the accounting department. These confirmations are kept
in the annual audit binder.

8. Random checks for compliance with this policy may be conducted by the Manager of Finance or Program
Manager. Employees mismanaging Petty Cash funds will be subject to disciplinary procedures.

Cash Advances/Emergency Funds For Program Use

9. The Agency acknowledges there are occasional circumstances where purchase orders are not accepted and
expenses will amount to limits greater than Petty Cash policy allotments. Examples may include out of town client
trips, summer day camps, etc.

10. With the Manager’s permission, accounting will disburse funds to an employee to cover the cost of these
expenditures. A Petty Cash Authorization form shall be completed and signed by both the manager and the
employee stating the one time use of the funds. Accounting will also code these amounts to the petty cash
account. Receipts for expenditures and any cash not expended must be handed back to Accounting within a one
month period. In these circumstances, reimbursements are not made to the employee.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: PURCHASE OF GOODS AND SERVICES POLICY NO.: E.12

DATE ISSUED: November 1, 1997 ASSOCIATED STANDARDS

CARF – Financial Planning and Management
DATE REVISED: May 2019

The purpose of this policy is to provide guidance to employees and supervisors on proper purchasing procedures.
POLICY

1. Employees making purchases on behalf of the Agency should strive to obtain such goods and services at the
lowest possible price for the quality of item needed.

2. Trellis shall favor local suppliers above international suppliers given comparable quality and price.

3. The Agency aims to select to whom we can establish partnerships and develop them into a supporter of Trellis.
To create the potential for partnership relationships with our vendors, Trellis will strive to use the same vendor
for needed services and goods. Long term relationships will be pursued with invitations to our special events
sent to those vendors.

4. Program Manager must approve all unbudgeted or capital items before ordering the item or service as described
in the capital and fixed assets policies.

PROCEDURE

1. Purchase orders (PO) are to be used when making purchases of items greater than $20 each whenever possible.

2. Supervisors of programs and employees running programs may request PO books through accounting.
Employees signing out PO books are responsible for their use, the proper completion of the forms and
responsible for ensuring all POs are properly authorized.

3. When using a PO, the employee shall:

a. Complete the PO in detail including all items purchased, their cost and the coding.
b. Have their supervisor authorize the accounting copy of the PO if they are not an expenditure authority.
c. Pick up the items needed in exchange for the vendor’s copy of the PO.
d. Forward the accounting copy of the PO to the Accounting Assistant, where it will be matched up with the
appropriate invoice. POs should be forwarded to the Accounting Assistant within one week of the date of
purchase.
e. Invoices should come directly to the Accounting Assistant, where they will be matched up with the proper
PO and then paid. Any invoice received without a PO will be held unpaid until the PO with proper
authorization and coding is received.

4. Purchases exceeding approved spending limits as set out in the Expenditure Authority policy require managerial
approval. This approval must be obtained prior to ordering the item or service and will be formalized through
both signatures on the PO.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: RECORDS MANAGEMENT POLICY NO.: E.13

DATE ISSUED: May 2003 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

POLICY

1. The Agency will maintain a comprehensive records management system for all financial files.

2. Files will be locked and maintained in accordance with accepted records management practices, regulatory
requirements and Privacy Legislation.

3. Files will be sent to storage periodically. Routine corporate files will be retained in storage for 7 years and then
disposed of through proper practices. Certain records of historical nature will never be destroyed. These will be
retained on the premises or sent to archives. Any records related to clients involved in Child Welfare will not be
destroyed or done so in accordance with current legislation.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: RECOVERABLE EXPENSES POLICY NO.: E.14

DATE ISSUED: May 2003 ASSOCIATED STANDARDS

CARF – Financial Planning and Management
DATE REVISED: May 2019

This policy is designed to facilitate effective program delivery while maintaining accountability for expenses and is
intended for approved expenses only.

POLICY

1. An employee/volunteer may be entitled to recover expenses incurred while conducting business or program
activities on behalf of the Trellis. Expenses must be accompanied by a receipt, if available,and be claimed on a
“Mileage Claim Form” and/or a “Petty Cash Reimbursement/Expenditure Reimbursement Form”.

PROCEDURES

Travel Expenses for TRELLIS Business Activities

1. When employees/volunteers use their personal vehicle or a Trellis vehicle in the performance of job-related or
volunteer duties they may be entitled to a reimbursement as outlined below:

a. The claim cannot include travel between the employee’s home and the work place each day.
b. Trellis expects all employees/volunteers to be prudent when incurring business- related travel
expenses. Whenever possible TRELLIS vehicles should be used for all business related activity. Thus,
employees are to consider the following:

i. Is the trip necessary? When able, complete business by phone, fax, e-mail, or in combination with
another trip, etc. Consider the intent of the trip and required frequency, e.g., picking up mail at the
administrative offices two times/week vs. five times/week.
ii. Is the trip effectively planned? Take the most direct route, e.g., pick up mail on your way to work vs.
making a round trip from your first place of work. Schedule the trip to reduce travel time and costs,
e.g., schedule the appointment at the beginning or end of a work shift and en route to first place of
work or from last place of work.

TRELLIS Business Activity Reimbursement

2. When using a TRELLIS-owned vehicle, gas cards can be used.

3. Within Calgary city limits, the employee/volunteer using their own vehicle shall be entitled to receive a vehicle
allowance at a set rate of .50 cents per kilometer.

4. Outside Calgary city limits, the employee/volunteer using their own vehicle shall be entitled to receive
reimbursement of .46 cents per kilometer if the trip is for program purposes. For trips related to training and
employee development the reimbursement amount should be negotiated and approved by your supervisor.

Transporting Program Participants

5. Employees/volunteers who use their own vehicles to transport program participants must ensure that they are in
compliance with all aspects of the TRELLIS policies regarding eligible drivers prior to using their own vehicles to
transport program participants. Employees/volunteers must be an approved driver by the Agency and have a sign
off declaration that they have read the Agency Driver’s Manual.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: RECOVERABLE EXPENSES POLICY NO.: E.14

6. Employees/volunteers transporting clients in personal vehicles are to consider thefollowing:

a. Is a dependency being created with the use of the employee’s/volunteer’s vehicle?

b. Is (are) the program participant(s) able to access and use public transportation?
c. Is there an alternate location for the activity that is more accessible to publictransportation?
d. Can schedules be altered to accommodate public transportation?

Reimbursement for Transporting Program Participant(s)

7. The driver may arrange for and request reimbursement from the program participants in order to cover the costs
associated with the trip. This reimbursement will be no more than the reimbursement that would be calculated if
the employee were to submit a Mileage Claim Form.

Parking

8. A receipt is required whenever possible.

Telephone Charges

9. Long distance calls and cellular phone charges that are incurred due to emergency personal calls on Agency land
lines and cellular phones must be reimbursed back to the Agency. In the event that an employee incurs an
expense of this nature, they are to notify the accounting department to ensure that the costs are billed back to the
employee.

Program Supplies

10. Supplies that are required for programs and are not attainable by any of the processes outlined in the Budgeted
Expenditures policy.

Meals/Accommodation/Travel

11. Pre-authorized expenses incurred while on TRELLIS business.

12. Employees are to refer to the On-going Professional Development policy for expense allotments associated with
meals, accommodation and travel for conferences and workshops.

13. Alcoholic beverages are not approved expenses.

14. An approved advance may be issued. Refer to Policy on Budgeted Expenditures – Cheque Requisition. Receipts
must support all advances, whenever possible, and excess advances returned for deposit.

Other

15. Other expenses outside the scope as outlined above are acceptable only as pre-authorized by a Director/Manager
and or Designate.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: SIGNING AUTHORITY POLICY NO.: E.15

DATE ISSUED: January 1, 1998 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

This policy’s purpose is to increase internal controls over expenditures and cash management. Only those
authorized by the CEO or Board of Directors will have authority to sign for cashtransactions.

POLICY

1. The CEO and or Board of Directors will identify those authorized to sign for financial transactions on behalf of
TRELLIS. Currently authorized for the agency are:

a. Board Chairperson
b. Treasurer
c. CEO
d. Chief Operating Officer
e. Chief Development Officer
f. Director of Finance

2. The Director of Finance will notify the banks of those authorized to sign on behalf of TRELLIS.

3. Those selected will provide the requisite identification and sample signature for the banks.

4. All financial transactions will require 2 signatures.

5. In the event that there is a vacancy in a Chief Officer position within the agency, the CEO will appoint a Director
to also carry signing authority to ensure there is no disruption to the financial responsibilities of the organization.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: HANDLING OF MONEY FOR DEPOSIT POLICY NO.: E.16

DATE ISSUED: August 31, 2011 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

The purpose of this policy is to provide guidance to employees who handle money (cash, cheques and/or credit card
slips) being held for deposit.

POLICY

1. All money being held for deposit shall be kept in a locked cashbox in a locked cabinet in a locked office until
such time as it is brought to the Renfrew Office for deposit processing.

2. When cash is received, employees must create a receipt in duplicate. One copy is to be given to the person
giving the cash. One copy is to be kept and brought to the Renfrew Office when doing the deposit.

PROCEDURES

1. Only full-time employees shall have access to the locked cashbox containing money being held for deposit.
Keys will be kept in a safe place known only to full-time employees.

2. Only full-time employees shall receive and receipt money. Once this has been completed, all money shall be
placed in the cashbox, locked and stored in a safe place.

3. No cash shall be removed from the cashbox to purchase supplies, give refunds or for any other purpose. There
are separate procedures for purchasing supplies and issuing refunds.

4. All deposits shall be brought to the Renfrew Office on a weekly basis (or more frequent if needed) for
processing.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: USE OF TRELLIS CREDIT CARD POLICY NO.: E.17

DATE ISSUED: June 1, 2012 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: July 11, 2019

The purpose of this policy is to improve internal control over the use of the TRELLIS credit card and to
provideguidance to employees who wish to use the TRELLIS credit card.

POLICY

1. Standard credit card limits for employees are listed in the table below. Employees requiring a higher limit than
listed in the table will need to issue the Finance Manager a “Change in Credit Limit” form before a change in
limit can be made.

Position Credit Card Limit

Front Line Staff $500.00
Coordinator $1,000.00
Manager $2,000.00
Director $5,000.00
CEO Limit specified by direct supervisor
Chief Officers
Director of Finance
Director if appointed

2. Credit card holders are required to make timely Certify credit card expense report submissions. A hold will be
put on credit cards that have unsubmitted expense reports of more than two months. A card cancellation will
occur when a credit card holder has missed submitting their expense report three times in a fiscal year.

PROCEDURES

1. To obtain a credit card, the employee’s direct supervisor should email the Finance Manager specifying the
employee name, position and credit limit (the credit limit should be in line with Credit Card Policy stated above).
Director email approval is required when the requesting supervisor is a Manager.
2. The Finance Manager will request the card through the RBC link.
3. Upon receipt of the credit card, the Finance Manager will email the credit card holder information on how to
activate the card and, set up a time for employee to pick up the credit card.
4. The employee is expected to sign off on the “Credit Card Compliance” form before being issued the card
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

FINANCIAL
INTERNAL FINANCIAL CONTROLS

POLICY: BUDGET REVISION POLICY NO.: E.18

DATE ISSUED: December 2012 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

POLICY

1. The Board of Directors must be notified if a potential revision to the budget results in any of the following
conditions:

a. A change of $250,000 or more for a new program;

b. Greater than $1,250,000 in aggregate budget changes within a three month period.

PROCEDURES

1. Finance team must track changes to the approved budget, and include in the financial package distributed to
the Board.

2. Proposed revisions to the budget that meet the above criteria must be submitted to the Board of Directors for
information purposes prior to the submission of the proposal for the program(s).
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

MARKETING

POLICY: EXTERNAL COMMUNICATIONS AND See Trellis Media and Communications Policy on
KEY MESSAGES / MEDIA ADP
RELATIONS
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: GUIDING PRINCIPLES POLICY NO.: F.2.1

DATE ISSUED: January 2004 ASSOCIATED STANDARDS:

CARF – Leadership
DATE REVISED: May 2019

POLICY

1. Trellis will accept gifts from individuals, corporations and foundations in a manner that supports the purposes and
activities of TRELLIS, is accepted by the Board of Directors and consistent with the presentation of information.
All solicitations are done in an ethical, professional manner and in keeping with the standards put forth by the
Canada Revenue Agency.

2. All Business Development activities occur in accordance with legislated statutes, regulations, by-laws and rules
as defined by Federal, Provincial and Municipal authorities.

3. All program-specific, Business Development activities (i.e., proceeds designated for a specific program or
department) must be approved by the Director of Business Development & Marketing. The Leadership team will
be informed of the activity prior to implementation.

4. The CEO must approve extraordinary organizational Business Development activity.

5. The Business Development Manager will coordinate all solicitation of funds or donations from external contacts. To
avoid duplication of solicitations, the Business Development database will be checked prior to the contact being
made.

6. All employees are representatives of TRELLIS with respect to the media, donors and the community and
willrepresent the Agency’s best interest at all times.

Trellis follows the Association of Fundraising Professionals (AFP) Code of Ethical Principles and
Standard as our guiding principles as seen below:

Solicitation and Use of Philanthropic Funds:

7. Employees shall take care to ensure the contributions are used in accordance with donors’ intentions.

8. Employees shall take care to ensure proper stewardship of all revenue sources, including timely reports on the
use and management of such funds.

9. Employees shall obtain explicit consent by donors before altering the conditions of financial transactions.

Presentation of Information:

10. Employees shall not disclose privileged or confidential information to unauthorized parties.

11. Employees shall adhere to the principle that all donor and prospect information created by, or on behalf of, an
organization or a client is the property of that organization or client and shall not be transferred or utilized except
on behalf of that organization or client.

12. Employees shall give donors and clients the opportunity to have their names removed from lists that are sold to,
rented to or exchanged with other organizations.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: GUIDING PRINCIPLES POLICY NO.: F.2.1

13. Employees shall, when sating fundraising results, use accurate and consistent accounting methods that conform
to the appropriate guidelines adopted by the Canadian Institute of Certified Public Accountants (CICPA) for the
type of organization involved.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: CORPORATE PARTNERSHIPS AND POLICY NO.: F.2.2

SPONSORSHIPS
DATE ISSUED: January 2004

DATE REVISED: May 2019

Trellis values its corporate partners and will address sponsorship opportunities as they arise.TRELLIS framework for
sponsorship is based on the amount of recognition a company may desire in exchange for theirsupport.

POLICY

1. All sponsorship proposals will be detailed in writing with the terms and conditions outlined by the application.

2. All sponsorship agreements are to be approved in writing by the CEO, Chief Development Officer or Director of
Business Development & Marketing.

3. Copies of all sponsorship agreements will be given to the Director of Business Development & Marketing and will
be retained in a file.

4. The Business Development employees associated with the corporate sponsor will document the terms of the
sponsorship in Raiser’s Edge.

5. Program employees may approach businesses for their fundraising needs. When this happens, program
employees need written approval from Business Development prior to reaching out to the business soliciting
donations of any kind (gift in kind, cash donations, prizes, gift cards, etc.). Programs receiving donations are
required to recognize the donor: Complete the Donation Form and submit it to the Business Development
department to ensure donors are recognized for their contributions. See Fundraising policy for further details.

6. Sponsors and/or donors will be thanked and recognized as agreed upon. The value of the recognition will be
appraised and determined by the Director of Business Development & Marketing in consultation with the CEO or
Chief Development Officer. For items donated with an estimated value over $1,000, the value of the item will be
determined by fair market value.
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BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: DECLINING A GIFT POLICY NO.: F.2.3

DATE ISSUED: January 2004 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis values its donors and respects the rights of donors. There are times however thatTRELLIS may choose to
decline a gift (cash or gift in kind).

POLICY

1. The following are the parameters in which TRELLIS would decline a gift:

a. If the gift constitutes a non-gift as per CRA IT-110R3, outlined in Section 15 of Gifts and Official Donation
Receipts.
b. Use or receipt of the gift is contrary with the objectives, values, and goals of TRELLIS.
c. The gift could not be fairly assessed and processed prior to calendar year end as per Revenue Canada gift-
in-kind guidelines.
d. The gift could financially or morally jeopardize the donor and or TRELLIS.
e. The gift or terms of the gift are illegal.
f. TRELLIS is unable or unwilling to honor the terms of the gift.
g. Receipt of gift will result in unwarranted or unmanageable expense to TRELLIS.
h. The gift could jeopardize TRELLIS charitable status.
i. The gift could improperly benefit any individual.
j. We don’t require the item at this time.
k. Conflict of interest between the work of TRELLIS and activities or donations of proposed donor.
l. Donor’s reputation or associations may be such that accepting funds would undermine confidence in the
charity’s independence and adherence to core values.
m. There are circumstances where court may intervene, for example, where a donation is set-aside in a claim
under the inheritance (provision for families and dependents) act or in bankruptcy proceedings.

2. Employees who are unsure as to the suitability of a proposed gift must check with the Business Development
department.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: DONATIONS POLICY NO.: F.2.4

DATE ISSUED: July 31, 2003

DATE REVISED: May 2019

Trellis may be the recipient of donations, gifts-in-kind and bequests. For purposes of this policy the following
definitions will be used:

• Cash donation - a voluntary cash amount provided to TRELLIS from any individual, corporation or organization.
• Gift in Kind - a contribution of goods and/or services to the organization from any individual, corporation or
organization where goods and services are provided free of costs to TRELLIS. There is to be no benefit returned
to the donor other than a tax receipt for the fair value of the goods and/or services and public
acknowledgement of the gift, if appropriate.
• Bequest is a residual cash or property designated to the ownership of TRELLIS by an individual, estate
orcorporation.
• Gift of Securities – a voluntary gift of securities provided to the Agency from an individual or corporation.

POLICY

1. Employees will not receive for personal use any portion of donations acquired under the name of TRELLIS and/or
received by the organization. Any donated gifts not required are to be disposed of as outlined in the Policy
regarding Disposal of Surplus Goods.

2. Employees who are given gifts (e.g., as thank you) must return the gift to the Agency. The CEO will determine
the best way to disperse the item(s) so there is not a conflict of interest either presently or in future interactions
with the gifting party.

3. Gifts-in-kind of new equipment i.e. new furniture, and real or personal property shall be accepted by the Agency
at fair market value. Fair market value will be determined by Canada Customs and Revenue Agency guidelines,
plus the procurement of at least one proof of independent value (on-line catalogue, print material, and comparable
item from same company as invoiced in last calendar year).

4. All gifts-in-kind, such as real estate and securities with estimated values over $1,000, will be appraised by
qualified consultants and should be valued at fair market value. All gifts of the above will require acceptance by
the Business Development Manager. Such gifts should be valued at fair market value and will require an
independent appraisal, received in writing, from an individual or organization competent to issue such appraisal.

5. A Donation Intake Form will be completed for all gifts-in-kinds and given to the Business Development department
for processing and recognition.

PROCEDURES

Cash and Cheques

1. TRELLIS program employees complete the Donation Intake Form noting the program code, donor name, address
andtelephone number. The Donation Intake Form along with the form of payment (cheque, credit card, cash) is given
to
Finance for processing.
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BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: DONATIONS POLICY NO.: F.2.4

Gift in Kind

2. TRELLIS will accept donated items if deemed necessary and appropriate for programs and/or clients.
TRELLISwill not accept gifts that will not be used or may be inappropriate or questionable in nature.

3. A completed Donation Intake Form is provided for all GIK gifts and is given to Business Development for data entry
into Raiser’s Edge for the purpose of recognizing and thanking for the gift.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: DONOR PRIVACY POLICY NO.: F.2.5

DATE ISSUED: January 2004

DATE REVISED: May 2019

POLICY

1. In accordance with the principles of the Freedom of Information and Protection of Privacy (FOIP) Act; Bill-44,
the Personal Information Protection Act (PIPA AB), and where required, Bill-C6, the Personal Information
Protection and Electronic Documents Act (PIPEDA), Trellis is committed to respectingdonor privacy.

2. Respect for donor communications as a best practice will be upheld with implied consent and an option to
unsubscribe from online communications.

3. TRELLIS does not sell, trade, or rent personally identifiable information to others.

4. Personally identifiable information collected may be used for such purposes as:

a. Processing authorized transactions;

b. Providing users with TRELLIS Newsletter (via Canada Post) and other communications
(email/CanadaPost);
c. Responding to donor questions, inquiries, comments and instructions;
d. Maintaining records about donations;
e. Maintaining the security and integrity of TRELLIS systems;
f. Conforming to purposes and procedures as required by law, and;
g. Generating of TRELLIS donors list for inclusion in Agency communications and presentations.

5. If donors do not wish to receive the TRELLIS Newsletters or such other communications, they are responsible
to indicate this by emailing their wishes to [email protected]. This information will then be updated in Raiser’s
EdgeConstituent file.

6. TRELLIS maintains physical, electronic, and procedural safeguards to help protect personal information by:

a. Using industry-standard secure encryption software to protect information that is submitted overthe
secure portions of the website;
b. Restricting access to donor personal information to only those persons who need to know that information
and for other authorized purposes consistent with this privacy policy (including, but not limited to,
Business Development & Marketing and Senior Leadership) and who have agreed to hold such
information confidentially and use such information only for the purposes for which that information was
provided.

7. TRELLIS will adhere to the Donor Bill of Rights as outlined by the Association of Fundraising Professionals (AFP)
below:

a. To be informed of the organization's mission, of the way the organization intends to use donated
resources, and of its capacity to use donations effectively for their intended purposes.
b. To be informed of the identity of those serving on the organization's governing board, and to expect the
board to exercise prudent judgment in its stewardship responsibilities.
c. To have access to the organization's most recent financial statements.
d. To be assured their gifts will be used for the purposes for which they were given.
e. To receive appropriate acknowledgement and recognition.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT
POLICY: DONOR PRIVACY POLICY NO.: F.2.5

f. To be assured that information about their donation is handled with respect and with confidentiality tothe
extent provided by law.
g. To expect that all relationships with individuals representing organizations of interest to the donor will be
professional in nature.
h. To be informed whether those seeking donations are volunteers, employees of the organization or hired
solicitors.
i. To have the opportunity for their names to be deleted from mailing lists that an organization may intend to
share.
j. To feel free to ask questions when making a donation and to receive prompt, truthful and forthright
answers.

12. Donors, unless otherwise specified, may be mentioned publicly in the Annual Report, Achieve Newsletter,
TRELLIS Website, social media or other public domain by way of recognition for their community
contribution.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS
BUSINESS DEVELOPMENT AND MARKETING
BUSINESS DEVELOPMENT

POLICY: FUNDRAISING POLICY NO.: F.2.6

DATE ISSUED: November 1999

DATE REVISED: May 2019

Trellis recognizes the need to procure funds through various fund raising activities in order tosupport the mission of
TRELLIS. All fund development performed on behalf of TRELLIS must be consistent with the valuesof the organization.

POLICY

1. No employee, volunteer or Board Member of Trellis shall personally benefit from any Business Development
activities conducted on behalf of Trellis (e.g., personally usingdonated tickets to an event).

2. Any potential Agency fundraising initiatives which may include, raffles, third-party fundraisers, and general
agency events must be approved by the Director of Business Development & Marketing prior to
implementation. The Director of Business Development & Marketing will use discretion to determine the
involvement and approval needed from the Chief Development Officer and CEO based on the
potential revenue the fundraising initiative in question will generate.

3. All third party fundraising events and activities that wish to utilize the name and/or image of Trellis must be
clearly outlined and approved in writing by the Director of Business Development & Marketing or the Chief
Development Officer.

4. All third party agreements will be documented by Marketing and signed by the Director of Business Development
& Marketing.

5. TRELLIS employees are welcome to identify potential contact(s) for solicitation of funds and/or donations.
Each prospect will be communicated to the Manager of Business Development who will then reach out in the
form ofa phone call, email and/or meeting.

6. Any contact with TRELLIS existing donors will be done solely at the discretion of the Business Development
Manager (e.g., purchasing tickets for the event, auction items). Full documentation and recognition will be
completed in keeping with TRELLIS policy on Donations.

7. TRELLIS will be proactive in determining event agenda and activities to ensure atmosphere is consistent with
TRELLIScore values. Business Development employees will ensure to the best of their ability that alcohol will not
be servedwhile kids are present at events.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

BUSINESS DEVELOPMENT AND MARKETING

BUSINESS DEVELOPMENT

POLICY: GIFTS OF SECURITIES POLICY NO.: F.2.7

DATE ISSUED: January 2004 ASSOCIATED STANDARDS:

Canada Revenue
DATE REVISED: May 2019

TRELLIS will accept gifts of securities that are done in an ethical manner in keeping with the standards of the Canada
Revenue Agency.

POLICY

1. Gift of Securities donations may be made online through CanadaHelps. Once CanadaHelps completes the sales,
they will notify the donor by email and send them a tax receipt for the value of their donation. They will also
disperse the funds to TRELLIS, less the non-commercial administration fee.

2. Shares electronically transferred to the TRELLIS account shall be issued a receipt valued equal to the closing
trading price on the day that the shares are received into the TRELLIS account.

3. TRELLIS shall issue a tax receipt for the value of securities as established at the close of trading on the day the
gift is received from the donor. Brokerage fees are a cost to TRELLIS, not the donor. The donor’s record shall
be credited following the sale of the securities with the gross proceeds of the transaction.

4. Letters of intent and/or pledge cards shall be retained as a permanent record by Business Development until
each pledge has been paid in full. Cards will then be held in the donor’s file. Although letters of intent will
constitute the nominal vehicle for the commitment of support, TRELLIS will accept appropriate “Letters of Intent”
from corporations, foundations, individuals and other donors. Verbal commitments will not be counted in the
annual funding total unless and until they are supported by a completed pledge card or acceptable “Letters of
Intent.”

5. Business Development & Marketing employees are authorized to accept gifts from any source, provided there
are no conditions attached that run counter to the policies, mandate or principles of TRELLIS. For TRELLIS
employees who are approached by a donor or prospective donor, consultation with Business Development &
Marketing employees should take place at the earliest possible time with the donor being given the name and
contact number of the Director of Business Development & Marketing.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

VEHICLES AND DRIVING

POLICY: PROGRAM PROPOSALS AND POLICY NO.: F.2.8

GRANT ACTIVITIES

DATE ISSUED: November 10, 2004 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

As good fiscal stewards, Trellis seeks to ensure adequate funding for all programs. The Business Development
department understands the nature of the various funders and sources of available funding. To ensure donor
relationships are carefully developed and maintained, Business Development will receive copies ofall applications that
have been submitted.

POLICY

1. Decisions to apply for funding are made by the CEO and Senior Leadership team if the addition of the funding or
new program will further enhance alignment with the Agency’s strategic direction. A lead to write the proposal will
be identified and this lead will be responsible for the facilitation of the completion of the grant.

2. If accepted, all requirements of the contract are adhered to in full unless previously agreed to by the funder. The
project is not considered complete until a copy of the final report is noted in Raiser’s Edge and filed in the Business
Development files.

3. Any program fundraising events and/or endeavors must be approved by both the Program Manager/Director and
the Business Development Manager. This will ensure the program employee’s time invested into executing the
activity is approved and that the activities do not conflict with Agency stakeholder relationships and activities.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: CONFIDENTIALITY POLICY NO.: H.1.1

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Legal Requirements
DATE REVISED: May 2019 CARF – Rights of persons served

Trellis believes it is an ethical and professional obligation of employees and volunteers to adhere to a strict code of
confidentiality to protect the rights of the clients receiving services in the Agency. All representatives of Trellis,
including employees who have limited access to confidential information, shall be made aware of the confidentiality
and related employee policies.
POLICY

1. In providing services, Trellis is privy to personal and sensitive information about children,youth and their families
in both verbal and written form. This information is shared with various employees with the understanding that it
will be held in trust and used for the benefit of the client(s). This relationship of trust is essential to the integrity of
a therapeutic relationship and therefore client information must be handled with the utmost of care. Upon
commencement of employment or volunteering with Trellis, all employees are required to sign a Confidentiality
Agreement that does not expire after the termination of an employee’s association with the Agency.
2. The Agency prohibits the disclosure of any information pertaining to the personal history or record of a client to
any person without the prior written consent of the guardian, unless otherwise authorized by legislation, specific
Court Order, or the Minister of Human Services. [Note: This policy does not apply to the disclosure of information
to a person who requires that information and who is identified in the Child, Youth and Family Enhancement Act].
Written consents will specify the parties between which information may be shared, the period of time during the
consents is valid, and what specific written information will be shared.
3. A client and the client’s agent or guardian * may examine those portions of the Agency’s documentation which
relates to the client’s personal history or record by submitting a written request. (Owned by the Agency refers to
documents and materials written by the Agency employees. This excludes district office documents,
psychological reports, school reports and other documents which were written by persons not working for the
Agency).
 NOTE: If there is a Children’s Services Agreement in place with the client, the parent or guardian does not
have access to file information without Children’s Services prior approval.
4. Intake to Trellis results in the creation of records and documentation. From the referral stage to discharge, all
client information is confidential.
5. All paper records on clients currently at Trellis remain double locked in a secure setting. All electronic information
regarding clients will be secured as per the Information Technologypolicy.
6. Under no circumstances are records of clients removed from programs, excluding Portable Records, without the
consent of the Manager. The Manager must ensure that there is good reason for the client file to be removed,
that there is a plan to ensure the ongoing security of the file, and that there is documentation of the security plan
as well as the signing out and signing in of the file.
7. Special circumstances or requests not covered in this policy, such as those authorized by legislation, specific
Court Order or the Minister of Human Services, require consultation with the CEO, especially if legal
complications exist prior to the release of confidential information.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: CLIENT RECORDS POLICY NO.: H.1.2

DATE ISSUED: May 2003 ASSOCIATED STANDARDS

CARF – Legal Requirements
DATE REVISED: May 2019

Trellis will maintain an individual file, information or membership forms for each client.

POLICY

1. All employees will follow the regulations as according to FOIP (Freedom of Information and Privacy Act), PIPEDA
(Personal Information Protection and Electronic Documents Act), and PIPA (Personal Information Protection Act).

2. Files will be stored in the office in double locking system (e.g., locking file cabinet in a locked office). They will
remain locked unless in use. The Main Doors to a facility are not considered part of a double locking system.

3. Program Managers are responsible for ensuring that all file information pertaining to client records is current and
accurate. Some programs are required by CARF to complete quarterly quality reviews that include open and
closed client files and case management planning for clients to ensure that services provided are timely and
appropriate. These are the responsibility of the Manager.

4. Upon discharge from a program, the file will remain double locked in the program for one (1) year, or, the file will
be transferred for safe keeping to a double locked, secure storage area at the Administration Building or an off-
site facility for one (1) year.

5. One (1) year from discharge, if the file has not already been transferred off-site, it will then be properly
documented for easy location and transferred to a secure off-site facility for safe keeping.

6. All Children’s Services client files are kept according to the requirements of the Alberta Government legislative
protocols, currently identified as indefinitely. All other client files and information will be stored, archived and
disposed of under current privacy legislation.

7. Should a legal process be initiated against the Agency, any destruction or disposal of Agency documents or
information is prohibited until there is resolution of the issue.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: CLIENTS’ ACCESS TO THEIR POLICY NO.: H.1.3

INFORMATION

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019

POLICY

1. From the intake stage to discharge, individual files will be maintained for each client by the Trellis program. The
client has access to portions of the Agency’s file which are generated by the Agency and which relate to the
client’s personal history or record. Upon admission, the client and their guardian will be informed of the right to
have access to file information generated by theAgency.

2. Access to client files are limited to the client, the Caseworker, their guardian and those involved in immediate
service or involved with the supervision of that service.

3. Requests for access to client information by any other person other than the aforementioned are referred to the
client’s Caseworker for approval. For those clients without Intervention status, permission from the Chief
Operating Officer or CEO is required prior to the release of information. If a guardian (other than the Caseworker)
of a client 12 years of age or older wants access to a client’s personal information, this request will go through the
Program Director.

4. Some file information may be emotionally charged for some clients. Employees are expected to exercise
considerable care when clients have reviewed their files. Employees will take into account the nature of the
material and the possible impact that it may have on a client.

5. Requests for the correction of inaccurate information on the client’s file can be done by submitting a written
request stating the inaccurate information and the correct information. This request can be submitted by the client
or from an employee advocating on behalf of the client to the Program Manager.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS
AGENCY SERVICE DELIVERY
CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: DISCLOSURES POLICY NO.: H.1.4

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

When employees enter into relationships with clients, they are sometimes in a position where clients disclose
information that may put the client or other people at risk.

POLICY

1. Employees must explain to clients that if they disclose information that may be putting the client, their family or
the community at risk, they have an ethical obligation to ensure the information is passed onto their Manager,
legal guardian and/or authorities.

2. If a client does make a disclosure that poses a threat or risk, a Critical Incident must be completed and the
Manager/On-Call Supervisor and Caseworker will be immediately advised. Depending on the disclosure, the
Caseworker or Manager may also contact the client’s legal guardian.

3. Employees will ensure that they protect the client’s right to privacy and not disclose this information to other
employees outside of the Program team, except in these specific circumstances:

a. the disclosure puts the client or others at risk;

b. as directed by the Manager;
c. as elements of on-going supervision, and/or;
d. information disclosed is distressing for employee and they need to debrief the situation.

4. If there is a situation that poses imminent danger in the community, Emergency Services will also be notified.

5. If in the event, an allegation or disclosure by a client involves an employee, foster parent, volunteer or TRELLIS
contracted personnel, they will be immediately removed from direct client contact until further notice. This may
include any or all of the following:

a. paid leave of absence

b. temporary re-delegation of duties

Until such time the matter is determined to be resolved by the Program Director.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: INFORMED CONSENT POLICY NO.: H.1.5

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Rights of person served
DATE REVISED: May 2019

POLICY

1. Except in emergency situations and when the client is over 18 years old, Trellis will not provide service, treatment
or training to a client without their guardian’s prior written consent. In cases of emergency, if prior written consent
cannot be obtained, verbal consent will be obtained and documented and is to be followed by written consent.

2. In all cases requiring a client’s consent, the consent sought must be given voluntarily, without coercion or undue
influence, and only after the client has been fully informed of: all aspects of the specific service, procedure,
treatment, training or other action proposed; and their right to withhold, give and revoke consent.

3. This policy does not apply in situations where a client specifically requests informal counseling, advice,
information or referral by telephone or in person.

4. In Youth Shelter programs, the Agency will attempt to obtain the written and/or verbal consent from the guardian
in all cases except for those where a client is non-status and there is indication that they may be in need of
protection.

5. Written client consent is required for the following:

a. Any service or treatment intervention;

b. Audio-visual recordings;
c. Research participation and data collection;
d. Disclosure of information;
e. Consent for release of information
f. Use of restrictive procedures;
g. Behavior management techniques;
h. Special medical procedures or diets as prescribed by a physician;
i. Prescription of routine medicine, and ;
j. Participation in any specialized or challenging recreational activities.

6. When obtaining a client’s consent, the following information must be included on the consent form:

a. the name of the client;

b. the purpose of the consent and who the information will be given to;
c. the dates that the information will be used and the conditions under which the authorization expires;
d. the consent sought will be given voluntarily, without coercion or undue influence;
e. the client has been informed of their right to withhold, give and revoke such consent, and;
f. the signature of the client and parent/guardian (if applicable).

7. Employees will be responsible to describe what is entailed and any expectations of the client. Once the client
understands the implications of their consent, a consent form can be completed and a copy placed on the
individual’s file.

8. If a client is incapable by reason of legal, mental or physical disability, of understanding and giving consent,
consent will be obtained from the client’s guardian using the same guidelines.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: PHOTOGRAPHS, ART WORK, AUDIO Please see Trellis’ Media and Communication
AND/OR VISUAL RECORDING OF Policy on ADP
CLIENTS
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: REPORTING CLIENT ABUSE, POLICY NO.: H.1.7

HARASSMENT OR NEGLECT

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Definition of Abuse

1. Any behavior by one person against another which may endanger that person’s survival, security or well-being
in the following ways:

a. Sexual Abuse - the improper exposure of an individual to sexual activity or behavior which includes sexual
touching, intercourse or exploitation by anyone:

i. in whose care the individual has been left, or;

ii. who takes advantage of the individual.

b. Physical Abuse - any form of striking, shaking, punching, slapping or other means of physical force are
intended to inflict violence or pain. Also includes administration of medication for an inappropriate purpose.
c. Emotional or Psychological Abuse - putdowns, criticisms, intimidation, isolation, controlling with fear or
any behavior that undermines the mental or emotional well-being of another.
d. Neglect – the act of omission which causes significant emotional or physical harm to an individual for whom
one is responsible.
e. Bullying – repeated and systematic physical attacks, threats, retaliation, humiliation, extortion of money,
possessions and/or exclusion perpetrated by individuals or groups.
f. Exploitation – taking advantage of others by using them or their belongings and/or persuading them to be
involved in illegal actions or actions not in their best interests.

Indicators of Abuse

2. As a preventative measure, where appropriate program employees will inform clients about abuse, describing
characteristics of the different types of abuse and high risk situations. Employees will provide strategies to clients
to help them avoid and/or get out of high risk situations.

3. In order to detect instances of abuse, Agency employees will know the indicators of abuse and high risk situations
and will identify if any of these signs are present during their regular and frequent meetings with the clients.

Definition of Harassment

4. Any unwanted physical or verbal conduct that offends or humiliates and can consist of a single incident or several
incidents over a period of time. Harassment is discrimination and may include:

a. Threats, intimidation, or verbal abuse;

b. Unwelcome remarks or jokes about race, religion, disability or age;
c. Displaying sexist, racist or other offensive pictures or posters;
d. Sexually suggestive remarks or gestures;
e. Inappropriate physical contact, such as touching, patting, pinching, or punching, and;
f. Physical assault, including sexual assault.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: REPORTING CLIENT ABUSE, POLICY NO.: H.1.7

HARASSMENT OR NEGLECT

POLICY

1. Trellis prohibits abuse, harassment and neglect. In an instance where a client shows signs of abuse, harassment,
neglect or illness, or reports any of these, Trellis will ensurethat the matter is properly reported and documented
and that, when required, the client receives prompt medicalattention.

2. Direct program service employees need to be familiar with the Child, Youth and Family Enhancement Act
regarding reporting abuse, harassment and neglect. Employees need to familiarize themselves with the
Government of Alberta Handbook on “Responding to Child Abuse”, which can be found on-line. Each program
will also post the numbers to report abuse.

Obligation to Report

3. Agency employees must report child abuse, harassment and neglect under the Child, Youth and Family
Enhancement Act as set out in law. The Child, Youth and Family Enhancement Act requires every person
who has a reason to believe, and believes, that a child has been, or there is substantial risk that they will be
abused, harassed or neglected by a parent/guardian, or might need protection, to promptly report the matter to
a Caseworker.

4. If a client discloses abuse, do not probe for details. Listen to the information provided and record it as soon as
possible in the child’s own words. Be supportive and let the client know it is right to tell someone.

5. The employee or volunteer must discuss their concern with their immediate supervisor and together decide if
there is probably grounds to believe that the client is need of protective services. For clients with Children’s
Services status, the Caseworker needs to be contacted. If it is after regular business hours or on a weekend or
if the client does not have Intervention Status, call Calgary Region Child and Family Services through their 24-
hour Intake Line at 403-297-2995 or the Child Abuse Hotline at 1-800-387-5437.

6. Upon making a report of abuse, harassment or neglect the Agency employees will document the report on an
Agency Critical Incident Report Form. Information regarding the contact with Calgary Region Child and Family
Services (including date, time, district office and name of Caseworker who received the call) will be documented.
Critical incidents regarding reports of abuse will be kept on the client file.

7. Program Manager and Director will be notified that a report has been made.

8. Any clients with Children’s Services status showing signs of abuse or neglect will receive a medical examination
as soon as possible and all results will be documented. A medical examination is also recommended for non-
status clients. In all cases, request direction from the responding Caseworker with Calgary Region Child and
Family Services.

9. The Manager and Director will ensure that appropriate support is provided for clients reporting or experiencing
abuse, harassment or neglect. The supervisor will also ensure that appropriate support is given to any Agency
employees affected by the situation.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: RESEARCH PARTICIPATION POLICY NO.: H.1.8

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis supports the participation of person’s served in research under specific conditions. Consent for
participation is to be received as per the Informed Consent policy.

POLICY

1. Before a client participates in research, the following conditions must be met:

a. Participation in research must be completely voluntary;

b. Continuation of service is not dependent on participation;
c. All or any honorariums and financial incentives are addressed and agreed upon prior to participation in
research, and;
d. Clients and their parents/guardians will sign an Informed Consent prior to research commencing that
specifies the criteria as outlined in the Informed Consent policy.

2. Any research being conducted within the Agency or with clients involved with TRELLIS services must be
approvedby the Chief Operating Officer.

3. Research projects conducted by external institutions (i.e., Universities, Research Foundations) must provide
proof of an ethical review process.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

CONFIDENTIALITY AND RIGHTS OF CLIENTS

POLICY: RESPONDING TO SUBPOENAS, POLICY NO.: H.1.9

SEARCH WARRANTS AND
INVESTIGATIONS
DATE ISSUED: ASSOCIATED STANDARDS:
CARF
DATE REVISED: May 2019

Trellis ensures that employees are aware of how to respond to subpoenas, search warrants,investigations and any
other legal actions in a way that complies with the law as well as protects the confidentiality ofthe Agency and its
clients.

POLICY

Agency Search Warrants and Investigations

1. If the police arrive at a program with a search warrant for the facility, employees will review the warrant to ensure
that it is correct and then allow access to the program.

2. Once police have entered the program, the employees will notify Manager. If this occurs after hours, the On-Call
Coordinator and Manager will be contacted.

3. If the police arrive at a program as part of an investigation, the Manager will be notified prior toany information
being released. Employees will refrain from offering information until the Leadership team has been notified and
is aware of the reason for the information request.

Subpoenas

4. Occasionally, employees in the Agency are served with subpoenas due to their work with children, youth and
families. It is the employee’s obligation to inform their supervisor should this occur. Any employees attending
court for work will be reimbursed for their time as per the Leave of Absence policy.

Search Warrants and Investigations of Children and Youth

5. All minors have the right to have a legal guardian present in the event of a search warrant or investigation. If the
police arrive at a program and have a warrant to search a minor or the possessions/belongings of a minor, the
parents/guardians would be notified and give consent prior to the search commencing. In the event that a
parent/guardian cannot be reached, the employees would contact the Manager prior to providing access to the
child/youth.

6. If the police want to speak with a child or youth for investigations, the employees would again contact the
parent/guardian to gain their approval. If the child/youth is lodging a complaint against their parent/guardian, all
notifications would be handled by the police and/or Calgary Region Child and Family Services.

7. All of these incidents require that the employee involved complete a CIR report.
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: RECREATIONAL ACTIVITIES POLICY NO.: H.2.1

DATE ISSUED: February 1, 1997 RELATED POLICIES: Weather and Outdoor Activities,
Day Trip Plan, Out-of-City Trip Plan, Specialized
DATE REVISED: May 2019 Recreational Activities

Recreational activities are a part of growing up in Canada and offer many physical, emotional and developmental
benefits to participants. Many activities are inexpensive, easy to learn and accessible within the communities that
we serve. For many of our clients, indoor and outdoor recreational activities provide an opportunity to learn new
skills, meet new friends, reduce stress and develop a healthy lifestyle. TRELLIS encourages participation in indoor
and outdoor recreational activities for its clients, when the following safety procedures are followed.

DEFINITIONS

This policy applies to any indoor or outdoor recreational activities that:

a. do not require employees to have specialized training and appropriate certifications to be qualified to
lead;
b. do not require special permits by the City of Calgary or the appropriate authority to participate in or
organize on the authority’s property;*
c. do not have a specific policy in the TRELLIS Policy and Procedures Manual;
d. do not meet any of TRELLIS’s criteria for specialized recreational activities.

*Note: Any recreational activities that utilize Kananaskis Country trails/facilities must be identified on the TRELLIS
Kananaskis Country Guiding Permit, otherwise they are considered Specialized Recreational Activities. Employees
are required to carry a copy of this permit whenever they take a group to Kananaskis Country.

Some examples of recreational activities are, but not limited to: archery, go carting, fishing and laser tag.

To determine if an activity is included on our Kananaskis Country Guiding Permit, contact the Manager,
Experiential Learning.

If you are unsure whether a proposed activity meets these criteria, consult your supervisor.

POLICY

1. If a helmet is made for the activity you are proposing (e.g. skiing, biking, skating, skateboarding) all clients,
employees and volunteers must wear one. If helmets are required by law (biking under 18 years old) or by the
facility/site they must be worn.

2. The employee-to-client ratio for this activity must match your program’s employee-to-client ratio.

3. Employees are responsible for knowing or learning the proper rules, regulations and etiquette for the
proposed recreational activity prior to introducing it to clients.

4. Keep all equipment in good condition and inspect it prior to use for broken parts, sharp edges and cracks.
Do not use equipment that is not in good condition and report any equipment concerns to your supervisor.

5. Prior to starting the activity, do a visual site assessment and identify any risks. If employees determine that
the site/facility is not safe, move the activity to a safe place, or end the activity.

6. Prior to starting the activity, teach participants all relevant safety procedures and skills to prevent injuries.
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: RECREATIONAL ACTIVITIES POLICY NO.: H.2.1

7. Employees are required to have a First Aid kit with them at the site/facility where the recreational activity is
taking place.

8. Any activities that are violent in nature (paintball, shooting range) must have Program Manager approval as
well as signed permission from parents/guardians.

9. It is the responsibility of TRELLIS employees to verify that any proposed recreational activity is permitted at
the chosen site/facility by the City of Calgary (or appropriate authority). The City of Calgary’s official web site:
www.calgary.ca is a recommended resource for this verification.

10. Most activities in Provincial and National Parks (this includes Fish Creek Provincial Park) require a
Permit.
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: SPECIALIZED RECREATIONAL POLICY NO.: H.2.2

ACTIVITIES

DATE ISSUED: February 1, 1997 RELATED POLICIES: Weather and Outdoor Activities,
Day Trip Plan, Out-of-City Trip Plan, Recreational
DATE REVISED: May 2019 Activities, Camping

Specialized recreational activities can provide our clients with unique and positive life-changing experiences.
Research shows that when young people master challenging skills and situations, they acquire competencies that
boost their likelihood of success in all facets of their life. These types of activities do, however, typically require
higher skill levels, specialized equipment, skilled employees/instructors, higher levels of fitness and strength, take
place outside of the city and may expose clients to a greater degree of risk than typical program activities. As a
result, TRELLIS supports participation in specialized recreational activities for its clients, when the following
procedures are followed.

DEFINITIONS

A SPECIALIZED recreational activity is defined as any indoor or outdoor recreational activity that meets at least
one of the following criteria:

a. requires employees to have specialized training and appropriate certifications to be qualified to lead or
requires hiring a guide/skilled instructor with appropriate qualifications to lead (such as outdoor rock
climbing, white water rafting/kayaking, canoeing, backcountry hiking, scrambling, etc.),
b. requires special permits by the City of Calgary or appropriate authority to organize/participate in on
authority property,
c. is not covered by the agency’s Kananaskis Country Guiding Permit (contact the Manager, Experiential
Learning for details on what activities and locations are included in this permit),
d. takes place in avalanche terrain,
e. takes place on trails or backcountry campgrounds within a National Park (a specific guiding permit is
required).

Some examples of what would be considered to be a specialized recreational activity are: all watercraft activities,
horseback riding, outdoor climbing, caving and bouldering. If you are unsure whether a proposed activity meets the
criteria to be considered a specialized recreational activity, contact your supervisor and the for guidance PRIOR to
making any plans.

POLICY

1. A written proposal for the proposed specialized activity must be provided to the Program Manager; the
proposal must include the following information:

a. Detailed description of the activity, level at which it will be undertaken, cost, etc.,
b. Consideration of the location (i.e., mountainous terrain, outdoor water, urban versus remote setting),
c. Purpose/benefits for clients participating in activity,
d. Safety precautions/considerations, including the age-appropriateness of the activity, the qualifications,
experience and certifications of instructors, employees and volunteers, employee-to-client ratio, fitness
level and experience of the children/youth and seasonal conditions,
e. List of required permits, insurance requirements, TRELLIS waivers, third-party waivers and how
theserequirements are being met,
f. How the activity meets the goals of the program logic model and/or the agency’s strategic plan,
g. Communication devices (satellite phone, cellphone, etc.).
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: SPECIALIZED RECREATIONAL POLICY NO.: H.2.2

ACTIVITIES

2. For children/youth with Children’s Services status, written approval must be received from Calgary Region
Child and Family Services. All written approvals must be kept on the child/youth client file. For all specialized
recreational activity outings, written approvals and consents from guardians must be obtained prior to the
activity. Written approvals/consents must be kept on file with the Specialized Activity Plan.

Note: Approvals, waivers and consent forms for specialized recreational activities can take several weeks to
be completed, so it is advised that these types of activities be planned 2 or more months in advance of the
start date for the activity.

3. Activities NOT Covered by TRELLIS General Liability Insurance Policy

a. Aviation activities (aircraft or helicopter rides)

b. Hot air balloon rides
c. Parasailing
d. BASE jumping
e. Sky diving
f. Excursions requiring the use of non-commercial aircraft (i.e., private airplanes)
g. Any other aviation or aircraft-related activity
h. Automobile activities (i.e., demolition derbies, auto races)
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: WEATHER AND OUTDOOR POLICY NO.: H.2.3

ACTIVITIES

DATE ISSUED: February 1, 1997 RELATED POLICIES: Out-of-City Trip Plans,

Recreational Activities, Specialized Recreational
DATE REVISED: May 2019 Activities

Providing opportunities for our clients to participate in outdoor activities, year-round, contributes to their overall
health and well-being, while helping them develop their physical literacy. TRELLIS supports participation in a wide
variety of outdoor activities for its clients when the following weather considerations and safety procedures are
followed.

Outdoor activities in any season can expose clients to potentially harmful UV rays by over exposure to the sun
(even on cloudy days). Participants, employees and volunteers are encouraged to wear a hat (employees can have
extra hats to provide to participants) and to regularly apply sunscreen (with an SPF of 30 or greater); it is
recommended that employees bring extra sunscreen for participants who require it.

POLICY – Cold Weather

1. Cold weather, outdoor activities are permitted at or above -20C with a wind chill factor at or above -25C. If the
temperature OR the wind chill factor is colder than these values, the outdoor activities will need to be moved
indoors.

2. Skin can freeze when exposed to very cold temperatures (at a wind chill of -25C, frostbite can occur in 45
minutes). As a result, the following safety precautions must be followed:

a. Employees must ensure temperatures meet the policy requirements prior to trip departure.
b. Employees must ensure that clients are wearing appropriate clothing; this requires employees to plan
ahead to notify parents and to bring extra gear (coats, snow pants, socks, mittens, hats).
c. Employees must ensure clients are not at risk of frostbite. Young children may not verbally indicate that
they are cold, so employees need to visually check for signs of frostbite or extreme cold, in the case of
toes a verbal check is sufficient. If you suspect that a child’s toes may be getting too cold and are at risk
of frost bite, check them visually.
d. Employees should do “extremity checks” (verbal or visual) at regular intervals during outdoor activities -
extremities include toes, fingers, nose and ears (check your First Aid Handbook for the signs and symptoms
of frostbite).
e. Bring children/youth inside when they say they are cold.

3. Remember that children get colder much faster than adults do and their skin is more prone to freeze – so always
be prepared with a back-up plan!

POLICY – Hot Weather

4. The length of activities (ex: 45 min or less) and access to shade or indoor spaces should be considered if
temperatures are above 30C with a humidex factor above 35C.

5. If the temperature is at or above 36C employees need to ensure access to shade and/or an indoor space, and
fresh water, and need to consider the length of the activity and level of physical excursion required. If these
considerations and access cannot be managed appropriately the activity needs to be rescheduled for a cooler
part of the day (early morning, early evening) or cancelled.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: WEATHER AND OUTDOOR POLICY NO.: H.2.3

ACTIVITIES

6. High temperatures and high relative humidity make it difficult for children/youth to dissipate heat, which puts
them at risk for overheating, heat exhaustion and heat stroke. As a result, the following safety precautions must
be followed:

a. Employees must ensure temperatures meet the policy requirements prior to trip departure.
b. Employees must ensure that clients are wearing appropriate clothing; this requires employees to plan
ahead to notify parents and to bring extra gear (sunscreen, sun hats, long sleeve shirts and pants).
c. Employees must ensure clients are not at risk of sunburn and dehydration/overheating and should check
in with clients regularly. Children may not indicate that they are too hot, so employees need to check for
signs of sunburn, dehydration and/or overheating (check your First Aid handbook if you are unsure of the
signs of sunburn/dehydration/overheating).
d. Employees must ensure that participants stay hydrated – during moderate activity, participants should
drink 150-250mL of fluid every 15 minutes; this requires employees to ensure sufficient water is available
on-site or to bring enough for all participants for the duration of the activity. Remind participants to drink
regularly.
e. Bring children/youth inside or move them to a cooler place when they are too hot.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: CAMP FIRES POLICY NO.: H.2.4

DATE ISSUED: February 1, 1997 RELATED POLICIES: Weather and Outdoor

Activities, Day Trip Plan, Out-of-City Trip Plans
DATE REVISED: May 2019

Camp fires provide children and youth with an opportunity to learn about science, experience the outdoors,
participate in singing and story-telling and go to new places within their community. TRELLIS supports the
participation in camp fire activities for its clients, when the following safety procedures are followed.

POLICY

1. Employees must be aware of regulations pertaining to fires and firewood in the areas they are using andmust
follow the regulations. Camp fires must be kept in established fire pits or designated fire areas.

2. The employee-to-client ratio for this activity must match your program’s employee-to-client ratio.

3. Fires must be started without the use of accelerants.

4. Fire wood and kindling used for camp fires must be supplied by a commercial fire wood vendor or purchased at
a retail site. On day hikes and overnight trips in areas where fires are permitted it is the responsibility of the
employees to know if gathering firewood from the natural environment is permitted.

5. Employees are required to have a First Aid kit with them at the camp fire site. The contents of the First Aid kit
must meet the requirements provided in the TRELLIS Emergency Response Manual.

6. It is the responsibility of TRELLIS employees to check fire hazard levels for the proposed location of their camp
fire prior to leaving for the activity. TRELLIS employees are not permitted to hold camp fire activities when the
fire hazard level is rated as “high”; an alternate location and/or activity must be identified. The following web
site provides up-to-date information on fire bans in the province of Alberta: www.albertafirebans.ca

7. Employees are responsible for having enough water to completely extinguish the camp fire at the end of the
activity and must ensure that the fire is completely extinguished (including hot coals).
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: CAMPING POLICY NO.: H.2.5

DATE ISSUED: February 01, 1997 RELATED POLICIES: Weather and Outdoor Activities,
Camp Fires, Specialized Recreational Activities,
DATE REVISED: May 2019 Recreational Activities, Out-of-City Trip Plans

Camping provides children and youth with the opportunity to have primary experiences in nature, to experience a
different sense of place and to build outdoor recreation skills they can utilize throughout their lives. TRELLIS
supports participation in camping activities for its clients, when the following safety procedures are followed.

DEFINITIONS

Front country camping occurs in outdoor areas that are easily accessible by vehicle and are visited by day users
and overnight campers alike. Developed campgrounds with potable water, washroom facilities and even showers,
are also considered front country areas.

Backcountry camping occurs in outdoor areas that cannot be reached by vehicle, have no facilities, no potable
water, probably no cell coverage and require you to get there under your own power, bring everything that you
need and pack out everything that was brought in.

POLICY

1. Front country camping activities must take place at an approved camp site.

2. Backcountry camping is considered a specialized recreational activity by TRELLIS and must follow the
procedures in the Specialized Recreational Activity policy.

3. The employee-to-client ratio for this activity must match your program’s employee-to-client ratio, with both male
and female employees present when camping with a co-ed group.

4. Ensure all camping equipment is in good condition and inspect it prior to use for broken parts, holes in
tents/sleeping bags or stoves/lanterns in disrepair. Do not use camping equipment that is not in good condition
and report any equipment concerns to the Manager, Experiential Learning.

5. Employees are required to have a First Aid kit with them at the camping site. The contents of the First Aid kit
must meet the requirements provided in the TRELLIS Emergency Response Manual. If additional first aid
supplies are deemed necessary for the outing, employees must ensure that these supplies are included.

6. It is the responsibility of TRELLIS employees to review all area reports, closures and advisories prior to leaving
for a camping activity. The area reports must be provided to the On-Call Coordinator and Manager 24 hours
prior to departure. If you are uncertain how to access any of this information, contact the Manager, Experiential
Learning..

7. An out-of-city trip plan must be completed and approved prior to any camping activity. See the out-of-city trip
plan policy for specifics.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: ALPINE SKIING AND POLICY NO.: H.2.6

SNOWBOARDING

DATE ISSUED: February 1, 1997 RELATED POLICIES: Weather and Outdoor

Activities, Out-of-City Trip Plans
DATE REVISED: May 2019

Alpine skiing and snowboarding are winter activities that provide children and youth with outdoor, aerobic exercise
while developing their coordination, balance, confidence and self-esteem. Although not always considered a
financially accessible activity, TRELLIS can often obtain funding and donors that make it possible to introduce
children and youth to these sports, both within Calgary and at mountain ski resorts. TRELLIS supports participation
in this winter activity for its clients, when the following safety procedures are followed.

DEFINITIONS

CSIA = The Canadian Ski Instructors' Alliance is the leader in the profession of ski instruction in Canada; the CSIA
develops programs to ensure a safe and positive guest experience, a progressive approach to learning and sets
national standards in ski teaching.

CASI = The Canadian Association of Snowboard Instructors is the professional snowboard teaching body in
Canada. The aim of CASI is to train and certify snowboard instructors and to ensure that a national standard of safe
and efficient snowboard instruction is maintained to serve the Canadian snowboarding public and the
ski/snowboarding industry.

POLICY

1. Only commercially operated ski/snowboard facilities, with suitable teaching areas (gentle slopes) are permitted
to be used by TRELLIS programs. A dedicated facility operated ski patrol/emergency first response system
must be in place and operating on-site.

2. Helmets that are approved for skiing/snowboarding are required to be worn by all clients, volunteers and
employees.

3. The employee-to-client ratio for this activity must match your program’s employee-to-client ratio.

4. Employees must be able to see all clients within their care, at all times; employees and clients may be splitinto
groups to allow for different skiing/snowboarding abilities and interests within the group.

5. Employees are responsible for checking weather conditions prior to departing for any ski/snowboard
activities, as per the Weather and Outdoor Activities policy.

6. Employees are required to have a First Aid kit with them at the skiing/snowboarding site. The contents of the
First Aid kit must meet the requirements provided in the TRELLIS Emergency Response Manual.

7. All participants are required to take a minimum of one lesson from a CSIA or CASI-certified ski/snowboard
instructor from a recognized ski hill operator on the first day of a TRELLIS program or prior to any out-of-
city Ski/snowboard trip. Or demonstrate their ability to ski/ride in control and make stops or change
directions safely and as instructed.

8. It is the responsibility of TRELLIS employees or the instructor to educate participants on the Alpine Responsibility
Code, slope ratings, the ski area boundaries, the role and location of ski patrol and the rules/etiquette of the ski
hill/resort. The Alpine Responsibility Code is available at: http://www.cwsaa.org/alpine-responsibility-code
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: ALPINE SKIING AND POLICY NO.: H.2.6

SNOWBOARDING

9. Clients, employees and volunteers must ski/snowboard within ski hill/resort boundaries.

10. Participants must be taught the importance of skiing/snowboarding in control at all times.

11. Participants must be taught how to properly load and unload lifts. Long hair should be tied back or tucked in
and loose articles such as scarves, long hats or toggles should be removed or tucked in prior to accessing any
type of lift. Backpacks are not permitted on lifts.
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: ICE SKATING POLICY NO.: H.2.7

DATE ISSUED: February 1, 1997 RELATED POLICIES: Weather and Outdoor Activities,
Out-of-City Trip Plans
DATE REVISED: May 2019

Ice skating is a community-driven, accessible winter activity that can be enjoyed both outdoors and indoors. In
Canada, learning to ice skate is a cultural constant and an activity that people of all ages participate in. TRELLIS
supports participation in this winter activity for its clients, when the following safety procedures are followed.

POLICY

1. Helmets are required to be worn by all clients, volunteers and employees. Hockey or skating helmets are
preferred, but ski/snowboard helmets are acceptable. Note: Some indoor rinks only permit hockey or skating
helmets to be worn while ice skating; employees are responsible for checking helmet requirements prior to
taking clients skating.

2. The employee-to-client ratio for this activity must match your program’s employee-to-client ratio.

3. TRELLIS or the skating facility may have ice skates that employees or clients can use. Employees must ensure
borrowed equipment is in good condition prior to use (including if skates are sharp). Consult with your
supervisor or a skating facility staff if you have concerns about borrowed equipment.

4. Employees are required to have a First Aid kit with them at the skating site. The contents of the First Aid kit
must meet the requirements provided in the TRELLIS Emergency Response Manual.

5. Indoor skating opportunities and public skate times can be found on the City of Calgary web site:
www.calgary.ca

6. Outdoor skating rinks in Calgary are weather-dependent and are typically open December through February.
City-maintained outdoor rinks are free to use and are flooded as needed during low usage hours. Hockey sticks
are not permitted. The City of Calgary web site (www.calgary.ca) indicates the current status of these rinks
(open/closed).

7. There are also over 35 outdoor rinks throughout Calgary that are maintained on a volunteer basis through the
Adopt-a-Rink program. For more information and rink locations, go to the Adopt-a-Rink program page on the
City of Calgary’s web site.

8. Any skating activities done outside the City of Calgary must also be at an indoor rink or an outdoor location
that is designated for ice skating by the appropriate authority. For example, ice skating is permitted on Lake
Louise by Parks Canada. An out-of-city trip plan is required for this activity.
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: TOBOGGANING POLICY NO.: H.2.8

DATE ISSUED: February 1, 1997 RELATED POLICIES: Weather and Outdoor

Activities, Out-of-City Trip Plans
DATE REVISED: May 2019

Tobogganing is one of the least expensive winter activities to participate in and is often seen as a “rite of passage”
for Canadian children. Tobogganing offers children and youth the opportunity to experience the outdoors in the
winter, while helping them meet Canadian physical activity guidelines. TRELLIS supports participation in this winter
activity for its clients, when the following safety procedures are followed.

DEFINITIONS

A toboggan is typically a long, runner less, flat‐bottomed sled that curves upward and backward at one end.
Traditionally, toboggans were made of small slats of wood, but now are often made of a solid piece of plastic or
foam. Toboggan’s for the purpose of this policy may or may not have the upward and backward curve at one end.

A sled is composed of a flat surface with runners or rails attached. The surface of the sled is lifted off the snow
by the runners, which glide along the top of the snow.

POLICY

1. Only toboggans are permitted to be used by TRELLIS participants (such as, wooden, foam or plastic
toboggansand crazy carpets).

2. Sleds with any type of runner and inner tubes are not permitted.

3. Keep all equipment in good condition and inspect it prior to use for broken parts, sharp edges, cracks and
splits. Do not use toboggans that are not in good condition and report any equipment concerns to the Program
Manager.

4. Helmets are required to be worn by all clients, volunteers and employees. Ski/snowboard helmets are
preferred, but bicycle helmets are permitted.

5. The employee-to-client ratio for this activity must match your program’s employee-to-client ratio.

6. Participants must not stand on toboggans. They should be seated or kneeling. Tobogganing head first or
lying down is not permitted because it increases the risk of head injury.

7. Toboggans should not be overloaded; employees must ensure an appropriate number of participants are on
each toboggan.

8. A safe procedure for participants to clear bottom area and to return to top of the hill should be established.

9. Employees must ensure the sledding hill is clear of obstacles and safe for sledding prior to beginning this
activity.

10. Employees are required to have a First Aid kit with them at the tobogganing site. The contents of the First
Aid kit must meet the requirements provided in the TRELLIS Emergency Response Manual.
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AG E N CY S E R V IC E D E L I V E RY
R E C R E AT I O N AL AC T I V I T I E S

POLICY: TOBOGGANING POLICY NO.: H.2.8

11. It is the responsibility of TRELLIS employees to verify that any proposed tobogganing location for a TRELLIS
program is on the City of Calgary’s permitted list prior to tobogganing. This list can be found on the City of
Calgary’s official web site: www.calgary.ca.

12. Any tobogganing activities outside of Calgary must also be done at a location that is designated for
tobogganing by the appropriate authority. For example, tobogganing at the Canmore Nordic Center must be
done in the designated area, as per Alberta Parks and Recreation. An out-of-city trip plan must be submitted
for these events.
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AGENCY SERVICE DELIVERY

RECREATIONAL ACTIVITIES

POLICY: SWIMMING POLICY NO.: H.2.9

DATE ISSUED: February 1, 1997 RELATED POLICIES: Weather and Outdoor

Activities, Out-of-City Trip Plans
DATE REVISED: May 2019

Swimming is a life-long skill that all children/youth will benefit from learning. It is also a fun and social activity that
helps children and youth meet Canadian physical activity guidelines. TRELLIS supports participation in indoor and
outdoor swimming activities for its clients, when the following safety procedures are followed.

POLICY

1. Swimming during TRELLIS programs for clients is only permitted at indoor/outdoor pools, lakes and all
otherwaterfront facilities where a certified National Lifeguard Services (NLS) Lifeguard is present and on-
duty.

2. TRELLIS employees can be the lifeguard, provided they have the NLS certification and are not relied upon
tobe in ratio/regular client supervision for the duration of the swimming activity.

3. The employee-to-client ratios are based on client age:

a. For clients 7 years and younger, the ratio is 1:3, and;

b. For clients 8 years and older the ratio is 1:10

4. Clients 7 years and younger must be within arm’s reach of an employee or responsible adult at all times.

5. Clients 5 years and younger must wear a personal flotation (PFD) device at all times.

6. A well-marked, first aid kit and related rescue equipment must be readily available in the swimming area;
employees are responsible for knowing where this equipment is located for any facility that they bring clients.
The contents of the First Aid kit must meet the requirements provided in the TRELLIS Emergency Response
Manual.

7. Rules and regulations of swimming area must be followed.

8. Diving is permitted only in areas where it is marked as permitted.

9. Clients must swim only in designated areas.

10. Outdoor swimming activities must be discontinued if there is an indication of lightening (this includes thunder,
storm clouds, etc).

11. Outdoor swimming or waterfront activity is not permitted during darkness or 30 minutes before dawn and
after dusk.
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A G EN C Y S E R VI C E D EL I V ER Y
R E C R E A T I O N A L A C T IV IT IE S

POLICY: INDOOR CLIMBING POLICY NO.: H.2.10

DATE ISSUED: February 1, 1997 RELATED POLICIES:

DATE REVISED: July 2019

Indoor climbing takes place on a simulated rock wall located in an indoor gym. The idea is to learn the skills of rock
climbing in a safe and controlled environment. Although some indoor rock climbers do not ever make the step into
outdoor climbing, indoor climbing gyms provide learning and practicing venues for those planning to move outdoors
eventually. TRELLIS supports participation in this activity for its clients, when the following safety procedures are
followed.

DEFINITIONS

ACMG = The Association of Canadian Mountain Guides; dedicated to protecting the public interest in mountain
travel, the ACMG is the only internationally recognized professional association of trained and certified mountain
guides and instructors in Canada.

POLICY

1. Indoor climbing outside of TRELLIS facilities, falls under Policy H.2.2 – Specialized Recreational Activities.

2. Only employees who have a valid (not expired) TRELLIS Internal Belay Certificate or an ACMG-certified indoor
climbing instructor are permitted to take TRELLIS clients indoor climbing.

3. TRELLIS clients must have signed the Risk Acknowledgement Form found in the client membership form. For
clients who are not TRELLIS members, a stand alone Risk Acknowledgement Form will be provided. For all
clients this form must be completed before they are permitted to climb on the TRELLIS climbing wall (at the
Hangar facility).

4. The employee-to-client ratio is 1:4 per rope.

5. Employees belaying clients must ensure that all harnesses fit properly, knots are tied properly and buckles are
doubled-back.

6. Lead climbing or protection placement by clients is not allowed.

7. Clients should be allowed to select the challenge of their choice, as long as they do not exceed their own limits.

8. Ropes and associated climbing equipment designed specifically for wall climbing must be used. A correct base
anchor plate belay system or belay off the harness, incorporating a mechanical belay system must be used,
e.g., Gri Gri, Sticht plate, ATC, or Tuber type of belay device.

9. Keep all equipment in good condition and inspect it prior to use. Report any equipment concerns to the
Climbing Wall Lead. The Climbing Wall Lead will be designated by the Director of Clubs.

10. Employees are required to have a First Aid kit accessible at the indoor climbing site. The contents of the First
Aid Kit must meet the requirements provided in the TRELLIS Emergency Response Manual.

11. Clients 12 years old and younger are required to wear a helmet on the Renfrew Climbing Wall. Helmets are
optional for clients 13 years old and older. Belayers are not required to wear helmets.
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AGENCY SERVICE DELIVERY

SERVICE PLANNING

POLICY: ACCESS TO CLIENTS OUTSIDE POLICY NO.: H.3.1

PROGRAM MANDATE

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

All Trellis employees are expected to adhere to the highest level of professionalism in the area of boundaries. All
employee relationships must serve the best interests of the client while preserving the safety and security of the
client, employee, student, volunteer and Agency.

POLICY

1. Employees may not have contact, outside of program parameters, with clients who are presently, or have
previously been, in a TRELLIS program unless all of the conditions below have been met. Employees no longer
with the Agency must also adhere to these conditions.

a. A Consent Form (Permission to Maintain Relationship) is on file and signed by each of the Program
Manager and/or Director, the client’s guardian and/or Caseworker;
b. Written reports are submitted documenting the date, duration, and nature of the activities undertaken, and;
c. Written reports are kept in the clients’ program file with a copy to be held by the Program Manager, with
updates being provided to the Program Manager. For former TRELLIS clients, the appropriate database
should reflect this information.

2. Employees may not share personal information including phone numbers, home address or email address
unless all of the conditions above have been met.

3. The original Consent Form will be retained in the client’s file with a copy being placed in the employee’s
personnel file.

4. The above conditions will cease to be in effect one year after the 18th birthday of the client or one year after
they leave Agency, which ever is later.

5. Employees will sign, upon commencement, a commitment to the above conditions to be adhered to even in the
event that they leave the Agency.

SOCIAL MEDIA

1. TRELLIS employees and volunteers must not use their personal social media accounts to contact or
interact, ‘friend’, follow, or otherwise engage on social media directly or indirectly with current TRELLIS
children, youth orfamily clients.

2. To maintain professional integrity, TRELLIS employees and volunteers must only engage on social media
(including 'friend', message or interact on social media) with any former TRELLIS children, youth or
familyclientsin accordance to the TRELLIS ACCESS TO CLIENTS OUTSIDE PROGRAM MANDATE Policy
outlined above.

3. Any current client, who may approach TRELLIS employees on their personal profile should be declined and sent
apolite message outlining why they have been declined, directing them to an alternate and official TRELLIS
sourceof communication i.e. phone, email, Facebook, Twitter, etc.
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AGENCY SERVICE DELIVERY

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POLICY: ACCESS TO CLIENTS OUTSIDE POLICY NO.: H.3.1

PROGRAM MANDATE

4. If there are concerns about the safety or whereabouts of a child or youth who has initiated communication via
social media, proper communications and crisis / emergency protocol must be followed.

5. If there are significant, immediate and defendable concerns relating to a young person's whereabouts, personal
safety or risk to themselves or the community, it may be appropriate to access publicly available information
about a young person on social media networks to locate the young person or to connect with them directly.
This should only occur if TRELLIS employees can access information without disclosing their own details and
without identifying the young person as being involved with TRELLIS or breaking relevant privacy laws. If there
is information relevant to the young person's whereabouts, TRELLIS employees should consult with their
immediatesupervisor, and program Manager to discuss the appropriateness of using this information, with
particular emphasis on safety.
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AGENCY SERVICE DELIVERY

SERVICE PLANNING

POLICY: BEHAVIOR MANAGEMENT AND POLICY NO.: H.3.2

DISCIPLINE

DATE ISSUED: November 1, 2005 ASSSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019 CARF - Program/Service Structure
CARF – Nonviolent Practices

POLICY

1. The Agency supports and encourages positive behavior management strategies which focuses on the client’s
ability to change their own behavior The following strategies are supported:

a. Natural and logical consequences

b. Strength Based Approach
c. Solution Focused
d. Nonviolent Crisis Intervention

2 The Agency prohibits the use of, and training in the following:

a. Corporal punishment;
b. Engaging in any form of conduct which is intended to ridicule, humiliate, degrade, insult or otherwise
undermine the dignity and self-worth of a client;
c. Mechanical restraints for physical control or punishment;
d. Group punishment for one client’s behavior;
e. Medication for punishment; or
f. Painful aversive stimuli.

3. The following forms of discipline are prohibited:

a. Withholding of basic needs, including meals, sleep, snacks, bedding, shelter or clothing;
b. Withholding allowances; unless held for purposes of restitution or as a temporary consequence;
c. Denying or restricting visits or contact with family or guardian unless for safety reasons; and
d. Denying or restricting visits or contact with the client’s Caseworker, lawyer, or the Child and Youth
Advocate; and
e. Denying access to spiritual observances.

4. The Agency prefers the use of natural and logical consequences with clients. However on rare occasions there
may be other approaches required, these could include:

a. The choice of a cool off period for the client to regain regulation of their emotions and behaviors. These
periods may be accompanied or unaccompanied by employees. If accompanied by employees, the focus
remains regulation. If unaccompanied, employees will actively check in with clients 12 years old and over
after 20 minutes, and with clients under 12 they will actively check in after a period not exceeding one
minute per year of the age of the client. Check-ins will determine if clients have sufficiently regulated to
process the incident or if they require more cool off time. Clients at risk of self-harm or harm to others
should not be left alone for any amount of time.
b. Loss of privileges, T.V., telephone if these have been abused; or
c. Restitution to cover the cost of damage or a portion thereof; this may include withholding allowances.
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SERVICE PLANNING

POLICY: BEHAVIOR MANAGEMENT AND POLICY NO.: H.3.2

DISCIPLINE

5. Upon admission, the Agency will inform clients of disciplinary methods and will obtain written permission for the use
of these methods by the client or their parents/guardian.

6. Disciplinary practices, other than the use of natural and logical consequences and those taught in Nonviolent
Crisis Intervention and/or Therapeutic CRISIS Intervention are acceptable provided the consequences are
sensitive to the developmental level of the client and present no risk of doing psychological or physical harm to
the child.

7. All disciplinary actions will be documented and placed on the client’s cumulativefile.

8. Any behavioral method of control implemented by Agency employees will ensurethat:

a. The client’s fundamental rights are protected;

b. That the employees are supported in appropriate application of behavioral control methods that are known
to be effective and humane;
c. The results of the intervention are documented and evaluated;
d. That the client is aware of how to reinstate privileges that are lost or restricted, and;
e. Written consent(s) are obtained by the guardian and client for any methods of control that may be
considered restrictive in nature; i.e. house arrest.
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SERVICE PLANNING

POLICY: CLIENTS WITH INFECTIOUS DISEASE POLICY NO.: H.3.3

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis will provide services to clients with an infectious disease provided the safety of the client, other clients
and employees will not be compromised.

2. A client with an infectious disease may be admitted into a program given there has been careful consideration
of the following:

a. The ability of the program to make a reasonable accommodation for the client served;
b. The risk of transmission of the disease;
c. The ability of the client served to exercise precautions against transmission of the disease;
d. The ability of other clients served to protect themselves from infection; and
e. The risk of the infected client becoming infected with another disease (i.e. a person served who has the
measles or HIV coming into contact with an individual who has pink eye).

3. Approval for placement must be obtained through the parent, guardian or Caseworker, Program Manager
and Director.

4. Employees must practice Universal Precautions at all times, regardless of the health status of the clients in the
program. Employees must note that clients may not always be aware of any infectious diseases or may
choose not to disclose their health status.

5. Program Managers or On-Call Coordinators must be notified immediately if a client or employee is exposedto
an infectious disease. In these circumstances, employees will comply with the policy and procedures as per the
Universal Precautions policy.
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AGENCY SERVICE DELIVERY

SERVICE PLANNING

POLICY: CONSENT FOR BEHAVIOUR POLICY NO.: H.3.4

MANAGEMENT

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019

POLICY

1. Trellis programs responsible for using behavior management approaches that may impact clients will inform them
and their guardians of the behavior management restrictions used by the Agency, including the circumstances of
when unlocked confinement, cool off period and withdrawal of privileges may be used.

2. At admission, these methods will be explained to the client and their guardian as well as the process for
reinstatement of privileges.

3. Consent from the client’s guardian will be voluntarily provided. In the case of an agreement with Children’s
Services with a client over the age of 16, the client’s consent is required and must be kept in the client’s cumulative
file.
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AGENCY SERVICE DELIVERY

SERVICE PLANNING

POLICY: CRITICAL INCIDENTS POLICY NO.: H.3.5

DATE ISSUED: May 1, 2005 ASSOCIATED STANDARDS

CARF – Leadership
DATE REVISED: May 2019 CARF – Health and Safety
Licensed Preschool

Critical Incidents are events that are out of the ordinary and may require the notification of parents/guardians, Calgary
Region Child and Family Services, Child Care Licensing Officer, Probation Officers, and other involved parties or,
are events that are required to be documented by provincial standards and/or Agency policy.

Trellis may have situations arise that require employees to provide prompt documentation and notification of incidents
to their Manager and other individuals noted through the normal lines of accountability.

Some funders (i.e., Calgary Homeless Foundation, Licensed Child Care) have specific guidelines for reporting major
critical incidents which are also documented in this policy.

POLICY

1. A Critical Incident Report must be completed and legal guardian notified within 24 hours of any critical incident
involving a client or employee. Critical incidents may arise in a variety of situations during the provision of service
delivery. Some of these situations might include, but are not limited to:

a. Medical emergencies including an illness or injury to a child that requires the program to request
emergency health care and/or requires the child to remain in the hospital overnight;
b. Medication errors or refusal of medication;
c. Physical, sexual or emotional abuse disclosures and/or allegations by child, youth, parents, employees or
volunteers;
d. Exposure to infectious diseases;
e. Suicide attempts, gestures, ideation and/or threats of self-harm;
f. Accidents, emergencies and/or dangerous situations, including vehicular and biohazard;
g. Run-away and run-away returns (AWOL’s);
h. Drug and/or alcohol use and/or possession;
i. Death of a client or family member;
j. Serious legal offence and/or serious assault to employees or other children;
k. Sexual activity;
l. Use or possession of weapons;
m. Vehicular accidents;
n. Biohazard accidents;
o. Client searches;
p. Emergency evacuation or unexpected program closure;
q. Intruder on the premises;
r. A child removed from the program by a non-custodial parent/guardian;
s. Child left on the premises outside of program operating hours;
t. If a child is involved in an illegal offence while in program.

2. Any employee confronted with a Critical Incident with a client will undertake all steps necessary to ensure the
client is kept safe. The employee will exercise their best judgment. In the event that the incident involves illegal
drugs or weapons, the police will be called in to the program.
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AGENCY SERVICE DELIVERY

SERVICE PLANNING

POLICY: CRITICAL INCIDENTS POLICY NO.: H.3.5

3. Once the situation has been resolved, the employee will complete an Agency Critical Incident Report that
describes the nature of the incident, and action taken, and any follow-up that may be required. A Critical Incident
Report must include at a minimum:

a. Immediately notified regarding the incident;

b. If the incident involves a CS Status client, the CIR must be sent to the client’s Caseworker within 24
hours. Notification to the Contract Manager and Program Manager will be completed in a quarterly report
from the staff involved.
c. Any symptoms of serious illness and physical or sexual abuse are documented, and that an examination and
treatment by a physician is made available to the client, and they are encouraged to attend within twenty-
four (24) hours;
d. If the incident involves a CFS Status client, and the incident requires that Emergency Medical Services is
contacted, the Guardian or Calgary Region Child and Family Services must be contacted as soon as
possible.

4. The Manager who receives the report is responsible for notifying other individuals through the normal lines of
accountability. The Manager will determine what follow-up may be required and will undertake any action that
may be deemed warranted.

5. All critical incidents should be debriefed with the client, employees and any other person involved in the incident.
If required, outside professional support will be provided to those involved and will be arranged by the Program
Manager and Director.

6. Situations that led up to a critical incident may be reviewed in a Quality of Care or Investigation meeting. In cases
where these incidents may be occurring frequently, a decision may be made to alter the approach being utilized.

Critical Incident Reports can be subpoenaed by the courts and therefore needs to be legible, dated and signed by
the person completing the report and the Program Manager.

Major

7. The following critical incidents require immediate notifications to the Manager:

a. Death or serious injury of a client or employee;

b. Damage to facility requiring evacuation;
c. Whenever media is involved.

In the event of “a” or “b”, employees will also notify parents/guardians or Calgary Region Child and Family Services
should the event occur after hours.

8. Employees will only address the media as per the Media Policy. Managers will be responsible to notify the
Director/Chief Officer(s) and/or CEO in the event the media has been involved.

9. A Critical Incident Report must be completed by the employee on shift and any documentation attached to the
report. Notes will be left in the communication logbook for the team as to the incident and any follow up
required.

10. In the event of a major critical incident, a Manager and/or Director will be onsite within 24 hours of the event.
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AGENCY SERVICE DELIVERY

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POLICY: CRITICAL INCIDENTS POLICY NO.: H.3.5

11. The offering of a debriefing session, either with a professional or a member of the Leadership team, will be
provided within 48 hours of the incident for the clients and employees involved in the incident.

12. Major critical incidents are debriefed with the Leadership team within 14 days of the event. An analysis of
critical incidents will be reviewed on a quarterly basis with the program employees and Manager as well as an
annual review of all critical incidents in the Agency. The review of these trends will be documented.

13. CRITICAL INCIDENT REPORTING FOR PRESCHOOL PROGRAMS

Incidents occurring in the preschool settings will be reported immediately to the Regional Child Care office using
the prescribed form available at www.child.alberta.ca/childcare. The following is a list of the incidents requiring
such notification in addition to the overall critical incidents listed for the Agency:

a. Emergency evacuation;
b. Unexpected program closure;
c. Intruder on the program’s premises;
d. Serious illness or injury to a child that requires the program to request emergency health care and/or
requires the child to remain in hospital overnight;
e. Death of a child;
f. Unexpected absence of a child from the program; (i.e., lost child)
g. Child removed from the program by a non-custodial parent or guardian;
h. Allegation of physical, sexual, emotional abuse and/or neglect of a child by a program employee or
volunteer;
i. Commission by a child of an offence under an Act of Canada or Alberta, and/;
j. Child left on the premises outside of the program’s operating hours.

14. MAJOR INCIDENT REPORTING FOR CALGARY HOMELESS FOUNDATION PROGRAMS

In addition to the critical incidents outlined in this policy, CHF also requires notification in the following instances:

a. Death of a client;
b. Attempted self-harm/suicide of a client requiring medical assistance;
c. Risk to public safety including criminal charges, violent/dangerous offences, Form 10 mental health;
d. Abuse, serious threat or serious harm to another client or program employee, and;
e. Allegations of abuse.

In the event that one of these serious incidents occurs within a CHF program, employees are to contact the
Program Manager. After consultation with the Director if needed, The CalgaryHomeless Foundation Program
Advisor must be notified within 12 hours of the incident occurring. A written document must be also received
by the CHF within 48 hours of the incident.

Agency Review

15. Critical Incidents are compiled by the Agency and reviewed for causes, trends and improvement to policies and
procedures on a yearly basis as well as quarterly by individual programs with the support of the Program
Manager. All reviews will be documented in meeting minutes.

16. Major Critical Incidents will require a Leadership debrief, with no fewer than three members of the Leadership
team including a Chief Officer, within 14 days of the event. The purpose of the Leadership debrief is to provide
written documentation regarding the Agency response, outcome of the event and enhancements that can be
implemented to prevent or decrease the likelihood of future incidents. The will also allow for a review of the
systems and supports required for the critical event and as a means to strengthen the response to critical
events within the Agency.
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AGENCY SERVICE DELIVERY

SERVICE PLANNING

POLICY: ENTERTAINMENT POLICY NO.: H.3.6

DATE ISSUED: May 1, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis provides entertainment and recreation opportunities that are developmentally and age appropriate for
clients. Movies and materials that are rated “R” or “Restricted” may be used under specific circumstances.

POLICY

1. The rating on all movies viewed and videos rented or bought for use in the program must be appropriate for the
age of the clients. Restricted or “R” rated movies are not permitted unless used as an educational resource that
has been approved by the Manager.

2. Any recreational activities that may be viewed as violent in nature (i.e. paintball, shooting range) cannot be
engaged in unless the Program Manager has approved a written proposal for the activity and all
parents/guardians of the clients have provided written permission.
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AGENCY SERVICE DELIVERY

SERVICE PLANNING

POLICY: MEDICATIONS POLICY NO.: H.3.7

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

CARF - Program/Service Structure
DATE REVISED: May 2019 CARF – Medication Use

The delivery of services and care of our clients sometimes will include the administration of medication when
prescribed by a physician. Medications include: Prescription, both Prescribed and Over-The-Counter PRNs (Per
Required Need/As Needed) and Alternative Medications. Alternative medications can include, but are not limited to
herbal or mineral supplements, vitamins, homeopathic remedies, hormone therapy, or culturally specific treatments.
All medications brought into a TRELLIS program must be given to staff for safe storage. In instances where it is
safe and appropriate for clients to self-administer, including the transportation and storage of medication, see #42
belowfor specific criteria and procedures.
All medications must be handled, stored, transported and administered as per the policy and procedures outlined
below. All medication errors by employees require documentation and follow-up as described in the policy and
procedures outlined below.
Trellis DOES NOT dispense medications. Dispensing of medications is considered thepractice of the pharmacy and
includes the process of preparing, packaging and labeling by a physician or pharmacist.

POLICY

1. All TRELLIS programs are required to post the contact information for PADIS (Poison & Drug Information
Services) 1-888-944-1012, Calgary 403-944-1012, in common areas and employee offices. Signage should be
posted in areas of high visibility.

2. All Program/Service employees, regardless of their employment classification, will receive training in
administering and controlling client medications. This includes any employees who work/provide service to a
client-serving program. Employees in areas such as Finance, Business Development, Communications, People
Services, and general Administration do not require Medication Training. All job descriptions should specify the
need for Medication Administration Training. The training will take place during employee orientation, and
throughout the year. Those employees working directly with children/youth must have completed Medication
Administration Training before being left alone with children/youth.

3. Training will include administering medication in accordance with a prescription from the physician, monitoring of
clients, obtaining consultation, transportation and reception of medications, recording, safe storage and disposal,
refusal to take medication, documentation, the storage and retention of medical records, incidents and using
PRNs.

4. A) Employees will administer prescription and PRNs (prescription, over-the-counter, medical Cannabis products
and alternative medications) and/or medical procedures only when authorized by the client’s guardian on a
Delegation of Authority and/or Consent Form, and when prescribed by a medical doctor. All employees are
required to be familiar with the medications and administration of all prescribed medications including all medical
Cannabis products.

B) All prescriptions for medical Cannabis must be in an alternative form to smoking. Should clients enter programs
with prescriptions for medical Cannabis that is smoked, the prescribing doctor must be contacted for a
prescription of medical Cannabis in an alternative form. Smoking is prohibited in Trellis programs, Foster Homes
and/or properties, unless otherwise designated.

5. Trellis will ensure it is in receipt of relevant medical information available on a client at the time of admission and
that this information is kept current. Changes to their health status that may affect
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POLICY: MEDICATIONS POLICY NO.: H.3.7

the use of medication, and the effect of medication on clients who are pregnant or of a child bearing age will be
communicated with the guardian and client.

6. In the circumstance where the client is not under care of the program (i.e., home visit) , the responsibility for
administering the medication will be transferred directly to a responsible and capable adult, along with clear and
precise instructions as per Medication Administration Training.

7. For clients under the age of 18 years, the storage and administration of medication will be done only by
employees unless specific approval is received for self administration. Only clients with written permission from
their guardian are permitted to administer their own medications. Employees will ensure that the client can
administer their medication and that no other clients have access to it. In cases where the client must
administer their own medication (such as insulin injections), the employees will provide the client a private
space to do so and monitor the procedure in terms of distribution of medication. Employees will access
assistance from the client’s guardian or physician when specialized medical procedures are required.
Employees will not be expected to perform these procedures (i.e., insulin injections). Clients cannot self
administer any medication that is a narcotic.
For the purpose of this policy, medical Cannabis is not considered a narcotic.

8. All prescribed medications and PRNs (prescription, over-the-counter, medical Cannabis products and alternative
medications) will be labeled with the name and dosage of the medication, the name of the client for whom it is
intended, the name of the prescribing physician (if applicable) and a number or code identifying the written order.
Client medication must be bubble packed (if possible) in 24 hour programs. If the pharmacy is unable to bubble
pack, follow H.3.7 36.

9. Medication, including PRNs, will be kept in a double locked space with no access to clients. Exception occurs
when clients require Emergency Medication (I.E. Epipen) and have written Guardian consent to Self- Administer,
which is located on the client file. In these cases, the client must keep the Emergency Medicationon their person
or in their locked private space (I.E. bedroom).
A further exception is in programs serving clients under the age of 6 years (Ready, Set, Go Program). In these
programs, Emergency Medication (I.E. Epipen) is to be stored in an unlocked box, out of the reach of the
children, but still readily accessible in case of emergency.
Detailed records of administration will be kept in all cases.

10. All medications, including PRNs, shall be supplied, transported, received, stored, administered and discarded in
a manner that ensures strict safeguards against accidental or unauthorized administration and according to
Medication Administration Training.

PROCEDURES

Consent For Medication

1. A signed Delegation of Authority or permission form will be on the client’s file consenting to the administration
of medication, including PRNs.

2. All prescribed medication will be administered only in accordance with a time-limited prescription from the
physician and as per the directions prescribed.

3. In programs where medications are typically ‘stored, administered and transported’, the following
applies:
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Each client will have a Medication Inventory Record: Child/Youth Prescription Needs. If the client has no
medications, this will be noted on the Medication Inventory Sheet. If the client has prescription medication(s),
then a Medication Administration Record (MAR) (Prescription) for Child/Youth will be used to track all
information regarding the administration of the prescription(s).
Each client will have a Medication Inventory Record: Child/Youth PRN Meds. If the client has no PRNs,
this will be noted on the Medication Inventory Record: Child/Youth PRN Meds
The first time a client is in need of a PRN, a Medication Administration Record (MAR) (PRN) for
Child/Youth will be used to track information and effectiveness of the PRN.
Programs may choose to have on site non-prescription medications for client use from time to time. All
program medications must be listed on the Medication Inventory Record: Program PRN Meds. Program
inventories must be kept up to date at all times and all medication stored in the program must be listed.
Examples of such medications are Advil, Tylenol, cough lozenges, etc.

In programs where medications are not ‘stored, administered or transported’, the following applies:

Guardians will provide for consent for clients to ‘self-administer’ any medications. Consent for self-
administration is found in the Program Intake Package.

Intake Into 24 Hour Care Programs

4. Medication use by clients will be taken into consideration as part of their treatment planning process. This will
include but not be limited to how medication use may affect their progress, the on-going use of the medication/
PRN or any changes and adjustments that are made.

5. Programs that provide 24 hour care will review at intake the following items pertaining to medication use:

a. Review of past medication including:

i. Effectiveness;
ii. Side Effects, and;
iii. Allergies or adverse reactions.

b. Identification of alcohol, tobacco, recreational cannabis and other drug use;

c. Use of all PRNs; prescribed, over-the-counter, all cannabis products and alternative medications;
d. Use of medication by clients of child bearing age, and;
e. Use of medications during pregnancy.

Administering Medication

6. All employees will be responsible for the administration of medication upon completion of the medication
administration training. In cases of home visits, employees will transfer the responsibility to another
responsible adult who has received instruction on specific administration of the medication.

7. All prescribed medications must be labeled with the name, time and dosage of the medication, the name of the
client for whom it was intended, the name of the prescribing physician and a number or code identifying the
written order, also known as a DIN. Medication can be administered one hour prior to the time or one hour
after the time, unless otherwise indicated by the physician, pharmacist or PADIS (Poison & Drug Information
Services) 1-888-944-1012, Calgary 403-944-1012. This must be documented in a Critical Incident Report.

8. Employees should thoroughly wash their hands before administering any medications.
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9. Pull the MAR (Medication Administration Record) and the medication for the client. Employees must double
check that the medication corresponds with the time, dosage and medication name as prescribed by the doctor.
For example, if a client is to take 3-10mg tablets in the morning, ensure that three tablets are in the bubble
pack, and that the name of the med and client appear identical on the bubble pack and administration sheet.

10. Dispense the medication either directly into the client’s hand or into a medication cup. Employees should never
physically touch the medication as this will cause contamination. Employees should always wear gloves.
Encourage the client to take the pills with water, unless otherwise advised by the doctor. Medications should
never be taken with juice, especially grapefruit juice. Client’s should always take the meds in front of employees
unless approval has been obtained for self-administer in the case of an overnight absence.

11. Once the client has taken the medication, employees should complete the appropriate Medication
Administration Record (MAR), and complete all required fields on the MAR.

12. If a medication is dropped on the floor, it is to be considered a “dead med” and cannot be given to the client.
This med should then be placed into a biohazard bin in the program. In the event that the program does not
have a biohazard bin, then the employee will store the med in a labeled envelope or jar, and give it to the
Manager or designate to be taken to the pharmacy for disposal. Employee will then take another dosage
from the end of the bubble pack, documenting this in the communication book so other employees are aware
that all meds are accounted for and that a refill is required earlier.

13. Typically employees are prohibited from the administration of medications which require contact with a client’s
genitals and/or secondary sexual glands, require injections, and/or involve the administration of psychotropic
medications unless otherwise approved by the physician and the parent/guardian due to extreme circumstances.

14. If a client vomits within one hour of medication administration, the employee will contact the pharmacy or
PADIS (Poison & Drug Information Services) 1-888-944-1012, Calgary 403-944-1012, to determine if the
medication needs to be re-administered.
Refusal Of Medication

15. In the event that a client refuses to take their medication, medication errors, adverse effect or other emergency
situations, the employee will contact the prescribing doctor, a pharmacy or PADIS to determine the effects of
not taking the medication. The parent/guardian will be notified and the incident will be recorded on the client’s
file on a Critical Incident report. It shall be determined at the time whether the client will need medical attention
as a result of not taking their medication. If it is determined that the client does require medical attention, the
Program Manager/On-Call Coordinator will be notified immediately.

16. Refusal of medication must be coded on the medication sheet as such, and a Critical Incident Report
completed. A consult with the doctor, pharmacy or PADIS is also required for refused medication.

17. Any adverse effects that may be observed as per the consultation must be recorded in the program
communication book so other employees are aware and can monitor the client.

Missed Or Wrong Medication

18. In the event of administration of the wrong medication or dose, a call must be made to the physician, the
pharmacy and/or PADIS to determine if the youth should be transported for medical attention. The Program
Manager/On-Call Coordinator must be notified immediately, as well as notification to parent/guardian. The
incident must be documented on a Critical Incident Report and kept on the client’s file.

19. Missed medication must be coded on the medication sheet as such, and a Critical Incident Report completed.
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20. All Critical Incident Reports due to Medication Administration errors due to employee error must be forwarded
to Program Managers for Agency tracking and reporting.

21. Employees may be asked to repeat training should they dispense the wrong medication. If errors continue to
occur, this will result in a verbal warning, a written warning and may result in disciplinary action.

PRNs: Prescription, Over-The-Counter, Medical Cannabis Products and Alternative Medications

22. Employees only have permission to administer PRNs if a consent form has been obtained from the
parent/guardian or the Delegation of Authority authorizes medication administration.

23. Employees will ensure that the medication is appropriate for the illness, and that the correct dose is
administered according to the client’s age and weight. If the dosage is not clear in relation to specific child, the
employee will contact Health Link (811) and document advice and direction.

24. If considering administering a non-prescribed PRN (i.e., allergy pill) and the client is already receiving
prescription medication, a call must be made to the pharmacy or PADIS prior to administration. The outcome
of this call should be documented for the team for future use if necessary.

25. If a client has any known allergies, the employees must contact the pharmacy or PADIS prior to administering
PRNs.

26. Employees will complete a Medication Administration Record (PRN) for child/youth each time a PRN is
administered, completing all appropriate fields. It is the employee’s responsibility to check this record prior to
administering meds to ensure that the previous dosage was not given within the recommended time frame.

27. Employees must provide clients with information regarding ‘common side effects’ from the PRN Information
Sheet and/or Information provided on the packaging of the PRN. This information must be provided to the client
PRIOR to the administration of the PRN.

28. Employees are responsible to check with the client and inquire as to any adverse effects of the PRN. Check-ins
with clients should be completed within 30 minutes of administering the PRNs and must be documented on the
PRN MAR (Medication Administration Record). Documentation will include the time (in 24 hour clock) of the
check in with the client and the reaction of the client to the PRN.

29. Should a client report an adverse reaction to the PRN, the employee will contact the pharmacy or PADIS
(Poison & Drug Information Services) 1-888-944-1012, Calgary 403-944-1012, for further instruction.
Employees should document this incident on a Critical Incident Report.

Home Visits/Planned Leave from Program

30. In the event that a client leaves the program for an overnight visit, the medication should be given to a
responsible adult. For youth residing in shelters, medications may be given to youth who plan to leave the
program overnight, provided there is written documentation by the guardian on file. If this is not possible, each
dosage of medication must be sealed in an envelope and there must be permission from the parent/guardian
for the client to transport their own medication. Employee will document on the envelope the following:

a. Client’s Name
b. Date of administration
c. Name of Medication
d. Dosage
e. Time of administration
f. Total number of doses in envelope
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Employee will seal the envelope and sign the seal. Employee must also advise the adult where the client is
going that they will be arriving with medication that needs to be dispensed.

Youth Under The Influence

31. If a client returns to the program under the influence and is scheduled to take medication, employees must call
the Pharmacy or PADIS to ensure that it is safe to administer. If they advise it is safe, ensure this is
documented in the communication book along with potential adverse side effects. If it is advised that they
should not take the medication, indicate on the appropriate Medication Administration Record that no
medication was taken and print CIR in the space where the time would normally be recorded. In this way, the
details of the event can be read and tracked through the CIR. Complete the CIR recording detailed information
regarding the direction by PADIS to not administer the medication to the client. Also, reference the decision and
the CIR in the Communication log.

Documentation And Labelling Of Medication

32. Detailed records of any special medical needs of the client will be collected at the time of intake and updated
regularly throughout the course of the client’s involvement in agency services.

33. Supplies of medication will be kept in a double locked cabinet and dispensed by Employees. Detailed records
of any medication dispensed by employees will be kept. See Policy #9 for exceptions.

34. Prescription medication and PRN medication (which may include prescriptions) will be documented on separate
Medication Administration Records; a Prescription Medication Administration Record and a PRN Medication
Administration Record. A separate record will be kept for each client. As each page of the medical record is
filled, it will be filed on the client’s cumulative file.

35. If an adverse effect or emergency situation arises from the administration of medications, the employee will
ensure the client receives immediate medical attention and will immediately inform the Program Manager orthe
On-Call Coordinator.

36. Labels on medication will include the name and dosage of the medication, the name of the client for whom it is
intended, the name of the prescribing physician and a number or code identifying the written order.

37. Medication which has been prescribed by a physician will be dispensed to a client only if it is in the container
labeled by the issuing pharmacist and there is written or verbal authorization from the legal guardian. Any non-
prescription medication given to a child will not be dispensed unless it is in the appropriately labeled container
and appropriate authorization has been obtained. Prior to dispensing, employees will be satisfied that the
medication is that for which authorization has been received.

Storing, Transporting And Discarding Of Medication

38. All prescription and PRN medication will be kept in a locked cabinet in a locked room at all times. Clients are not
allowed to access this cabinet. Exception occurs when clients require Emergency Medication (I.E. Epipen) and
have written Guardian consent to self-administer, which is located on the client file. In these cases, the client
must keep the Emergency Medication on their person or in their locked private space (I.E. bedroom).
A further exception is in programs serving clients under the age of 6 years (Ready, Set, Go Program). In these
programs, Emergency Medication (I.E. Epipen) is to be stored in an unlocked box, out of the reach of the
children, but still readily accessible in case of emergency.

39. When the prescription/PRN is no longer being used, employees will take it to a pharmacy for disposal, ensuring
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the client’s name does not appear on the container. The appropriate Medication Inventor Record should be
updated completing all fields.

40. Only employees or the client’s guardian or designate will transport medications.

41. All tablet medication for clients in 24 hour care programs must be bubble packed. In the event that the pharmacy
cannot bubble pack a medication, the program employee assigned to the client will be responsible for doing a
complete medication count weekly. Each bubble should be marked with the administration date and clearly
marked “am”, “noon” or “pm”, as well as be labeled from the pharmacist with client and medication information
as per Labeling Policy.

42. There may be instances where it is appropriate and safe for clients to have authorization to self-administer
medications including the transportation, storage and discarding of the medications. In these instances,
authorization for self-administration of medications by clients must be made in consultation with the Guardian
and the Program Manager to ensure the safety for all program clients/residents. All authorizations for clients to
self-administer medications must be in writing and signed by the Guardian. Written authorizations must be
maintained on the client file.

43. Certain medications requiring refrigeration must be stored in the office refrigerator.

Processes for Community Club Clients

44. When clients of Community Clubs require prescription medications all efforts should be made to ensure that the
client is able to take their medication prior to or after leaving their program.

45. In the event that medication must be administered during program in order to ensure optimal functioning and
wellbeing for the child/ youth, Parents/ Guardians may provide consent for the child/ youth to ‘self administer’
their medication, or request that Club Staff store and administer this medication to their child.

46. In an effort to increase staff awareness and ability to administer medication to the various clients who may
require it, the following medication windows have been established.
i. Morning Medications: 9 am- 11 am (optimal time for administration 10 am)
ii. ‘Administer with food’ medications: 11am- 1 pm (optimal time for administration 12pm)
iii. Afternoon Medications: 3pm- 5 pm (optimal time for administration 4pm)

All medications will be administered to clients within these windows in accordance with the overall Medication
Administration policy.

47. In the event that a client who requires medication is unable to take their medication within an identified and
approved window, the Guardian must meet with the Club Manager to identify a process by which Club staffwill
be able to safely administer medication without creating undue stress on the staff member responsible for
medication administration, and the required program ratio. This plan may be reviewed and approved or
recommended for revision by the Program Manager.

48. Staff members will be responsible for the safe and responsible medication administration for children/ youth
registered for their specific program. The agency has outlined the following methods to ensure program staff
are reminded to check for/ administer medications at their required times:
a. Signage to be posted in the staff office prompting staff to check for required medications. This signage will
not include names of children/ youth or any other identifying information.

b. A highlighting system for paper check in/ outs that does not identify why the child’s name is highlighted and
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POLICY: OUT OF CITY AND DAY TRIP PLANS POLICY NO.: H.3.8

DATE ISSUED: February 1, 1997

DATE REVISED: May 2019

The Agency seeks out opportunities to provide our clients with experiences that enhance their quality of life and our
program services. When these opportunities are outside of the program mandate and involve traveling with clients,
the program will ensure that the necessary documentation of the trip is completed along with an assessment of the
benefits and risks for engaging in these activities.

POLICY

1. All necessary forms and proposals required for day and overnight trips are located on the Agency Forms
Databases.

2. Programs proposing day trips that are under 200 kilometers (round trip) and do not involve overnights will
complete the Day Trip Proposal at least one (1) day in advance of the trip.

3. Trips that are over 200 kilometers and /or overnight trips will complete a Trip Proposal Form at least one month
in advance of the proposed dates. A complete Out of City Trip Plan must be finalized seven (7) days prior to the
trip.

4. Programs will ensure that all necessary consents from parents/guardians are obtained prior to departure.

5. A proposal is developed for each special or challenging activity that the client will be participating in on the trip,
and that includes:

a. the purpose of the activity;

b. precautions for safety in doing the activity, and;
c. the teaching methodology to train clients in safety and technical skills.

6. In preparing for out of city trips, the program will teach the client appropriate safety skills such as:

a. specialized safety guidelines for the activity, season and weather, and;
b. rescue and emergency procedures.

7. Programs will ensure that the necessary client/employee ratio is implemented for the trip and the activities on
the trip and that there is a means of communication available back to the Program Manager or designate.

8. Trips may be cancelled due to unsafe weather and road conditions, as per the Weather and Restrictions policy.

9. A permit is required for most trips and activities in Provincial and National Parks. Please check with
your Program Manager.

a) All permit requirement will be followed

b) Trip itinerary may be required for park staff
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POLICY: SUICIDE THREATS & SUICIDE POLICY NO.: H.3.9

PREVENTION

DATE ISSUED: June 01, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All suicidal or para-suicidal and self-harm attempts will be taken seriously and addressed immediately. In an
effort to prevent future attempts, clients will be assisted in resolving issues and circumstances which may have
motivated the attempt.

2. All clients displaying suicidal, para-suicidal or self-harm behaviors will be continuously supervised by employees
until a risk assessment can be completed by either a clinician, a medical doctor, or a professional employed by
Alberta Health Services revealing that the client is no longer in need of continuous supervision. A risk
assessment must be completed within 24 hours.

3. Trellis front line employees working directly with clients require Suicide Intervention Training within 6 months of
commencement of employment. Training will consist of 14 hours of training and will be renewed every 3 years.

PROCEDURES

1. Provide emergency intervention if required (e.g., first aid, police, ambulance, etc.).

2. Employees will consult with the Program Manager or On-Call Coordinator and guardian as soon as possible.

3. Agencies will provide continuous employee supervision until a risk assessment can be completed by either a
clinician, a medical doctor or a professional employed by Alberta Health Services who is qualified to complete a
risk assessment.

4. Indigenous clients will be offered a referral for an Indigenous Resource Person during the period of crisis from
an appropriate community resource.

Once an assessment by a qualified professional has been completed, employees will follow the direction of
the professional and will proceed as follows:

High Risk Clients

5. Ensure the client is not left alone;

6. Defuse immediate crisis by:

a. talking with the client alone or with input from other employees, and/or;
b. taking the client to appropriate counseling agency or nearest medical facility;

7. Upon defusing the situation, contract with the client whereby they promise to speak to the worker or the
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PREVENTION

Distress Line before attempting further harm. The contract will be re-negotiated as frequently as required and
the client will be able to repeat back their understanding of what they have promised to do.

8. Notify the Program Manager/On-Call Coordinator as soon as possible, who will in turn notify the Manager;

9. Notify the Social Worker/Crisis Unit or the legal guardian;

10. Make sure any means of attempting to commit suicide have been removed;

11. When appropriate, document in the program log book;

12. Notify other employees, as appropriate;

13. Complete a Critical Incident Report;

14. Follow up with the client by providing support through information referral and counseling, as necessary;

15. Re-assess the need for further risk assessment as required by the situation. Remember an improvement in
emotional state may not indicate a lessened risk of suicide.

Moderate Risk Clients

16. Discuss the situation with the client;

17. Determine plan of action (with Caseworker if possible). Risk could be moderate now but may change at a
future time;

18. Contract with the client whereby they promise to speak to the worker or the Distress Line before attempting further
harm. The contract will be re-negotiated as frequently as required and the client will be able to repeat back their
understanding of what they have promised to do;

19. Notify the Program Manager/On-Call Coordinator as soon as possible;

20. Notify the Caseworker/Crisis Unit or the legal guardian;

21. When appropriate, notify significant others to watch out for any change in the client;

22. Make sure any means of attempting to commit suicide have been removed;

23. Note in the program log book when appropriate;

24. Notify other employees, as appropriate;

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PREVENTION

25. Complete a Critical Incident Report;

26. Re-assess the need for further risk assessment as required by the situation. Remember an improvement in
emotional state may not indicate a lessened risk of suicide.

Low Risk Clients

27. Discuss the situation with the client;

28. Determine a plan of action (with Caseworker when possible);

29. Develop a plan with the client to explore different coping mechanisms, and where appropriate, arrange for
counseling;

30. Note in the program log book when appropriate;

31. Notify the Program Manager/On-Call Coordinator as soon as possible;

32. Notify the Caseworker/SACIS or legal guardian and other employees;

33. When appropriate, notify significant others to watch out for any change in the client or their situation;

34. Complete a Critical Incident Report;

35. Follow up with the client by providing support through information referral and counseling, as necessary;

36. Re-assess the need for further risk assessment as required by the situation. Remember an improvement in
emotional state may not indicate a lessened risk of suicide.

PROCEDURES FOR PREVENTION

37. Suicide Intervention Training should be comprehensive and should include, but not be limited to, the following
content areas:

a. Risk factors;
b. Strategies to protect the client against suicide;
c. Contributing factors that increase the risk of suicide for Aboriginal clients;
d. How to determine the level of risk;
e. How to intervene with a client who presents “at risk” for suicide;
f. Appropriate resources for referring the client; and
g. Culturally diverse material for and not limited to Indigenous, Immigrant and LGBTQ2S+ youth.

38. Increased emphasis with an experiential component will focus on skill development related to intervention.
Current knowledge, skills and attitudes will be included in the following topics:
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a. Risk factors for clients, including demographic influences.

b. Contributing factors that increase the risk of suicide for gay and lesbian clients.
c. Determining the presenting level of risk.
d. Responding immediately to a clients who presents “at risk” for suicide.
e. Intervening with Indigenous clients in ways that are culturally based.
f. Intervening with clients from diverse cultures
g. Referring the client to appropriate resources.
h. Strategies to protect clients against suicide.
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POLICY: SUICIDE THREATS & SUICIDE POLICY NO.: H.3.9a

PREVENTION

DATE ISSUED: June 01, 2005 ASSOCIATED STANDARDS:

POLICY NO.: H.3.9b
DATE REVISED: May 2019

POLICY

1. All suicidal ideation or attempts will be taken seriously and addressed immediately. In an effort to prevent
future attempts, clients will be assisted in resolving issues and circumstances which may have motivated the
attempt.

2. All clients displaying suicidal ideation or behaviour will be assessed by the program employee using the
protocols from ASIST training to determine level of risk and actions required. In the case of a high risk situation
as outlined below, employees will immediately engage emergency services. If an employee is working alone
and has not yet completed their ASIST and NSSI training, employee will immediately contact Program
Manager/On-Call Coordinator for direction. If Program Manager/On-Call directs employee to call Health Link
811, employee will respond according to Health Link’s recommendations.

3. Trellis front line employees working directly with clients require Suicide Intervention Training within 6 months of
commencement of employment. Training will consist of 14 hours of training and will be renewed as mandated
by ASIST.

4. The attached Protocol Flowchart serves as an addendum to complement H.3.9a and H.3.9b policies.

Note: At any time during this intervention, if an employee is in doubt as to if a client is at risk of suicide,
they should treat the situation as high risk.
PROCEDURES

Determining if a client is at risk of suicide:

If suicidal ideation or behaviour is displayed or suspected, staff will determine if a client is at risk of suicide. Only
employees trained in ASIST can formally assess a client’s risk for suicide. Trained employees will determine risk of
suicide by using the following key questions as outlined in ASIST Training.
Program staff will ask the client: Program staff will respond as follows:
Does the youth have a plan to commit suicide? Focus on disabling the plan according to ASIST
protocols
Are there any immediate concerns with alcohol, drugs Focus on removing those items from access.
or medication?
Does the youth have any prior suicidal behavior? Focus on strengths and learning from previous
experiences to help youth stay safe in current situation.
Does the youth have any mental health concerns? Focus on strengths and learning to stay safe in current
situation, encouraging continued or referral to a mental
health professional.
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POLICY: NON-SUICIDAL SELF-INJURY (NSSI) POLICY NO.: H.3.9b

DATE ISSUED: July 21, 2017 ASSOCIATED STANDARDS: POLICY NO.:

H.3.9a
DATE REVISED: May 2019

POLICY

• All non-suicidal self-injury (NSSI) ideation or incidents will be taken seriously and addressed immediately. In
an effort to prevent future incidents of NSSI, clients will be assisted in resolving issues and circumstances
which may have motivated the NSSI.

• Trellis front line employees working directly with clients require NSSI Training within 6 months of
commencement of employment.

• All clients suspected of or displaying non-suicidal self-injuries or ideation will be assessed for severity of injury
and presence of suicidal risk. This assessment can only be made by front line staff once both ASIST and NSSI
training have been completed. If an employee is working alone and has not yet completed their ASIST and
NSSI training, employee will immediately contact Program Manager/On-Call Coordinator for direction. If
Program Manager/On-Call Coordinator directs employee to call Health Link 811, employee will respond
according to Health Link’s recommendations.

• The attached Protocol Flowchart serves as an addendum to complement H.3.9a and H.3.9b policies.

DEFINITION1

Non-suicidal self-injury (NSSI) is intentional bodily harm of a socially unacceptable nature, done without suicidal
intent and carried out to reduce or communicate psychological distress. Self-injury includes, but is not limited to,
scratching, interfering with wound healing, cutting, carving, burning, and hitting (self or other objects). Although self-
injury and suicide are distinct behaviours, it should be noted that self-injury is a significant risk factor for further self-
injury and attempted suicide. NSSI does not include socially sanctioned behaviours such as body piercing and
tattooing, and other behaviours resulting in unintentional damage such as substance abuse, eating disorders, and
other risk taking behaviours (i.e., unsafe sex and dangerous driving). NSSI is included in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders as a condition requiring further research before consideration as an official diagnosis.

PROCEDURES FOR PREVENTION2

NSSI training should be comprehensive and should include, but not be limited to, the following content areas:

• How to identify signs and symptoms of self-injury (recognizing the full range of self-injurybehaviours)
• Understanding the difference between self-injury and suicidal behaviour
• Understanding the risk factors and functions of NSSI
• Awareness of the conditions under which self-injury requires immediate medical attention
• How to respond to a client who presents with NSSI by being calm, kind, non-judgmental and using
“respectful curiosity”
• Understanding under what circumstances that guardians should be notified
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• Determining when and how to issue an outside referral

• Knowledge of both community and web-based resources for NSSI
• How to manage and limit social contagion

IDENTIFYING NSSI
NSSI can be detected through a number of means. A client could self-disclose that he or she is engaging in self-
injury. Or, a peer might notify a staff member of another client’s self-injurious behaviour. In other cases, staff may
notice signs and symptoms suggesting that a client is self-injuring.

It is critical that the first response to NSSI be emotionally calm, kind and non-judgmental. Staff should not
communicate that they may be angry, horrified, panicked, or upset. Staff members should monitor their reactions to
these clients. The client should be approached with “respectful curiosity,” which is an attitude of wanting to
understand the problem. Refer to Appendix A for how to appropriately respond and speak to a client regarding
self-injury. See also Appendix B for how to appropriately notify and engage parents in the situation.

PROCEDURES

1. First assess the severity of the injury and provide emergency medical intervention if wounds are severe or life
threatening (e.g., first aid, 911, ambulance, transport to hospital)
2. If wound is not severe, use ASIST training to assess for risk of suicide and refer to agency suicide policy
immediately if the client is risk of suicide is present
3. If the injury is not severe or life threatening AND there is no risk of suicide, assess the severity of the wound
and type of medical attention needed (i.e., basic first aid/ bandages or transport to a medical clinic)
4. Discuss the situation with the client and support them to find alternate coping strategies for dealing with
psychological distress. Staff will refer to Appendix A for how to appropriately respond and speak to a client
regarding their self-injury behaviour.
5. Employees will consult with the Program Manager or On-Call Coordinator as soon as possible.
6. Notify the legal guardian:

For clients with Child Welfare Status:

• For all clients with Child Welfare Status (Temporary or Permanent Guardianship Order) the
Caseworker/Crisis Unit must be notified in ALL situations regardless of the client’s age (0 to 18+). For
clients with PSECA status, refer to individual program procedures and what is in the best interest of the
client according to client files.
• Staff will refer to Appendix B for how to appropriately notify and engage parents/legal guardians in the
situation.

For clients 12 years old and under without Child Welfare Status:
• Notify the legal guardian in ALL instances if the client is 12 years old or under. Guardians are notified
regardless of severity and in every single instance if the self-harm occurs more than once. Complete a
Critical Incident Report in all cases.
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• Staff will refer to Appendix B for how to appropriately notify and engage parents/legal guardians in the
situation.

For clients over 12 years of age without Child Welfare Status:

• Legal guardians will always be notified the first time an incident of self-harm occurs. Staff will always
advise guardians of their responsibility to seek mental health support for their child. Offer support to
guardians to find appropriate mental health support for their child. Complete a Critical Incident Report
for all first time instances.
• If a second incident of self-injury occurs, legal guardians will be notified again. It will be considered a
protection issue if the legal guardians have willfully refused or knowingly neglected their responsibility
to seek professional mental health support for their child, and CFS will be notified. Complete a Critical
Incident Report for all second time instances.
• Do not complete a Critical Incident Report after the second instance if client is receiving professional
mental health support and the injury is a result of relapse during their recovery. DO document any
further incidents in the client’s case notes.
• Do notify legal guardians if the severity and frequency of self-injury suddenly increases. Complete a
CIR.
• Do notify legal guardians if any self-injury behaviour continues past 12 months. Complete a CIR.
• Staff will refer to Appendix B for how to appropriately notify and engage parents/legal guardians in the
situation.

For clients over 18 years of age:

• Legal guardians will only be notified if the client provides consent or has Child Welfare status.
Complete a CIR if the wound requires medical treatment by a professional. Document in client case
notes if wound is superficial /requires basic first aid.

7. When appropriate, document for the program in the program specific communication book/method
8. Notify other employees of NSSI incident as appropriate
9. Staff will limit social contagion to the best of their ability by ensuring that other clients have no knowledge of the
self-injury incident. Staff will refer to Appendix C for how to appropriate limit social contagion.
10. Continue to monitor and follow up with client and provide resources about self-harm and alternative coping
strategies
11. Any clients requesting cultural support will be referred to the appropriate community resource. This includes but
is not limited to Indigenous, immigrant and LGBTQ2S clients.
12. Program staff should provide updates to the Program Manager and team about the client’s support
strategies regardless of the estimated risk level.

Program staff should seek out additional support to meet their own personal and emotional needs, such as
debriefing, consultation, etc.
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APPENDIX A: Responding to NSSI

It is important for staff to know the Do’s and Don’ts of how to respond to NSSI situations. The way in which staff
respond can make a difference in the outcome.

Do’s
• Manner should be calm, matter of fact and compassionate
• Calmly assist in obtaining medical attention if necessary
• Provide supportive and active listening
• Validate the client regarding the intense emotions that have led to the self-injury
• Understand that this is a way of coping with the pain that he/she feels inside.
• Use youth related language for NSSI (ie, cutting, self-harm)
• Emphasize that self-injury is a mental health problem that is treatable.
• Encourage the use of any positive coping strategy which helps them to get through the urge toself-
injure.
• Encourage the client to share their feelings with other people, such as a close friend or family member,
when they are feeling distressed or have the urge to self-injure.
• Help the person think of ways to reduce their distress, for example, having a hot bath, listening to loud
music, or doing something kind for themselves.
• Offer the client information materials (e.g. a website or factsheet) about alternatives to self-injury.

Don’ts
• Be overly reactive as this could alienate clients and damage the developing alliance
• Respond with panic, revulsion, shock, or averted gaze
• Avoid dramatic outpourings of concern and support
• Do not dismiss or minimize the self-injury
• Do not ask the youth to stop self-injuring. Asking youth to give up self-injury when it is their best
emotion regulation technique is unrealistic. Expecting or demanding that youth quickly give up self-
injury can result in their lying or becoming evasive.
• Say or do anything to cause the student to feel guilt or shame (e.g., “What did you do toyourself?”,
“Why did you do that?”).
• Show excessive interest in the self‐injurious behaviour
• Permit the client to relive the experience of NSSI in detail, as this can be triggering
• Try to teach him/her what you think he/she should do.
• Tell the client that you won’t tell anyone if he/she shares self-harming behaviors with you.
• Use punishment or negative consequences if a student does SI.
• Make deals in an effort to get the student to stop SI.
• Make promises to the client that you can’t keep.
• Use excessive sympathy as that may inadvertently reinforce the behavior and condemning the
behavior may make an already distressed person feel worse.
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APPENDIX B: Notifying Parents/Legal Guardians

Ideally, all clients should be encouraged to call their legal guardian to talk about what occurred. If it’s deemed
necessary for program staff to notify the legal guardian, staff should expect a wide range of reactions from
guardians. Parents/guardians already have a difficult time trying to understand the behavior of a normal adolescent,
so dealing with an adolescent who self-injures can be very difficult and confusing. The way in which parents
respond can make a difference in the outcome. Some parents/legal guardians will respond quickly and favorably,
but others may need more time and help in coping with their own thoughts and feelings. While it is important to
validate parent’s/legal guardian’s reactions, certain attitudes towards self-injury can promote, trigger or maintain the
behaviour so it is important to effectively communicate and to educate the parent/legal guardian about NSSI. If
parents/guardians are educated on what NSSI is and the reasons why young people feel the need to self injure,
they may be able to respond in a more helpful way by seeing beyond the behavior itself.

Here are some suggestions you can share with parents/guardians:

• Educate the parent/legal guardians about NSSI; emphasize that it is used as a coping strategy but that
the severity of NSSI is linked to increased risk of suicide
• Parents may think that their child is self-injuring because of something that they did or did not do as a
parent. If the parent seems to be struggling with guilt or frustration, it may be helpful to remind them
that they can also get counseling. It is important for the family to have a strong support system of their
own.
• Tell parents/legal guardians that just because they have a child who self-injures, it does not make them
“bad parents.” Blaming themselves will not make the behavior go away.
• Parents/legal guardians also need to know that they are not alone. Many other parents struggle with
this same problem. Provide them with a list of resources about NSSI and community resources.

Online resources for youth and parents

https://selfinjury.com/
https://www.nssiresource.com/resources
http://teenmentalhealth.org/understanding-self-injury-self-harm/

INSYNC (Interdisciplinary National Self Injury In Youth Network Canada)

http://insync-group.ca/

Online Webinar for Parents: How to Understand and Help My Child Who Is Self-Injuring, A Parent Educational Opportunity
Dr. Wendy Lader, co-founder of S.A.F.E. Alternatives
http://store.selfinjury.com/parents-webinar-by-dr-wendy-lader/

APPENDIX C: Limiting Social Contagion

Many youth are introduced to self-injury through a peer. The contagion factor is most often a result of peers talking
to peers about NSSI. Self-injury may be encouraged and admired within a social context and may produce feelings
of cohesiveness with a group. To limit contagion, DO NOT provide broad NSSI education to clients; DO provide
this to staff. When discussing NSSI with clients, the following guidelines will help in preventing contagion:
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• To the best of the program’s ability, staff will use a strengths-based approach to discourage clients not
to share detailed information regarding NSSI, reveal their scars or share NSSI related images or stories
because of the contagion possibility.
• Do not use program activities, discussions or notices to address an “outbreak” of NSSI.
• When educating clients about NSSI, discuss the behaviour in its broader context; that is, as a coping
strategy that is used among several others (such as substance abuse, or risk‐taking).
• Emphasize the need for clients who are engaging in the behaviour to seek support.

References

1 Lloyd-Richardson, E., Lewis, S., Whitlock, J., Rodham, K., & Schatten, H. (2015). Research with adolescents who engage in non-
suicidal self-injury: ethical considerations and challenges. Child Adolesc Psychiatry Ment Health. 9(37): 1-14.

2 Bubrick ,K., Goodman, J., & Whitlock, J. (2010). Non-suicidal self-injury in schools: developing and implementing school protocol.
Cornell Research Program on Self-Injurious Behaviour in Adolescents and Young Adults. Available at:
http://www.selfinjury.bctr.cornell.edu/documents/schools.pdf

Andrews, T., Martin, G., Hasking, P., & Page, A. (2013). Predictors of continuation and cessation of nonsuicidal self-injury. J Adolesc
Health. 53(1):40-46.

Andrews, T., Martin, G., Hasking, P., & Page, A. (2013). Predictors of continuation and cessation of nonsuicidal self-injury. J Adolesc
Health. 53(1):40-46.

Berger, E., Hasking, P., & Reupert, A. (2015). Developing a Policy to Address Nonsuicidal Self-Injury in Schools. Journal of School
Health. 85(9): 629-640.

Walsh, B.W. (2006). Treating Self-Injury: A practical guide. New York: The Guildford Press.
 SUICIDAL THREAT & NON-SUICIDAL SELF-INJURY (NSSI) PROTOCOL FLOW CHART

• Staff with ASIST & NSSI training proceed as below. Staff suspects or identifies client with suicidal threat or self-injury through warning signs, peer disclosure or self-disclosure.
• Consult SACIS (403-297-2995) for ALL clients with Child Welfare Status.
• If an employee is working alone and has not yet completed their ASIST and NSSI training, employee will immediately contact Program Managerr/On-Call Coordinator for direction. If Program Manager/On-Call Coordinator directs employee to call
Health Link 811, employee will proceed according to Health Link’s directions.

In situations where physical injury is present or suspected In situations where there is verbal threat of suicide

No evidence of injury
or denial of NSSI:
monitor client Conduct injury assessment YES: Engage emergency services Assess for suicide risk using ASIST training
Notify legal guardian
Is the injury severe or life threatening?
Follow up as per medical professional
recommendations
NO: Proceed as below

Assess for suicide risk using ASIST training Is harm occurring/about to occur? YES: Engage emergency services
YES: Refer to agency
Notify legal guardian
NO: Proceed as below Is the client suicidal? suicide policy Is client unable or unwilling to Follow up as per medical professional
participate in the interventions? recommendations

Assess the self-harm injury

NO: Proceed as below
Does the injury require immediate medical attention?

NO (wound is superficial or it occurred in the past) YES (wound is current with tissue damage)
NO
• Provide basic medical treatment for wound if needed (i.e., bandage) • Ensure client receives medical attention by either accompanying client to
doctor/clinic or contact guardians to transport client • Use ASIST training to disable the plan and
• Notify legal guardian in every instance if child is under 12 years of age or has Child create a safeplan
Welfare Status (any age) • Notify legal guardian in every instance if child is under 12 years of age or
has Child Welfare Status (any age). For youth over 12 years of age,notify • Remove items/means of suicide and ensure no
• For youth over 12 years w/o Status, notify legal guardian if this is a first time event, drugs/alcohol are available
second time event, or if it reoccurs after 12 months from first incident legal guardian if this is a first time event, second time event, or if it
reoccurs after 12 months from first incident. For clients over 18, legal • Notify parents/guardians/emergency contact
• For clients over 18, legal guardian will only be notified with client consent or client guardian will only be notified with client consent or client has Child
has Child Welfare Status • Develop a follow up plan
Welfare Status
• Develop a follow up plan; Provide client with community resources about self-harm • Provide client with mental health resources
• Develop a follow up plan; Provide client with community resourcesabout
and refer to mental health professional if appropriate self-harm and refer to mental health professional if appropriate • Check in regularly and continue to monitor
• Check in regularly and continue to monitor risk risk and amend safeplan as often as needed
• Check in regularly and continue to monitor risk
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POLICY: COOL OFF PERIOD POLICY NO.: H.3.10

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019 CARF – Nonviolent Practices

POLICY

1. The choice of a cool off period is offered to clients so that they may regain regulation of their emotions and
behaviors within a program. Cool off periods may be taken unaccompanied or may be accompanied by
employees. Specific guidelines are established for the implementing and monitoring of cool off periods.

2. Cool off periods should take into consideration a client’s need for regulation, their relationships with employees,
their need/desire for space to themselves, and the client’s level of distress and potential risk must be considered
in evaluating options. Options may take the form of:

a. a short accompanied or unaccompanied walk or other form of rhythmic physical activity available at the
program
b. sitting in a designated space at the program with access to regulation aids such as music or colouring, (e.g.,
chair in the living room or dining room, desk in the homework help area, chair in the program space).
c. time in the client’s bedroom with access to regulation aids.

3. The purpose of the cool off period is to assist the client with regulating their emotions. Any cool off period should
be accompanied with appropriate support by the employee involved.

4. Employees will actively check in with clients 12 years old and over after 20 minutes, and with clients under 12
they will actively check in after a period not exceeding one minute per year of the age of the client. Check-ins will
determine if clients have sufficiently regulated to process the incident or if they require more cool off time.

5. For clients at risk of self-harm or suicide, unaccompanied cool off periods are not permitted. Instead, the focus
is on providing some one-to-one attention with appropriate consultation from employees, the Manager/On-call,
until a risk assessment by a qualified professional has been completed. Regulation should still be the primary
focus during the one-to-one time (employee may walk with the client, pass a ball back and forth, colour together,
etc.).
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POLICY: TRANSPORTING CHILDREN AND YOUTH POLICY NO.: H.3.11

TO HOSPITAL
DATE ISSUED: July 1, 2007 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis will ensure proper support is provided to clients who require medical attention at clinics and hospitals.

POLICY

1. In the event of a serious or life threatening injury, employees will not transport clients to the hospital but
rather contact Emergency Medical Services at 911. The Program Manager or On-Call Coordinator will be
responsible to ensure that the necessarynotifications occur as per the Critical Incident policy.

Script and Shelter Programs (Avenue 15 and Safe House)

2. Outreach, Prevention and Shelter programs will not transport clients to the hospital. Parents, guardians, SACIS
(Southern Alberta Children Intervention Services – After Hours: 403-297-2995 [previously known as SSRT])
and/or Caseworkers will be notified that a client needs to seek medical attention. The parents, guardians and
Caseworkers are responsible for the transportation and monitoring of clients in the hospital. In the event the client
is under the age of 18 and there is no contact information for parents or guardians, SACIS must be notified.

Programs Providing 24 Hour Care (Group Homes, Foster Care, Eleanor’s House, Independent Living
and Haven’s Way)

3. Clients who are under the age of 18 must be accompanied and supervised while at the hospital. The Program
Manager and On-Call Coordinator will work with the employees on shift to ensure that there is proper coverage
both at the hospital and in the program. Employees can be relieved at the hospital by another employee, a parent
or guardian or by an emergency one to one worker unless otherwise indicated by hospital staff.

4. Clients 18 and over can be at the hospital on their own unless otherwise advised by the doctor, parent, guardian,
Caseworker, Manager or SACIS although it is preferred that support from program employees or natural supports
be available. Employees will ensure that the hospital staff are aware that the client is alone, and will ensure for
proper transportation to and from the hospital.

Community Programs (Clubs, Education & Employment, Indigenous, HERA)

5. Regardless of age all clients must be accompanied and supervised while at the hospital. The Program Manager
and On-Call Coordinator will work with the employees on shift to ensure that there is proper coverage both at the
hospital and in the program. Employees can be relieved at the hospital by another employee or by a parent or
guardian unless otherwise indicated by hospital staff.
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POLICY: UNLOCKED OR LOCKED CONFINEMENT POLICY NO.: H.3.12

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS

CARF – Rights of persons served
DATE REVISED: May 2019 CARF – Nonviolent Practices

POLICY

1. Trellis prohibits the use of unlocked confinement except when a client is deemed to be out of control and is
presenting a security risk or a danger to self or others. Unlocked confinement includes any restriction or
isolation of a person served for behavior management purpose to a designated area for a period inexcess of 20
minutes.

2. When unlocked confinement is used because a client is deemed to be out of control and is presenting a security
risk or a danger to self or others:

a. the client will be removed from confinement once they have regained control and are no longer presenting a
security risk or a danger to self or others;
b. the approval of the Chief Operating Officer or CEO will be obtained for any period of confinement which
extends beyond four (4) hours;
c. for clients involved with Children’s services, the approval of the Chief Executive Officer of Calgary Region
Child and Family Services (or designate) will be obtained for any confinement which extends beyond eight
(8) hours;
d. there will be documented adult supervision and the assessment of resumption of self-control at a minimum
of five (5) minute intervals;
e. the name of the client, length of time and reason for confinement will be documented;
f. a Critical Incident Report will be completed within 24 hours of unlocked confinement, and
g. the supervisor will debrief the event with the employees involved within 48 hours of theevent.

3. Whenever unlocked confinement is used, the client and employees will have the opportunity to debrief the
confinement as well as the behaviors leading up to it as well as appropriate alternatives for the situation.

4. Trellis prohibits the use of locked confinement.

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POLICY: Narcan Nasal Spray Administration POLICY NO.: H.3.13

DATE ISSUED: July 1st 2018 ASSOCIATED STANDARDS:

CARF - Program/Service Structure
DATE REVISED: February 18th 2020 CARF – Medication Use

Trellis will train and equip its staff, youth at risk of overdose and volunteers to prepare for opiate overdose
emergencies in an effort to reduce the number of fatalities which occur as a result of opiate overdose by the proper
pre-emergency medical services administration of Narcan Nasal Spray. Trellis does not authorize the
administration of Intramuscular Injectable Naloxone.

Definitions
Naloxone is a medication used to block the effects of opioids which include respiratory depression, sedation and
hypotension. Naloxone can be administered by injection or as a nasal spray to reverse the effects of opioids
especially in the emergency treatment of opioid overdose.

Narcan revives people who overdose on opioids. Narcan is the brand name, nasal spray form of naloxone, an
opiate antagonist. In the event of an overdose (or possible overdose), Narcan can be administered immediately,
and reverses the overdose by blocking the brain’s opioid receptors. Narcan is specifically used to counteract life-
threatening depression of the central nervous system and respiratory system.

Opioids are drugs that act on the nervous system to relieve pain. Opioids can be made from the poppy plant — for
example, morphine — or synthesized in a laboratory — for example, fentanyl. Prescription opioids are used mostly
to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea. Opioids can
also make people feel very relaxed and "high" - which is why they are sometimes used for non-medical
reasons. Opioids include heroin, morphine, codeine, methadone, fentanyl, OxyContin, Percocet, Percodan, and
Demerol.

Opioid overdose symptoms include:

Confusion; unable to respond to questions
Difficult to arouse; unresponsive to voice, touch, sternal rub, or shaking
Extreme drowsiness
Pupils are very small like a pinpoint
Depressed breathing- it is very slow, irregular or has stopped
Slow or no heartbeat
Blue/purple tinged fingernails or lips
Pale and clammy skin
Deep snoring, gasping or gurgling sounds

POLICY

Training
1. No staff can break the seal on a Narcan kit or administer Narcan unless they have completed the
TRELLIStraining protocol within the last year (and must be repeated every 12 months).
2. The annual training protocol includes watching the Narcan Instructional Video, having current Standard
First Aid and CPR certification, reviewing the patient information, and reviewing this policy.
3. The training protocol learning tools and checklist are found on and must be completed via
TRELLIS’sLearning Management System, Absorb.
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Equipment and Maintenance

1. It shall be the responsibility of personnel assigned to each site where a Narcan kit is kept to inspect the kit
on a monthly basis and ensure the seal is intact. The Narcan kit and rescue breathing mask will be kept in
the first aid kit.
2. The expiry date on the Narcan kit will be verified and the kit replaced if the expiry date is less than 30 days
away.
3. When the seal is found not intact, or the kit is not found, it shall be reported to the site supervisor
immediately.

Response to Opiate Overdose

1. An assessment of the individual in distress as per first aid training should be conducted.
2. If conditions indicate a suspected opiate overdose, phone 911 immediately.
3. Deploy the Narcan kit.

Administration of Narcan during Opiate Overdose Emergencies

1. When the responding Trellis staff member is on the scene of a medical emergency prior to the arrival of
EMS and have made a determination that the patient is encountering an opiate overdose based upon an
initial assessment or witness accounts of the consumption of an opiate bythe patient prior to the
emergency, trained responding staff may refer to the Quick Start Guide and administer the Narcan Nasal
Spray (4mg) to the individual in distress.
2. Move the person on their side into the recovery position and watch them closely.
3. If the individual in distress is breathing less than 12 breaths per minute, perform rescue breathing
and chest compressions until emergency medical help arrives.
4. If after 2-3 minutes the person is still not responsive, or breathing normally, provide another dose in the
other nostril. Narcan Nasal Spray may be dosed every 2 to 3 minutes, if available.

Post Administration of Narcan

1. Monitor the individual until paramedics arrive. Youth who have been administered with Narcan are at high
risk for vomiting and choking if they are not fully conscious. Staff will use First Aid response for choking if
this occurs. Youth who have been administered with Narcan are at high risk for aggression and /or violent
response because they are immediately put into a state of withdrawal and/or may resent that their high was
interrupted. Staff will use crisis intervention skills training to watch for signs of aggression and violence and
ensure personal safety.
2. The effects of Narcan last up to 30 minutes, but the effects of opioids may last much longer. Just because
someone wakes up does not mean they are safe from a recurrent episode of overdose so continue to
monitor closely.
3. Update incoming EMS as to the treatment and condition of the person in distress.
4. Follow the policy/protocol for medical emergency.
5. The appropriate notifications must be made and a critical incident report must be completed.
6. All staff that respond to an overdose will be provided with an opportunity to debrief with a Supervisor.
7. Supervisors will replace Narcan kits when they have been used.

Distribution of Narcan to Youth at risk of Opioid overdose

1. Staff are permitted to provide Narcan kits to youth who believe that either their self or someone they know
is at risk of opioid overdose. Whenever possible and appropriate parents/legal guardians should be notified
that Narcan kit has been provided to youth.
2. Staff who are distributing Narcan kits need to be trained in CPR/First Aid and complete Narcan training video
found on Absorb.
3. Staff will review Narcan Youth Orientation found on Absorb with youth and provide a paper copy for youth
to keep before distributing Narcan Kit to youth. Explain to young people, it may also be used to save the life
of someone else (i.e. peers, family members) and it will be replaced.
4. Tracking the distribution of Narcan on the med admin form each time a youth is given a new kit or its
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replaced due to the following reasons:

• used
• lost
• stolen
• confiscated or
• nearing the Expiry Date
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SERVICE DELIVERY

POLICY: AWOL (Absent Without Leave) POLICY NO.: H.4.1

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis clients, aged 13 and over who do not return to their placement within two (2) hours of their curfew will
be called in as an AWOL (absent without leave) advisory to SACIS – After Hours (Southern Alberta Children
Intervention Services [previously known as SSRT]) at 403-297-2995.

2. Clients who are 12 and younger will be called in immediately as AWOL.

3. Program employees will assist in locating the client according to their last known whereabouts.

4. Clients who live independently in the community (e.g., client living in a community placement through YTA or
Infinity) will be called in as a Missing Person if:

a. they have failed to meet with their Support Worker on a weekly basis as per program requirements,
b. they have not contacted the program to inform them of their whereabouts in the absence of their weekly
meeting, and
c. if there has been no success in trying to reach them by phone and at their placement.

PROCEDURES

1. If the whereabouts of the client has not been confirmed, the following persons must be notified of the AWOL as
well as an AWOL/Missing Person report must be completed:

a. If applicable, Caseworker, SACIS – After Hours at 403-297-2995

b. Parent and/or Guardian (when applicable)
c. Program Manager via On-Call procedures
d. Probation Office (if applicable)

2. Employees will provide information to all involved about the last known whereabouts and if known, where the
client may be. Employees will work with police and guardians to assist in locating clients through phone calls,
talking to other clients, etc. In addition and when it is safe to do so for both the employees and program, a program
employee may be deployed to assist in the location of the missing client.

3. Once the client has returned to the home, all of the above persons must be notified of return and calls must be
documented on the AWOL form.

4. A Critical Incident Report must be completed for the AWOL and AWOL return and attached to the AWOL report.
All search efforts by Agency employees will be documented on this report. Any updated information pertaining to
an AWOL will be documented in Individual Case Notes.

5. Employee will contact the Caseworker the next business day. A decision to close a client’s bed due to AWOL
is at the discretion of their Caseworker and/or Placement Services.

6. AWOL’s over 72 hours require the written (email is acceptable) approval of CFS Executive Management to
continue to keep the youth’s bed open. AWOLS over 13 days require CFS Executive Manager approval (e-mail
is acceptable).
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: CLIENT RIGHTS POLICY NO: H.4.2

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019 CAC

In keeping with the Agency’s Mission Statement and Core Values, all clients are actively involved in the planning
and evaluation of their service delivery and are aware of their rights both at intake and throughout the service
delivery period.

POLICY

1. Upon admission, and at a minimum every year from admission date, program employees will review all rights
with the client. These rights are, but not limited to:

a. The right to be fully involved in all aspects of their service planning, including the specific procedures
pertaining to informed consent and release of information;
b. The right to be served regardless of race, color, religion, spiritual beliefs, socioeconomic status, language,
ethnicity, gender, gender minorities, sexual orientation, age, mental and physical ability;
c. The right to refuse services and to receive information about alternative services;
d. The right to review information in their file that is generated by the Agency (TRELLIS) and request correction
toinaccurate information;
e. The right to maintain their natural support networks and Caseworker support if the client has CFS status;
f. The right to access community resources available to them outside of the Agency (i.e., Child and Youth
Advocate office, Caseworker, Legal Aid);
g. The right to access an Indigenous worker and/or Indigenous Resource person and to participate in
traditional ceremonies and activities;
h. The right to access a Cultural Resource person and to participate in cultural activities;
i. The right to access an LGBTQ2S+ Resource person;
j. The right to engage in their cultural and spiritual practices;
k. The right to have their personal belongings in programs where clients live, and to have safeguards in place
to protect their belongings;
l. The process of lodging a grievance and the right to a fair, equitable, accessible and structured grievance
and appeal process, and;
m. In the event that privileges are restricted or lost, the right to understand the reasons, and method by which
privileges are reinstated.

2. All programs will discuss at Intake and provide information in the Intake Package information for how to access
the Child and Youth Advocate office.

3. Each program will ensure that the grievance procedure is included in the Client Welcome Package and is
accessible to clients.

4. Clients will receive and sign the Confirmation of Rights located in the Client welcome package.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: CLIENT SEARCHES POLICY NO: H.4.3

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

CARF – Health and Safety
DATE REVISED: May 2019

Employees will only conduct client searches to ensure the safety of the client, other clients in the program and
employees. During a search, every effort will be made to respect the client’s dignity, with undue or unnecessary force
prohibited.

POLICY

1. Searches may be conducted only to ensure the safety of clients or employees, to recover missing or stolen
property, or to control contraband.

2. Whenever possible, all programs will inform clients of the search prior to its occurrence.

3. Client searches within shelters will only occur with the consent of the client. The client may choose to discharge
from the program instead of consenting to a search. If the client re-accesses the program, the search will occur
at intake. In the event that the client cannot be contacted for consent and the health and safety of other clients
and employees is at risk, approval for a room and/or belongings search is required from the Program Manager
or On-Call Coordinator.

4. Client searches will be permitted only under the authorization of a Program Manager, On-Call Coordinator,
Manager or Director of Services.

5. Clients will not be subjected to body cavity searches, frisking or any other forms of arbitrary or harassing
searches. Police will be called in to complete a body search if required.

6. Whenever possible, two employees should be present to conduct a search. If this is not possible, employee will
remain on the phone with On-Call employee during the search.

7. When there is suspicion that a client may be in possession of drugs, drug paraphernalia, alcohol, stolen goods,
or weapons on their body, the client may be asked to empty their pockets, shoes, jacket, wallet or purse. The
police may be called into the program to complete a search if an employee believes that the search will put their
safety in jeopardy.

8. If the search uncovers illegal drugs or weapons, the Police will be called in to follow up with the items and/or
dispose of them. If the search uncovers drugs that do not belong to the youth, the Police may be called after
consultation with the Program Manager or On-Call.

9. Parents and/or legal guardians may or may not be informed of the search, depending on the circumstances.

10. All searches are classified as a Critical Incident for the purpose of recording and reporting, and will be
documented and forwarded to the appropriate Manager.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: CLOSURE OF SERVICE POLICY NO.: H.4.4

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

CARF – Transition/Discharge
DATE REVISED: May 2019 CAC

Trellis ensures clients have an appropriate exit from programs whenever possible. The steps we take to close services
with a client are in place to ensure that all relevant information is passed on to the client and their guardian when they
leave our services to provide the best care possible for the client.

POLICY

1. The decision to close or end service is made by those individuals involved in the Transition Plan. Prior to
discharge, the program will endeavor to ensure that:

a. Client participates in transition plan and/or is provided reason for and circumstances of discharge including
date.
b. review of individual plan with client to ensure goals have been met;
c. notification is given to the Caseworker and/or parent/legal guardian;
d. assistance is provided for securing an alternative placement;
e. referral information is available for community services and supports;
f. support with transition to new placement or community setting;
g. information about re-accessing the program;
h. information regarding any follow up appointments (i.e., health, medical, community supports), and;
i. any medication prescribed by a doctor is returned to client or parent/guardian.

2. A discharge report will be completed by the program that includes:

a. The date and reason for admission;

b. Review and update of Individual Plan goals and supports provided during service period, including
information pertaining to education and employment goals;
c. List of referrals and community supports given to the client, as well as recommendations for services and
supports needed by the client, and;
d. Reason for and circumstances of discharge including date.

3. The discharge report will be retained in the client’s cumulative file and a copy of the report will be sent to the
Caseworker if the client has CFS status.

4. In the case of an unplanned discharge, as many of the tasks that are possible to be done directly with the client
will be completed within 72 hours of discharge. In the event that there has been no contact with the client, all
necessary information above will be documented and sent to Caseworker and/or parent/legal guardian if
applicable.

5. Client, parent/guardian, Caseworker and significant others will be asked to complete a Satisfaction Survey at
discharge. All programs may offer satisfaction surveys to stakeholders at intervals throughout the year.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: DELEGATION OF AUTHORITY / POLICY NO.: H.4.5

CONSENT FOR SERVICES

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019

In providing service, treatment or training to a client, their guardian’s written consent will be obtained in advance,
except in cases of emergencies.

POLICY

1. In any instance where the client is a minor, a Delegation of Authority and/or a consent for services must be
obtained from the client’s legal guardian prior to admission. Each program will utilize the forms appropriate to the
service being provided:

a. In cases where the client is involved with Calgary Region Child and Family Services, a Delegation of
Authority must be completed by the Caseworker.
b. When the legal guardian is other than the Authority, the Consent for Services form must be completed and
signed by the parent/legal guardian.
c. Consent for Services must be signed upon admission to program and at a minimum once every year from
original date of signing.
d. When a youth is 16 years and older, refer to Program specific policies.

The Delegation of Authority must delegate powers and duties to Jeff Dyer, who is the CEO of Trellis.

2. The CEO must then Sub-Delegate powers and duties to the appropriate Foster Parent or Program Manager.The
“Sub-Delegation of Powers and Duties to a Child Care Provider” must be completed using the Alberta
Government Form CS1757 (2012/06).

3. In cases of emergencies, if prior written consent cannot be obtained, verbal consent will be obtained and
documented. Documentation confirming a verbal consent should consist of electronic consent from the
appropriate approving body. Verbal and electronic consents must be followed up by written consent the next
business day.

4. The following points will be considered when making decisions after the authority has been delegated:

a. all the relevant information to make this decision has been reviewed and the action is necessary;
b. the action is in the best interest of the client;
c. the client’s legal rights and human rights have been and will be respected and maintained.

5. The guardian will be consulted when there is any question regarding delegated decisions.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: DISBURSEMENT OF SPENDING MONEY POLICY NO: H.4.6

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Financial Planning and Management
DATE REVISED: May 2019

Trellis programs providing 24 hour care (except shelter) disburse allowances and spending money to clients.

POLICY

1. Program employees will provide allowances and spending money as per contracts with Calgary Region Child &
Family Services. A portion of allowance or spending money will be under the personal control of the person
served.

2. Allowances/spending money may be withheld only to provide restitution, or when temporarily held as a
consequence. This can only occur if:

a. There is written guidelines identifying the circumstances under which the allowance is held and under what
conditions it will be returned to the client;
b. There is a clear relationship between the money withheld and the object being reimbursed (i.e., cost to
replace damaged lost or stolen property);
c. There is a written plan for reimbursement that is negotiated with the client.

3. Programs are responsible to keep written records of disbursement for each client, which will be part of their
cumulative file.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: EMERGENCY SUPPLY KITS POLICY NO: H.4.7

DATE ISSUED: May 2008 RELATED POLICIES:

Disaster Preparedness Plan in the
DATE REVISED: May 2019 TRELLISEmergency Response Manual

POLICY

1. All Trellis programs providing 24 hour care to clients will be prepared with an emergencysupply kit in the event
that clients and employees are unable to leave programs due to natural disasters and emergencies.
2. Each 24 hour care program will ensure the emergency preparedness kit in the program is easily accessible to
employees (client access should be considered in regards to items such as knives and lighters/matches). This
kit will contain supplies that will allow the clients and employees to be self-sufficient for a period of no less than
72 hours. The supplies for employees should be based on the number of employees who would be in the program
during peak hours. The kit will consist of, but not be limited to:
a. Water – minimum of 2 litres per day per person
b. Non-perishable Food Items
c. Manual Can Opener and Plastic Spoons
d. Flashlight and Spare Batteries
e. Candles and Matches/Lighter
f. First Aid Kit
g. Battery Powered Radio and Spare Batteries
h. Sleeping Bags or Blankets
i. Scissors/Knife
j. Whistle
k. Garbage Bags
l. Toilet Paper
m. Hand Sanitizer and Disinfectant Wipes
In addition, programs can include optional items, such as:
a. Basic Tools
b. Change of Clothing and Footwear for clients and employees
3. Employees will also ensure that the portable records containing information on clients and emergency contact
numbers for both clients and employees is taken in the event of an emergency.
4. Employees will ensure that any client or employee medications on site are taken in the event of an emergency.
5. Emergency supply kits are to be checked annually to replace items with expiry dates, such as batteries, food
items, water, first aid supplies, disinfectant and hand sanitizers.
6. Community programs and administration sites will be prepared with minimal emergency supplies. Should any of
these sites be chosen as a central safe zone or disaster emergency shelter employees will ensure that the site
is equipped with enough non-perishable food, water (min 2L/day/person), and fuel to last 72hours.
7. Minimal emergency supply kits will consist of:
a. Flashlight and Spare Batteries
b. Manual Can Opener and Plastic Spoons
c. Scissors
d. Candles and Matches/Lighter
e. Disinfectant Wipes and Hand Sanitizer
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: MAINTENANCE OF CLIENT SUPPORT POLICY NO.: H.4.8

NETWORKS

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARD:

CARF – Family and Child Centered Care
DATE REVISED: May 2019

In alignment with the Mission Statement and Core Values, all Trellis programs will make provision for the development
and maintenance of support networks for clients and their families. Meeting the developmental needs of the client is
an important component of the Agency’s service environment. A supportive environment is necessary in overcoming
challenges and the Agency ensures that all natural supports for the client are maintained and/or enhanced.

POLICY

1. Family and natural supports for the client are encouraged to participate in service planning with the program
(when appropriate and safe to do so) in order to maintain their support network.

2. Program employees will assist the client in accessing the following resources, as required in addressing issues:

a. Basic needs - food, clothing, shelter, access to transportation and medical needs;
b. Educational and employment - advocating for supports and resources required for the client’s
developmental needs, employment training, life and living skills training;
c. Social supports – positive peer and adult interactions, and;
d. Community referrals – resources that will support the client in their well-being.

3. Where appropriate, natural supports within the client’s extended family or community will be utilized to assist the
client in establishing and maintaining community resources.

4. Upon intake, the program will work with the client to strengthen their natural supports and/or explore additional
supports needed for successful community living.

5. Programs will support families and the client’s natural supports with referrals to community resources that will
assist the client and the family.

6. When appropriate, program employees will keep the client’s family and natural supports current on information
to facilitate collaboration and decision making.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: MEDICAL CARE RESPONSIBILITIES POLICY NO: H.4.9

DATE ISSUED: February 1, 1997 RELATED POLICIES:

CARF – Program Services/Structure
DATE REVISED: May 2019

Trellis programs that provide 24 hour care are responsible to ensure that all clients receive adequate basic need care
and medical services, and receive opportunities to develop skills in the area of healthy living and medical needs.

POLICY

1. All programs are responsible for providing clients living in programs with:

a. A balanced, nutritional diet that meets the standards of the Canada Food Guide and respects cultural and
religious dietary practices;
b. Adequate clothing which is appropriate to the client’s physical needs and community standards;
c. Materials necessary for maintaining good grooming and hygiene standards, and;
d. A living environment that is clean, in good repair and home-like.

2. When appropriate, programs should provide clients with coaching and/or supervision on:

a. Nutritional requirements;
b. Hygiene;
c. Grooming and;
d. Appropriate rest and health care practices.

3. Program employees will maintain up-to-date medical records and have Treatment Service Cards and Alberta
Health Care Identification Plans for all clients, as is possible.

4. All clients admitted in any program who have not had a medical examination within one year prior to admission,
shall be scheduled for one within 10 days of admission. If an appointment has not been made within 10 days,
efforts made will be documented on the file. Clients will have annual medical check ups thereafter.

5. All clients who have not had a dental examination or optical examination within one year prior to admission shall
be scheduled for one within 10 days of intake. If an appointment has not been made within 10 days, efforts made
will be documented in the client’s file. Clients will have examinations at least once every year thereafter.

6. Any symptoms of illness and physical or sexual abuse are documented and the client receives an examination
and treatment by a physician within 24 hours.

7. Any lab tests or procedures will be booked according to the guidelines of the medical practitioner. The details
of the tests and procedures will be documented and retained in the client’s cumulativefile.

8. All Agency employees will play an educational role with clients with respect to medical and health care, and
help clients become knowledgeable of the services available in the community.

9. Employees in charge of preparing food for clients will be informed and will make allowances for any special
restrictions which may be presented by a client’s medical, dietary, cultural and/or spiritual needs. (Employees
will inform parents/guardians of the program or facilities’ ability to accommodate special dietary restrictions)
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: MEDICAL CARE RESPONSIBILITIES POLICY NO: H.4.9

10. In the event that a client requires special adaptive devices and equipment for care (i.e., hearing aids), the
Program employees will ensure that they are trained in the appropriate use and monitoring of such devices. The
training will also be available for the client, parents/guardians and any others responsible for client care on a
case by case basis.

11. Clients who are sick in programs will:

a. With the assistance of employees, seek medical attention for their condition when necessary;
b. Be given the opportunity to rest in general areas of the program when other clients are not at the program,
and have access to nutrition and activities appropriate for their condition, and;
c. Be encouraged to not have contact with other clients to prevent the spread of illness.

12. Changes to client’s medical status will involve a review of current medications with a physician to ensure that
there are no conflicts with existing medications and their condition.

13. Clients who are pregnant must have a review of the use of their current medication, including prescription and
over the counter medication, with a physician. This review will be documented in the client’s cumulative file and
recommendations shared with program employees.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: PORTABLE RECORDS POLICY NO.: H.4.10

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All Trellis programs will have a portable record of client information that will be accessible in the event
of an emergency evacuation or for out of city trips.

2. The portable record must include the following information:

a. The full name of each client;

b. The name, address and phone number of each parent and/or legal guardian;
c. The name and phone number of an emergency contact person, as designated by the parent and/or
legal guardian;
d. Specific information regarding health care numbers, medication, health concerns and allergies that the
client may have;
e. For clients living in 24 hour programs, a recent photograph.

3. Portable records must be under the continuous supervision of employees when taken out of the program.

4. Loss of these records constitutes a breach of privacy and the appropriate reporting protocols must be followed.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

AGENCY SERVICE DELIVERY

SERVICE DELIVERY

POLICY: USE OF PHYSICAL RESTRAINTS POLICY NO.: H.4.11

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Rights of persons served
DATE REVISED: May 2019 CARF – Nonviolent Practices

POLICY

1. The use of physical restraints in programs is prohibited.

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
FOSTER CARE

POLICY: TRAINING REQUIREMENTS POLICY NO.: I.2.1

DATE ISSUED: ASSOCIATED STANDARDS:

DATE REVISED: May 2019 CARF

POLICY

1. In addition to the provincially mandated Level 1 Core Foster Parent training (Policy 1.2.5), Foster Care licensing
requires Level 1 Foster Parent(s) to complete nine (9) hours of maintenance training annually. Level 2 Foster
Parent(s) are required to complete twelve (12) hours of maintenance training annually. All courses below can be
credited toward maintenance training hours. Upon Foster Care Manager approval, other courses may be credited.

Trellis requires the following mandatory training:

a. CPR is required prior to placement of a child and requires renewal every 3 years.
b. Shaken Baby Syndrome is required prior to placement of a child and requires renewal every 3 years for
Foster Parents fostering children between the ages of 0 to 36 months.
c. Medication Administration and Universal Precautions training are required prior to placement of a child and
requires renewal annually.
d. Cultural Diversity (3 hours) is required within 6 months of the initial Foster Care license and then 3 hours of
Diversity training must be taken during each calendar year.
e. Indigenous Awareness (3 hours) is required within 6 months of the initial Foster Care license and then 3
hours of Indigenous training must be taken during each calendar year.
f. SafeTalk (Suicide Awareness) (3.5 hours) is required within 6 months of the initial Foster Care license and
requires renewal every 3 years. Mental Health First Aid (12) hours may replace SafeTalk and requires
renewal every 3 years.
g. Nonviolent Crisis Intervention (6 hours) is required within 6 months of the initial Foster Care license and
requires renewal every 2 years.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
FOSTER CARE

POLICY: CAREGIVER ORIENTATION TRAINING POLICY NO.: I.2.2

DATE ISSUED: August 28, 2001 ASSOCIATED STANDARDS

CARF
DATE REVISED: May 2019

POLICY

1. Potential Foster Parents must complete 24 hours of Caregiver Orientation Training during the application process,
so that applicants can make an informed decision regarding fostering. Copies of training certificateswill be kept
on the Foster Parent’s file and originals will be given to applicants.

ACCOUNTABILITY AND AUTHORITY

The training is provided by Trellis employees or Calgary Region Child and Family Services staff.

PROCEDURES

1. The following modules will be covered in the 24 hours of the Caregiver Orientation Training.

a. Overview of Orientation for Caregivers (3 hours)

b. Motivation, Values and Self Esteem (3 hours)
c. Where do the Children Come From (3 hours)
d. Attachment, Separation and New Attachments (3 hours)
e. Child Development and the Impact of Organic Brain Dysfunction (3 hours)
f. Challenges of the Journey (3 hours)
g. Integration Into the Family and Community (3 hours)
h. Panel of Experienced Parents (3 hours)
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
FOSTER CARE

POLICY: CLIENT INTAKES POLICY NO.: I.2.3

DATE ISSUED: August 5, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All clients admitted and re-admitted into the Trellis Foster Care Program will have acomplete intake, and
an individual client file will be maintained.

2. Client Files will contain the following information:

a. Intake screening received from Placement Services, when possible.

b. Delegation of Authority
c. A complete intake package
d. Individualized service plans and quarterly reviews
e. Assessments (Internal and External)
f. Calgary Region Children’s Services Concurrent Plan, when possible.
g. Personal maintenance records (e.g. medical, dental, optical, clothing, allowance etc.).
h. Foster Parent monthly reports
i. Foster Care Support Worker contact notes.
j. Critical Incident Reports
k. Trauma & Attachment Specialist contact notes (when applicable)

3. Client files containing the above information are secured according to CARF Standards.

4. Admission procedure for the Foster Care Program provides for the following:

a. Pre-placement introduction of the client to the foster home when possible;

b. Foster Care Support Worker will review the Client Welcome Booklet with the client, or Case Worker when
the client is under 12; to ensure understanding of the reasons they are in care and their rights while in the
foster home including:

i. TRELLIS Mission, Vision, and Core Values

ii. Code of Conduct and Ethics
iii. Description of the TRELLIS Foster Care Program, and What Support Looks Like
iv. Introduction to their Support Team
v. Their Rights while in the TRELLIS Foster Care Program
vi. Expectations and Rules of the TRELLIS Foster Care Program
vii. Important phone numbers
viii. Grievance Procedure
ix. Access to the Children’s Advocate
x. The right to be involved in service planning
xi. Other legal rights

c. All clients, regardless of their age, will be provided with a developmentally appropriate orientation to the
home at Intake. The orientation will include, but is not limited to: rules and expectations in the home,
location of important phone numbers, introduction to other members of the family, fire escape routes, etc.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
FOSTER CARE

POLICY: CLIENT INTAKES POLICY NO.: I.2.3

DATE ISSUED: August 5, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

d. TRELLIS Foster Care Support Workers will request an intake meeting within 7 (seven) working days of
admission to gather and share information regarding the client and the family. When an intake meeting is
not possible within the 7 working day timeframe, this will be followed up on by the Foster Care Support
Worker and documented.
e. All biological family contact must be determined and approved by the Case Worker at Intake. Any changes
will be documented in writing.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
FOSTER CARE

POLICY: COMPLAINTS SCREENINGS AND POLICY NO.: I.2.4

INVESTIGATIONS

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY
1. All complaints, screenings and investigations against foster homes will be managed according to current
policies and practices of Calgary Region Children’s Services.
Complaints

2. All concerns, complaints, screenings, and investigations against a foster home and/or Foster Parents are
documented, and retained in the Foster Parent file.

3. A follow up meeting to address the concerns or complaints will be confirmed, and documented.

4. Written contact notes from the meeting determining the outcomes of the concerns will remain on the Foster
Parent file, with copies to the Manager.
Screenings, Pre-Investigation Meetings

5. To be attended by the Foster Care Support Worker and Manager

6. Written contact notes from the meeting will remain on the Foster Parents file.

7. Foster Parents are not to be involved or notified until otherwise directed by the Placement Resource
Assessment Team (PRAT)
Investigations

8. The Director of Community Based Care and Supports, Chief Operating Officer and the CEO will be informed of
all investigations.

9. Written contact notes, and the Placement Resource Assessment Team outcomes will remain on the Foster
Parent’s file. Copies will be forwarded to the Manager and Director of the TRELLIS Foster Care Program.

10. Foster Parents will be notified as directed by the Placement Resource Assessment Team. Foster Parents will
be informed of the services of CAST (Caregiver Allegation Support Team) by the TRELLIS Foster Care Support
Worker.

11. Foster Care Support Worker will attend all meetings with the Foster Parents and Assessor.

12. After an investigation, the Foster Care Support Worker and the Licensing Officer will meet with the family to
discuss the outcomes of the investigation.

13. The outcome of the investigation will determine the support and monitoring required for the Foster family. In the
event where a foster home is required to end services, the Foster Care Support Worker will support the Foster
Parents through this process, as well as all client transitions to new placements.

14. Placement Resource Assessment Team recommendations and outcomes will be submitted to the Foster Parents
in writing and placed on their file within 7 (seven) working days of the completed complaint or investigation.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
FOSTER CARE

POLICY: LEVEL 1 TRAINING POLICY NO.: I.2.5

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Foster Parents are required to complete 93 hours of CORE Training within 4 years following the initial licensing
date. This training is required before moving to a Level 2 status with Calgary Region Child and Family Services.
Copies of training certificates will be kept on the families file.

PROCEDURES

1. The following modules will be covered in the 93 hours of CORE Training:

a. Section A1 – Fostering by the CYFE Act

b. Section A2 – Your Role on the FosteringTeam
c. Section A3 – How to Observe, Record and Report
d. Section A4 – Safeguarding Against Allegations of Abuse
e. Section A5 – Addressing Allegations
f. Section B1 – Transitions Processes and Impacts
g. Section B2 – Tools for Transitions
h. Section B3 – Resources to Support Transitions for Youth to Adulthood
i. Section C1 – Childhood Development: Baseline and Influences
j. Section C2 – Assessing and Reporting Developmental Issues
k. Section C3 – Creating a Developmental Environment
l. Section D1 – Parenting our Special Children
m. Section D2 – Building Relationships with Your New Child
n. Section D3 – The Parenting Toolkit
o. Section D4 – The Goals of Misbehaviour
p. Section D5 – Monitoring, Evaluations & Reporting
q. Section E1 – The Effects of Abuse and Neglect on Brain Development
r. Section E2 – Managing Attachment Issues
s. Section E3 – Working with ADD/ADHD, ODD & Other Disorders
t. Section E4 – Understanding Fetal Alcohol Spectrum Disorder
u. Section E5 – Managing Fetal Alcohol Spectrum Disorder
v. Section E6 – Managing Substance Abuse
w. Section E7 – Suicide Awareness
x. Section E8 – Sexual Abuse
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POLICY: LEVEL 1 TRAINING POLICY NO.: I.2.5

y. Section G1 – Keeping Family Connections

z. Section G2 – Our Role in Reducing Risks
aa. Section H1 – Communication Skills
bb. Section H2 – Managing the Realities of the Fostering Experience

Honouring Indigenous Children:

cc. Section 1 – Family Teachings on Turtle Island
dd. Section 2 – Historical and Current Context
ee. Section 3 – Trauma and Healing
ff. Section 4 – Celebrating Children and Families on Turtle island
gg. Section 5 – CaregiverResources
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POLICY: CRIMINAL RECORD CHECK AND POLICY NO.: I.2.6

INTERVENTION RECORD CHECK

DATE ISSUED: August 28, 2001 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis will ensure that a Criminal Record Check and an Intervention Record Check is conducted on each adult
living in the home every three years. The Criminal Record Check and the Intervention Record Check should
indicate no record or the record indicates that a client placed in the home would not be atrisk.

ACCOUNTABILITY

The Foster Parent and Support Worker are responsible for adherence to this policy, reporting to the Program Manager.

PROCEDURES

1. Criminal Record Check on every person 18 years or older in the home indicating there is no record or the record
indicates that a client placed in the home would not be at risk;

a. Criminal Record Checks completed within the past 6 months will be considered current (new applicants).
b. Criminal Record Checks are to remain current, and must be renewed every 3 years.

2. An Intervention Record Check on every person 18 years or older in the home indicating there is no record or the
record indicates that a client placed in the home would not be at risk;

a. Intervention Record Checks completed within the past 6 months will be considered current (new applicants).
b. Intervention Record Checks must be renewed every 3 years.

3. Copies of all Criminal Record Checks and Intervention Record Checks will be kept on the Foster Parent file.
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POLICY: EMERGENCY PLACEMENTS POLICY NO.: I.2.7

DATE ISSUED: August 5, 2005 ASSOCIATED STANDARDS:

CARF
DATE REVISED: May 2019

POLICY

1. Trellis Foster Care Program will accept emergency placements under special circumstances agreed upon by the
Agency and Calgary Region Children’s Services. When considering an emergency placement, the Agency will
ensure that the client’s needs will be met by Foster Parents with skills to support the referred Foster Child(ren).
Emergency placements will be admitted following the admissions policy for Foster Care.

2. Emergency placements require the following:

a. Southern Alberta Crisis Intervention Services contacts TRELLIS on-call when a placement is required.
b. The On-Call Worker will determine suitability and placement options and consult with Foster Parents.
Additional supports required for the placement will be determined.
c. The Foster family will be contacted by the On-Call Worker and arrangements will be made for the child/youth
to be placed.
d. Southern Alberta Crisis Intervention Services will ensure the Delegation of Authority is completed and
provided to the family.
e. Case Worker is contacted immediately on the next business day to arrange an intake meeting within 7
(seven) days when possible.
f. Appropriate resources will be arranged to ensure the safety of the Foster home household members and
other clients.
g. The Foster home placement is within the approved licensed number of clients or approval from Calgary
Region Child and Family Services is obtained for an increase in license numbers. In the case where an
emergency placement is approved that is above the approved licensed number of clients, a conditional
license is required at placement.
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POLICY: FOSTER CARE SUPPORT, POLICY NO.: I.2.8

FAMILY RATIO AND REQUIRMENTS

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

CARF
DATE REVISED: May 2019

POLICY

1. Trellis full-time Support Worker will support 15-25 clients per case load.

2. There will be weekly phone and/or email contact with the Foster Parents.

3. Monthly home visits with the Foster Parents will occur.

4. Foster Care Support Workers will visit alone and face to face with each child/youth on their caseload. In the
case where a Foster Child will not leave the presence of the Foster Parent, the Foster Care Support Worker will
endeavour to conduct a face-to-face with as much privacy and confidentiality as determined appropriate by the
Foster Care Support Worker.

PROCEDURES

1. Foster Care program staff team members, but not limitedto:

a. Execute intakes, discharges, and support transitions of Foster Children and Youth;
b. Document all contact with the client and Foster Parents; as well as internal and external collateral individuals,
and ensure all contact notes are signed by the Support Worker, and maintained in the appropriate file;
c. Provide annual evaluations of Foster Parents skills;
d. Complete 30 day and every 90 day thereafter assessment/outcome tools with clients, and maintained in the
clients file;
e. Provide quarterly reports and service plans to the Case Worker regarding the client’s progress;
f. Complete annual Safety Environment Checks in collaboration with Licensing Officer;
g. Ensure that accreditation and licensing requirements are maintained by each Foster Parent;
h. Review files to ensure quality control and accreditation standards are being met;
i. Provide on call support as per TRELLIS agencypolicy;
j. Manage crisis situations;
k. Attend and participate in Case Conferences;
l. Liaison with Calgary Region Children’s Services;
m. Plan, facilitate, and/or support Foster Parent Support Meetings and Training;
n. Process and maintain records of foster parent expenses (allowance, clothing, travel, recreation, mileage etc).
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POLICY: FOSTER CARE FILE MANAGMENT POLICY NO.: I.2.9

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

CARF
DATE REVISED: May 2019

POLICY

1. Trellis Foster Care Client and Foster Parent files must comply with CARF standards, current Calgary
Region Children’s Services policies, and FOIP.

Client File Document Maintenance

2. Client files will be secured to comply with CARF and FOIP standards.

3. Client files will:

a. Files will be stored in the office in a double locking system (e.g. locking file cabinet in a locked office). They
will remain locked unless in use.
b. Foster Care Support Workers are responsible for ensuring that all file information pertaining to client
records is current and accurate.
c. Foster Care Client files are to be audited by senior program employees on a quarterly basis. This will
include open and closed Client files.
d. Foster Care Client files will be reviewed quarterly by the Program Manager for case management planning
to ensure that services provided are timely and appropriate, and for quality control.
e. All Calgary Region Children’s Services client files are kept according to the requirements of the Alberta
Government legislative protocols.
f. Should a legal process be initiated against the Foster Care Program, any destruction or disposal of program
documents and/or information is strictly prohibited.
g. All documents and/or information will be maintained and/or filed according to the Alberta Government
legislative protocols.

Foster Parent File Document Maintenance

4. Foster Parent files will be secured to comply with CARF and FOIP standards.

5. Foster Parent files will:

a. Files will be stored in the office in a double locking system (e.g. locking file cabinet in a locked office). They
will remain locked unless in use.
b. Foster Care Support Workers are responsible for ensuring that all file information pertaining to Foster
Parent records is current and accurate.
c. The Foster Parent files are to be audited by senior program employees on a quarterly basis. This will
include open and closed Foster Parent files.
d. Foster Parent files will be reviewed quarterly by the Program Manager for case management planning to
ensure that services provided are timely and appropriate, and for quality control.
e. All Foster Parent files are kept according to the requirements of the Alberta Government legislative
protocols.
f. Should a legal process be initiated against the Foster Care Program, any destruction or disposal of program
documents and/or information is strictly prohibited.
g. All documents and/or information will be maintained and/or filed according to the Alberta Government
legislative protocols.
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POLICY: FOSTER CARE FILE MANAGMENT POLICY NO.: I.2.9

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

CARF
DATE REVISED: May 2019

PROCEDURES

Foster Care Client File Procedures

1. The Foster Care Client files are to be audited by senior program employees on a quarterly basis. This will include
open and closed client files.

2. Foster Care Client files will be reviewed quarterly by the Program Manager for case management planning to
ensure that services provided are timely and appropriate, and for quality control.

3. Foster Care client file audits will remain on the client’s file.

Foster Parent File Procedures

4. At minimum once per month, Foster Parents will submit monthly internal and external (allowance records, monthly
reports, clothing reports, appointment records and medication records) forms and documentation to the Foster
Care Administrative Support Worker.

5. Foster Care Parent files will be reviewed quarterly by the Program Manager for case management planning to
ensure that services provided are timely and appropriate, and for quality control.

6. File audits will remain on the Foster Parents file.

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POLICY: FOSTER CARE SUPPORT SERVICES POLICY NO.: I.2.10

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All Trellis Foster Parents will be provided with support services required to meet the needs of the clients placed
into their care. Minutes and attendance of support meetings and trainings will be kept on file. Foster Parents can
access these upon written request to the Manager of Residential and Treatment services.

2. Documentation will reflect a visit with the client by the Foster Care Support Worker (FCSW) within the first five
(5) working days of placement.

3. Foster Care Support Workers will meet with clients face-to-face at least once per month, and maintain contact
notes on the clients file.

4. Subsequent documented contact will consist of:

a. Weekly phone contact with the Foster Parents;

b. Monthly home visits with the Foster Parents, and
c. Monthly alone face to face contact with the client.

5. The Support Worker will initiate contact and initial intake meeting with the assigned case worker within the first 7
(seven) working days after placement.

6. Foster Care Support Workers will document discussions and case conferences with the Case Worker at
minimum every three (3) months to discuss the client’s Individualized Support Plan.

PROCEDURES

1. Support Services include but are not limited to:

a. Initial home visit within five (5) working days of placement;

b. Supportive and consultative contact with the Support Worker (weekly phone contact, monthly home visits
with Foster Parents, and monthly face-to-face visits with the client); or as deemed necessary by the Foster
Care Support Worker, Manager, and/or Foster Parent.
c. Observations of interactions between the client and the Foster Parents once per month;
d. 24 hour emergency on-call services to the Foster Parent and client;
e. Supporting approved respite care or relief care is available to the Foster Parents, and ensured that it is used
regularly;
f. Support during investigations;
g. Eight (8) Foster Parent Support meetings provided throughout the year;
h. Training opportunities to meet licensing and CARF requirements;
i. Providing Foster Parents with knowledge around community resources appropriate to the client’s spiritual
and cultural needs;
j. Support to Foster Parents and client in the development of the Case Workers Concurrent Plan;
k. Access/consultation with other TRELLIS support services, including the Trauma & Attachment Specialist,
asdeemed necessary and as directed by the Foster Care Support Worker and/or Foster Care Manager.
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POLICY: FOSTER HOME CLOSURE POLICY NO.: I.2.11

DATE ISSUED: August 5, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

Planned Foster Home Closure

1. In the event of a planned Foster Home closure, the Agency will work collaboratively with children’s services follow
specific procedures for supporting and transitioning clients to a new placement.

2. Written correspondence indicating the closure date will be provided to the Foster Care Program Manager two
months prior to the termination date by the Foster Parents unless the closure corresponds with the client’s natural
transition home.

3. The Licensing officer and client’s Case Worker is notified that the Foster family is leaving the Agency and alternate
arrangements are made for the client(s) in the home.

4. Any information pertaining to the client(s) in the home will be provided to the Trellis Foster Care Support Worker
and archived as per the standards outlined in the contract with Calgary Region Children’s services

5. Foster Parent file information will be archived and can be accessed by the Foster Parents by providing a written
request to the Foster Care Program Manager.

Unplanned Foster Home Closure

6. In the event of a of an unplanned Foster Home closure, the Agency will work collaboratively with Children’s
Services Licensing officer and Case Worker, follow specific procedures for supporting and transitioning clients
to a new placement.

7. Written correspondence indicating the closure date will be provided to the Foster Parents, Case Worker and
Licensing Officer.

8. Any information pertaining to the client(s) in the home will be provided to the Trellis Foster Care Support Worker
and archived as per the standards outlined in the Calgary Region Children’s Services contract.

9. Foster Parent file information will be archived and can be accessed by the Foster Parents by providing a written
request to the Foster Care Program Manager.
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POLICY: FOSTER HOME PLACEMENT CRITERIA POLICY NO.: I.2.12

DATE ISSUED: August 5, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis believes that each client should be placed into a home that meets their individual needs.

POLICY

1. Newly licensed families can foster a maximum of two clients in their home upon agreement from the licensing
officer and the Agency.

2. A maximum of 4 clients may be placed in a Foster Home after the following criteria has been met:

a. One year with the agency;

b. A positive annual evaluation that supports additional clients;
c. Completion of all training requirements;
d. Licensing approval
e. Alberta Health Inspection

3. Homes may be conditionally licensed by Calgary Region Child and Family Services for more than their license
number if:

a. The client has resided in the homepreviously;

b. A teen client has a child;
c. Sibling groups
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POLICY: FOSTER PARENT EVALUATIONS POLICY NO.: I.2.13

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis Foster Care Program must complete regular evaluations on all Foster Parents. This evaluation will include
the assessment of skills, the knowledge and comprehension of trauma informed care, developmental goals,
challenges the family may be facing and recommendations for the type of client that should be placed in the
home. TRELLIS will reassess the Foster Home if there is a change in the Foster Parent’s circumstances that
could affect the client in care (i.e. change in family membership, change in family finances, health and relocation).

PROCEDURES

1. Support Workers will conduct an initial evaluation 6 months following the first placement which reflects the
assessment of skills, the knowledge and comprehension of trauma informed care, developmental goals,
challenges the family may be facing and recommendations for the type of client that should be placed in the
home.

2. Support Workers will reassess families annually unless otherwise required by circumstances (i.e. change in
family membership, change in family finances, health and relocation).

3. Foster Parents are provided with a copy of the evaluation to review, add comments and sign.

4. All evaluations are kept on the Foster Parents file.

5. A copy of the evaluation is included in the annual licensing package.

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POLICY: FOSTER PARENT / FOSTER CHILD POLICY NO.: I.2.14

MATCHING

DATE ISSUED: August 5, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis will ensure all of the following criteria has been considered prior to placement whenever possible:

a. Availability of bed space;

b. Individual needs of the client to determine if the family structure is appropriate;
c. Compatibility to the other children in the home (ages, sex, development);
d. Family Skill Level – is specialized training required (i.e. medically fragile)

2. Possible placements are reviewed by the Support Worker or Residential On-Call after hours ([5:00pm to 8:30am],
weekends and statutory holidays) to determine the appropriateness of the placement prior to the family being
contacted for consultation.
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POLICY: FOSTER PARENT SELECTION POLICY NO.: I.2.15

DATE ISSUED: August 28, 2001 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis will select and retain Foster Parents based on their suitability to offer care to the clients referred for
placement.

2. Trellis will ensure that all Foster Parents selected to provide services will adhere to thefollowing procedures:

PROCEDURES

1. The applicants must be 18 years of age or older and have the maturity and stability appropriate to fostering.

2. Criminal Record Check on every person 18 years of age or older in the home indicating there is no record or if
positive, a decision is made by TRELLIS CEO that the record would not cause risk to the client.

a. Criminal Record Checks completed within the past 6 months will be considered current (new applicants).
b. Criminal Record Checks are to remain current, and must be renewed every 3 years.

3. An Intervention Record Check on every person 18 years of age or older in the home indicating there is no record
or if positive, a decision is made by TRELLIS CEO that the record would not cause rick to the client.

a. Intervention Record Checks completed within the past 6 months will be considered current (new applicants).
b. Intervention Record Checks are renewed every 3 years.

4. A SAFE (Structured Analysis Family Evaluation) Home Assessment will be completed for all Foster Parents who
began fostering after 2010 and will be kept on the Foster Parent file.

5. Foster Parents who applied to foster prior to 2009 were “grandfathered” in and will not have a SAFE Home Study
on file, but will have a Home Assessment on file.

6. A medical reference on each applicant regarding the general health and freedom from illnesses or disabilities
which would interfere with the provision of Foster Care;

7. Three references pertaining to the suitability of the family to foster are obtained and contacted (2 work
references, and 1 personal reference). Additional references may be requested.

8. Copies of adequate Home and Auto insurance provided and retained on file (liability must be $1,000 000).
Copy of Vehicle Registration and Driver’s License(s).

9. Where the applicants have fostered or applied to foster for another agency or the authority, a fostering history
is required;

a. A written and signed declaration outlining previous fostering experience and applications tofoster.
b. A signed release of information allowing TRELLIS to contact the previous agency forinformation.
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POLICY: FOSTER PARENT SELECTION POLICY NO.: I.2.15

10. A Declaration of Confidentiality.

11. A Child and Youth Intervention Services Facility License.

12. A signed Environmental Safety Checklist.

13. Emotional/Psychological Statement

14. Fire Arms Declaration

15. Foster Parent Agreement Contract signed between TRELLIS and Foster Parents.
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POLICY: HOUSE / AUTO INSURANCE POLICY NO.: I.2.16

DATE ISSUED: January 1, 1997 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All Foster Parents contracted with Trellis will have adequate insurance on their homes, vehicles and contents.

2. Foster Parents will have the following minimum amounts of insurance:

a. Home: Replacement value

b. Vehicle: $1,000,000.00 liability
c. Contents Replacement value

3. Copies of current insurance will be placed on the Foster Parent personnel file. Copies to be provided prior to the
current policy’s expiration date.

4. Damages incurred through fostering either to the home or vehicles are not covered under basic insurance plan.
This can be added to policies for an additional charge. Other assistance can be sought through the Alberta Foster
Parents Association (AFPA).
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POLICY: LICENSING POLICY NO.: I.2.17

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis Foster Homes will be licensed in accordance to Calgary Region Child and Family Services policy. This
license requires renewal annually.

Initial License

1. The requirements for an initial Foster Care Home license are:

a. Completion of all requirements in Policy No. 1.2.15 Foster Parent Selection.

b. Completion of 24 hours of Caregiver Orientation Training which is provided by Calgary Region Children’s
services or a Calgary Region Children’s services or agency approved facilitator.
c. Completion of the License Application.
d. Completion of the following mandatory training within the specified time frame:

i. First Aid and CPR – prior to placement

ii. Medication Administration and Universal Precautions prior to placement and annual renewal
iii. Shaken Baby- prior to placement agency staff and/or licensing officer will have a discussion regarding
safe sleep practice with foster parents documentation will be placed in Foster parent file. Foster
Parents will be scheduled for first available training with Children’s Services or Agency.
iv. Safe TALK – within 6 months of licensing date
v. Non-Violent Crisis Intervention and/or TCI – within 6 months of licensing date
vi. Indigenous Awareness Training – within 6 months of licensing date
vii. Cultural Diversity Training – within 6 months of licensing date

e. Home visit occurs with the assigned Licensing Officer once all file information has been received and
reviewed. Document maintained in Foster Parent file.
f. Determination of number of placements, age range, sex and behavioral issues. Newly licensed homes will
only be licensed for a maximum of two (2) children. After one year of successful fostering, Foster Parents
can apply for an increase to their license in collaboration with Foster Care Support Worker and the licensing
officer.
g. In the case where a Conditional License is granted, all conditions must be met within the specified
timeframe.

License Renewal

2. Requirements for license renewals are:

a. Licensing package to be completed by the Foster Care Administrative Support Worker and provided to the
Licensing Officer 60 days prior to the license expiry.
b. A Licensing Package consists of:

i. Residential Facility License Application Renewal

ii. A copy of the Foster Parent Annual Evaluation
iii. Criminal Records Check – considered valid if within the past 3 years
iv. Child Intervention Check – considered valid if within the past 3 years
v. Current First Aid Certificates
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POLICY: LICENSING POLICY NO.: I.2.17

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

vi. Current Home Insurance as per Policy 1.2.16

3. A completed application package will be sent to the assigned Licensing Officer allowing for time to review
the Application/Renewal package.

4. Once all file information has been received and reviewed, the Licensing Officer and the Foster Care Support
Worker will arrange a home visit to complete the Environmental Safety Check.
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POLICY: RECORD OF CLIENT PROGRESS POLICY NO.: I.2.18

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis must retain a written record of the client’s progress that includes photographs, quarterly reports, assessment
tools, and other records of client activities while in the Foster Home.

PROCEDURES

1. Foster Parents are to retain information reflective of the client’s activities and progress and complete monthly
reports. This will include photographs, report cards, and other memorabilia. New photographs should be
submitted to the foster care support worker every 6 months and placed on the client file.

2. It is the responsibility of the Foster Parents to maintain “Life Books” or “Memory Books” for the clients in their
care. Foster Parents are responsible to ensure that the client’s “Life Book” is given to the Case Worker upon
discharge.

3. Program Client Files will be in compliance with accrediting standards and TRELLIS Policy and Procedures.
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POLICY: FOSTER PARENT RELIEF/RESPITE POLICY NO.: I.2.19

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All Trellis Foster Care Parents are eligible for twenty four (24) nights of relief per bed peryear.

2. Relief rates will be paid out monthly to Foster Parents on their monthly per diem payments.

PROCEDURES

1. Foster Parents will provide Support Workers with documentation of relief and/or respite time taken. Contact
information for relief/respite providers will be provided to the Foster Care Support Worker and Case Worker.

2. Foster Care Support Workers will track and retain documentation on the Foster Parent file.

3. Relief providers will be determined in consultation with Foster Care Support Worker and the Case Worker. Relief
providers may be required by Calgary region children’s services to submit a clear intervention record check and a
clear criminal records check on file with TRELLIS. Both checks must be current within 3 (three) years

4. Relief and/or Respite time must consider the best needs of the client in the home as well as the needs of the
Foster family.

5. Additional respite or emergency relief must be negotiated with the Support Worker and the Case Worker. This is
assessed and reflects the needs of both the Foster family and the client and will be documented in a Support Plan
completed by Calgary Region Child and Family Services. A copy of the Support Plan will be kept in the Client file.
Respite must be accessed in accordance with thesupport plan.

6. Respite must be provided by another licensed Foster Home.

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POLICY: SAFETY REQUIREMENTS POLICY NO.: I.2.20

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All Trellis Foster families providing placements to clients will ensure all safety requirements are met
as per the Environmental Safety Assessment for Caregivers.

2. The Foster Home must have adequate sleeping, eating and storage space to accommodate a client while ensuring
that privacy needs are met;

3. All cleaning agents and toxic substances including alcohol and tobacco, pesticides, fertilizers etc. are stored in
original containers, properly labelled, and stored out of reach of clients;

4. All matches/lighters must be stored out of reach ofclients;

5. All firearms must be trigger locked and kept in a locked cabinet. Ammunition must be locked in a separate cabinet
away from the firearm.

6. Sharp utensils, knives, scissors are to be kept out of reach of children.

7. A Firearms Declaration must be signed by the Foster Parents and retained on their file;

8. Clients can only use weapons if written consent is obtained from the Case Worker, direct adult supervision is
available and the client has training. Consents must be obtained prior to use and remain on the client’s file.

9. All medications are to remain in their original containers and must be kept in a locked container. Medications
requiring refrigeration must be kept in a locked box inside the refrigerator.

10. The Foster Home must be equipped with the appropriate safety equipment as required by licensing. All homes
require current and working fire extinguishers, smoke detectors and carbon monoxide detectors. Some homes
may require additional safety equipment such as escape ladders for bedrooms on second level where emergency
exit is greater than 8 feet.

11. Home, yard, and walkways must be kept clean and free of hazards.

12. Foster Home files will contain copies of signed annual safety checklists by the agency indicating compliance with
safety requirements.
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POLICY: SLEEPING ARRANGEMENTS POLICY NO.: I.2.21

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All clients must have appropriate sleeping accommodations as approved through the licensingprocedures.

2. All Foster Parents will ensure clear direction from the client’s Case Worker is received regarding all approved
sleeping arrangements.

3. Rooms can be shared by two or more clients if deemed appropriate by the licensing officer, Program Manager
and Case Workers.

4. Cribs must be provided for all clients under the age of two (2) years. Cribs need to have a visible CSA sticker
attached and meet requirements.

5. All Foster children must be provided with their own bed.

6. Bunk Beds are allowed if they are of good construction and approved by the licensing officer. IKEA bunk beds
must be approved on a case by case basis. A top bunk is required to have 4 rails on it and the ladder must be
securely attached. Children 6 years old and over can sleep on the top bunk if seen as safe by the Foster Parent,
Foster Care Support Worker and Case Worker.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
FOSTER CARE

POLICY: FOSTER CARE SUPPORT POLICY NO.: I.2.22

UNSCHEDULED HOME VISITS

DATE ISSUED: July 2010 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Upon consultation and direction of the Foster Care Manager, there are occasions when it is necessary to perform
unscheduled home visits to Foster Homes. Foster Parents are required to accommodate unscheduled visits by a
Trellis Foster Care Support Worker, Foster Care Manager or any member of the Trellis Senior Leadership team.

PROCEDURES

1. Contact notes will be retained on the Foster Parent’s file outlining the need for the visit and the outcome.

2. Refusal of admittance by the Foster Parent is grounds for dismissal.

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: SCREENING POLICY NO.: I.3.1

DATE ISSUED: March 2016 ASSOCIATED STANDARDS: I.3.2

DATE REVISED: May 2019

POLICY

Trellis follows a formal screening process for all youth referred to residential/group care programs.

PROCEDURES

1. Upon receipt of a referral package/placement screening, the Program Manager will review the
package/screening to determine if the eligibility criteria has been met.

2. If necessary, the Program Manager may consult additional employee team members and/or the Program
Manager as needed to determine if client meets all eligibility criteria.

3. The Program Manager will contact the client’s guardian and other appropriate professionals as needed to
further assess eligibility.

4. For PSECA programs, If the client meets all eligibility criteria, the program manager will contact the client and/or
Guardian by telephone or in person to provide a program description and answer any questions of the
client/Guardian.

5. The client and Guardian may be offered a pre-placement visit to the program site, as deemed appropriate,
when possible.

6. In the event the client does not meet the eligibility criteria, the referring source will be advised and provided with
alternate community resources.

Page 1 of 1
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.3.2

DATE ISSUED: February 16, 1998 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Clients will be admitted and re-admitted into Trellis Group Care Programs based on the eligibility criteria for the
program and program availability. Group care clients must have status with Children’s Services. Clients accessing
Eleanor’s House must hold PSECA status but may also have dual status with CS. Trellis does not maintain
waitlists for residential/group care programs. Notwithstanding this policy, the Program Manager may exercise
some discretion in regards to admissions to allow for special individual cases.

PROCEDURES

1. Client who are admitted and re-admitted into Group Care:

a. Are between the ages of thirteen (13) and seventeen (17) unless approval from Contract Manager, Program
Manager, Director and Case Worker;
b. Have an agreement with Calgary Region Child and Family Services, Central Region Child and Family
Services and/or Guardian;
c. Are experiencing conflict in the home, community or at school and for various reasons cannot live at home;
d. Have a need for and an ability to benefit from Group Care;
e. Are deemed likely to adjust to, and benefit from, the particular group of clients with whom they would be
placed;
f. Would not likelybe put at risk, or have a lasting negative therapeutic impact on the other clients;
g. Require or could most benefit from a degree of care or supervision beyond that which can be provided by a
family, and;
h. Have had the opportunity to refuse placement if they feel that the program does not meet their needs.

2. The referral package placement screening should be received and reviewed in reference to the above criteria
prior to a decision on admission being made by the Program Manager..

3. Admissions will be prioritized according to need by Calgary region Children’s Services placement services /
PSECA in consultation with the Program Manager as required.

4. In the event the client does not meet the eligibility criteria, the referring source will be advised and provided with
alternative community resources.

5. Trellis advocates for the placement of siblings together when appropriate. If the program is unable to
accommodate this, the program provides opportunities and advocates for regular visits of the siblings.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: EMERGENCY PLACEMENTS POLICY NO.: I.3.3

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS

DATE REVISED: May 2019

POLICY

1. Trellis Group Care Programs do not accept emergency placements but may do so under unusual circumstances,
specifically if a client has prior involvement with the Agency. Approval must first be obtained through Placement
Services, the Case Worker and Program Manager.

PROCEDURE

1. All emergency placements require that:

a. The client being placed meets the program eligibility criteria for the Agency;
b. An intake meeting must be scheduled within five (5) days from the day of the intake to review the
appropriateness of the placement;
c. Program Manager or On-Call Manager approval is required for all emergency placements;
d. Appropriate resources are put in place to ensure the safety of the facility and its residents;
e. Delegation from Calgary Region Children’s Services is obtained and all intake consent forms are
completed at time client enters into Program.

2. In the event that a client does not meet the eligibility criteria, the referring source will be advised and alternate
placements and supports will be recommended.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.3.4

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Upon admission to the Trellis Group Care programs, an assessment of the client’s needs will be completed and
a separate, identifiable and Individual Plan will be developed within thirty (30) calendar days of admission. The
client and their legal guardian and others relevant to the Individual Program Plan are given the opportunity to be
fully involved in the development of the client’s Individual Plan. The Individual Plan supports the goals of the
youth and is written in Youth Voice.

2. All Indigenous clients, when the family (when applicable) and client agree, have the right to have an Indigenous
Resource Person be involved in the development, implementation and review of the Individual Plan in order to
ensure that the plan is consistent with, and supports the needs of the client and family in a culturally sensitive
way.

3. All Clients, when the family (when applicable) and client agree, have the right to have a Cultural Resource Person
be involved in the development, implementation and review of the Individual Plan in order to ensure that the plan
is consistent with, and supports the needs of the client and family in a culturally sensitive way.

4. The Individual Plan will include:

a. an assessment based on strengths, needs, abilities and preferences (SNAP) of the client served;
b. the services to be provided, including:

i. the goals to be achieved;

ii. the tasks/activities/strategies for providing the services and meeting the goals;
iii. individuals involved to support the client;
iv. indicators/measures to determine when goals are met;
v. timelines for completion.

5. In the development of Individual Plan, special consideration is given to:

a. The arrangements by which the client’s needs may be addressed;

b. Ensuring appropriate referrals and follow up for external services (if any) are made;
c. Effective transition from the program to an alternate program or community setting will be made.

6. The Individual Plan will be reviewed every 90 days, with the client and the client’s guardian, to determine whether
the services are adequate or still necessary, or whether another service or the services of another agency may
be needed.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.3.4

PROCEDURES

Individual Planning at Admission

1. The Primary Assessment is the completion of the full intake package including the interpretive summary. Included
is the determination of the clients need and recommendations towards the development of their Individual Plan.
The Individual Plan will be developed based on the identifying needs of the client as well as all other information
gathered during the intake process. Information is obtained through contact with the client, Case Worker and
other relevant support systems where needed and appropriate.

2. The Individual Plan is developed with the youth within thirty (30) calendar days after the youth’s admission to the
program.

3. The client and others relevant to the Individual Plan are given the opportunity to be involved in the development
of the Individual Goal Plan.

4. The Individual Plan is developed in cooperation with the youth and the Case Worker in order to ensure that the
plan is consistent with and supports the goals of the Children’s Services concurrent plan, as well as the youth’s
goals. All Individual Plans will be written in Youth Voice.

5. The Individual Plan and all services provided will give specific consideration to:

a. the client’s culture, language, spirituality, ethnicity and religion and are responsive to the youth’s
disabilities/disorders or concerns;
b. the clients trauma history;
c. the opportunity to support the resolution of issues/ concerns identified by the client/ family and Calgary
Region Children’s Services;
d. the re-establishment of parental care and maintenance of contact between the family and the youth as
directed by CFS;
e. providing opportunity for stability and permanency planning;
f. the developmental level of the youth;
g. the goals of the youth.

6. The Individual Plan will be signed by the youth if 12 or older to indicate participation, as well as by the Case
Worker and parent/guardian, as appropriate.

7. Copies of the Individual Plan are forwarded to the Case Worker and/or guardian with a copy placed in the
client’s personal file.

Individual Plan Reviews/Case Conferences

8. Individual Plans are reviewed regularly after the initial (30 days) Individual Plan is developed. Individual Plans
will be reviewed every ninety (90) days minimally.

a. These reviews include those individuals who were involved in the development of the Individual Plan. The
purpose of the review is to evaluate:

i. Services, progress and outcomes of goals;

ii. whether goals are adequate and necessary;
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.3.4

iii. the cultural, religious and spiritual needs of the youth;

iv. tasks/activities/strategies/timelines for meeting goals and providing services;

v. the need for additional internal/external services;
vi. A proposed goal plan for the upcoming period based on the review of client success and needs.

A review of the Individual Plan may be requested at any time by a client, their guardian or the Case Worker, as well
as program employees.

*The review of progress on identified areas, the proposed goal plan and the timelines will be given to the Case
Worker and/or guardian.

b. To ensure coordination of services outlined in the Individual Plan, communication with other agencies
involved with the youth will occur when consent for release of information is obtained.

Special Considerations for Additional Reviews

*Review of the Individual Plan can also occur as needed

This review will address either a crisis that has occurred or a proposed adjustment or addition to the Individual Plan.
Consideration of the youth’s ability to keep themselves and others safe will be addressed.

The format will include a review of the issue and, when necessary, an addendum to the identified individual issues
listed in the Individual Plan and Transition Plan. Depending on the nature and severity of the issue(s), a Crisis Service
Review can occur by a phone conference or in a meeting.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: PROGRAM SERVICES POLICY NO.: I.3.5

DATE ISSUED: February 15, 1998 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All Trellis programs providing Group Care will deliver their contractual services within the parameters of the
service definition.

PROCEDURES

Service Definition

1. The program provides a care in group setting within a residential community. It provides a program of services
for youth to remediate social and emotional issues, to assist in healing from impact of trauma history, to foster
normal maturation, personality development and social functioning, and to integrate the client into the family and
community to the greatest extent possible.

2. The program provides care and services for youth who require increased care and supervision beyond that
which can be provided in a family.

Program Services

3. Group Care Programs will provide for the care of six (6) or fewer youth.

4. The mandate of the service is to ensure that the youth’s physical, social, medical, emotional, cultural and spiritual
needs are being supported. This service is achieved through a program that provides security and a sense of
belonging as well as developing skills for self sufficiency. The program emphasizes positive interpersonal
relationships, social development, community involvement, life and living skills and family support.

5. Through evidence based, Trauma Informed Practice, the program provides a nurturing and safe environment that
emphasizes individual growth and development through positive interactions between the youth and the
employees. The program promotes and encourages positive family relationships, daily life skill development,
education, recreation and community involvement. If family reunification is not possible, efforts and resources are
then directed toward assisting the youth in achieving emancipation and adult self sufficiency.

Group Care Objectives

6. Youth are physically and emotionally safe.

7. Youth have healthy attachments and relationships.

8. Youth have improved functioning and developmental competencies.

9. Youth have increased positive community connections.

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: INTAKES POLICY NO.: I.3.6

DATE ISSUED: September 3, 2000 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. The Trellis Group Care Programs follow a formal admission procedure for all clientsentering the program.

PROCEDURES

1. Upon the referred client being accepted into Group Care or PSECA Programs, the admission procedure will
minimally include:

a. An introduction to the other clients at the program;

b. An introduction to program employees;
c. An orientation to the program including all fire and evacuation procedures, transportation options and visitors
and guests;
d. A thorough explanation of the services provided by the program as well as the expectations of the group home
verbally at the Intake Meeting. The youth is provided with a written copy of the Welcome Manual at the Intake
Meeting;
e. The completion of an Intake package is completed at the intake meeting with the Case Worker, parents
and/or legal guardians, one program employee and cultural supports whenrequested;
f. An understanding of the reason for placement, the Delegation of the Powers and Duties to a Child Caregiver
and the role and contact information for the Child and Youth Advocate’s office, Voluntary Service Agreement if
appropriate.
g. Information pertaining to the safeguarding of client personal items and how the program manages items
abandoned by clients is included in the Welcome Manual;
h. The Agency’s policies around the use of tobacco, alcohol and illegal or legal drugs brought into the program;
i. Review of client rights, and;
j. Information regarding program and community activities.

2. The following admission forms are to be completed at intake:

a. Client Face and Information Sheet;

b. Delegation of Authority, if appropriate
c. Behavioral/Medical History;
d. Service Agreement (consent for services), Voluntary Service Agreement, if appropriate
e. Contract with Resident;
f. Behavior Management;
g. Youth Clothing and Item List;
h. Consent for Release of Information;
i. Consent for Medication Administration;
j. Consent to Search;
k. Grievance Procedures and;
l. Child and Youth Advocate’s role;
m. Personal Safety Plan;
n. Confirmation of Youth’s Rights;
o. Intake Bedroom Checklist;
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: INTAKES POLICY NO.: I.3.6

p. Youth Orientation Checklist;

q. Interpretive Summary;
r. Medical Information;
s. Youth Intake Demographic Information;
t. Permission to Transport;
u. Media Consent;
v. Privacy Statement and Consent.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
GROUP CARE PROGRAMS

POLICY: EMPLOYEE RATIOS POLICY NO.: I.3.7

DATE ISSUED: September 3, 2001 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis Group Care Programs employ qualified employees to ensure adequate supervision of clients
and maintain safety in the programs.

PROCEDURES

1. The supervision of the clients is continuously available. The program must ensure that one (1) employee is
available for every six (6) clients in the program.

2. Additional employees will be made available for peak activity periods according to the needs of the youth and the
employees. Extra employees must also be accessible to provide special or situational needs for youth. For
example, those who are aggressive, suicidal or pose a threat in the program. Case Workers may be asked to
assist financially if extra staffing is required for an extended period of time. This may include the use of one to
one workers.

3. Managers will ensure that adequate supervision is provided to front line employees.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
SCHOOL SUPPORTS PROGRAM – HERA

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.4.1

DATE ISSUED: ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Clients will be admitted and re-admitted into the Trellis Hera program based on the eligibility criteria for the program
and program availability. Notwithstanding this policy, the Program Manager, in consultation with the Program
Director, may exercise some discretion in regards to admissions to allow for special individual cases.

PROCEDURES

1. Clients who are admitted into the Hera program:

a. Identify as females and are between the ages of thirteen (13) and seventeen (18) unless approval from
Program Director and School Administrator;
b. Have a need for a specialized therapeutic classroom to support their re-engagement ineducation;
c. Are at risk of or already involved in sexual exploitation and as such are experiencing one or more of the
following: conflict in the home, community or school; failure to experience success in a regular school setting;
social isolation; poverty; risky sexual behavior; vulnerability to negative peer influences; substance abuse;
family violence, mental health issues or have been sexually exploited;
d. Have a need for and an ability to benefit from therapeutic wraparound supports that include: family in-home
support; case management; community referrals; experiential learning; mentorship; opportunities to support
life skills development; re-engagement in school and positive connection to community;
e. Are deemed likely to adjust to, and benefit from, the particular group of clients with whom they would be
placed, and;
f. Would not likely be a risk of having a lasting negative impact on the other clients;
g. Referred by another community agency.

2. The Hera program referral package should be received and reviewed jointly by the Program Manager and
designated Calgary Board of Education Staff in reference to the above criteria prior to a decision on admission
being made.

3. In the event the client does not meet the eligibility criteria, the referring source will be advised and alternate
placements recommended whenever possible.

4. The Hera program does not accept emergency placements.

5. A waitlist for the Hera program may be maintained by CBE Administration. No Services from TRELLIS are
offeredto youth while on the CBE waitlist.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
SCHOOL SUPPORT PROGRAM - HERA

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.4.2

DATE ISSUED: ASSOCIATED STANDARDS:

DATE REVISED: May 2019 CARF – Screening and Access

POLICY

1. Prior to admission to the Trellis’ Hera program, a readiness assessment of the client’s needs will be completed.
Upon intake an intake package and safety plan will be completed within the first seven
(7) days. An Individual Plan will be completed within the first ninety (90) days.

2. The Individual Plan will include:

a. an assessment using the current program assessment tool and/or goal setting tool;
b. the services to be provided, including:

i. the goals to be achieved;

ii. the tasks/activities/strategies for providing the services and meeting the goals;
iii. individuals involved to support the client;
iv. indicators/measures to determine when goals are met;
v. timelines for completion.

3. In the development of an Individual Plan, special consideration is given to:

a. the arrangements by which the client’s special needs may be addressed;

b. the services, if any, to be provided by other agencies and the arrangements to be made for obtaining them;
c. how an effective transition from the program to an alternate program or community setting will bemade.

4. The Individual Plan will be reviewed at all case conferences, with the client and the client’s guardian*, to determine
whether the services are adequate or still necessary, or whether another service or the services of another agency
may be needed.

* NOTE: If there is an agreement directly with the client, the client’s involvement in the agency service plan is to be
sought rather than that of their guardian.

PROCEDURES

Service Planning at Admission

1. Prior to intake a readiness assessment is completed. At intake, a primary assessment is completed. Included is
the determination of the client’s needs and recommendations toward the development of their Individual Plan.
Information for this report is obtained during the assessment interview and through contacts with the client and
other relevant support systems where needed and appropriate.

2. The Individual Plan is developed with the client prior to the semester Case Conference.

3. The client and others relevant to the Individual Plan are given the opportunity to be involved in the development
of the Individual Goal Plan.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
SCHOOL SUPPORT PROGRAM - HERA

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.4.2

4. When a client has Intervention status with Calgary Region Child and Family Services, the Individual Plan is
developed in cooperation with the Caseworker in order to ensure that the plan is consistent with and supports
the goals of the Transition Plan.

5. The Individual Plan and all services provided will give specific consideration to:

a. the client’s culture, language, spirituality, ethnicity, religion and sexual gender identity and are responsive to
the client’s disabilities/disorders or concerns;
b. the resolution or remediation of problems that have necessitated placement;
c. the re-establishment of parental care and maintenance of contact between the family and the client (unless
contraindicated) or the reintegration of the client into the family and community;
d. the stability and permanence in the care of the client;
e. the developmental level of the client.

6. Copies of the Individual Plan are placed in the client’s personal file. Clients will be offered a copy of the Plan.

Service Plan Reviews/Case Conferences

7. Regular service reviews take place subsequent to the development of the Individual Plan. These reviews will be
completed minimally each semester dependent on client and program needs.

a. These reviews include those individuals who were involved in the development of the Individual Plan. The
purpose of the review is to evaluate:

i. services and goals;

ii. whether goals are adequate and necessary;
iii. the cultural, religious and spiritual needs of the youth;
iv. tasks/activities/strategies/timelines for meeting goals and providing services;
v. whether another service or the services of another agency may be needed.

A service review may be requested at any time by a client, their guardian as well as by program employees.

b. The format will include at a minimum:

i. A review of progress on areas identified in the Individual Plan. Using the information gathered from the
assessment, transition plans and reviews, a brief summary of the goals, work to date, and outcomes for
each area is provided;
ii. A review of any new issues or major incidents;
iii. A proposed action plan for the upcoming period based on the review of issues.

8. The review of progress on identified areas, the proposed action plan and the timelines, together with the
minutes of the meeting, will be given to the guardian and a copy placed in the client’s file.

a. To ensure coordination of services outlined in the Individual Plan, communication with other agencies
involved with the client will occur when release of information is obtained.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
SCHOOL SUPPORT PROGRAM - HERA

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.4.2

Crisis Reviews

9. This review will address either a crisis that has occurred or a proposed adjustment or addition to the current
service or action plan. Consideration of the client’s ability to keep themselves and others safe will be addressed.

10. The format will include a review of the issue and, when necessary, an addendum to the identified individual issues
listed in the Transition Plan and Individual Plan. Depending on the nature and severity of the issue(s), a review
can occur by a phone conference or in a meeting.

Transitioning and Exiting from the Program

11. Current clients transition from the program when their goals are achieved and they are able to successfully
integrate into another school setting. This will occur at natural school breaks whenever possible. Client’s will also
transition from the program upon turning eighteen (18) years of age, at the appropriate school break closest to
their birthday. Clients can also exit the program by choice at any time.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
SCHOOL SUPPORT PROGRAMS – HERA

POLICY: PROGRAM SERVICES POLICY NO.: I.4.3

DATE ISSUED: ASSOCIATED STANDARDS:

DATE REVISED: May 2019

The Hera program will deliver their contractual services within the parameters of the service definition.

POLICY

Service Definition

1. The program provides youth with a variety of therapeutic programming and services to support their transition
back to healthy positive futures and reconnection to the normal supports of family, school, community, and
positive peer relationships. Services include case management, referrals and system navigation for community
supports and resources, family support services, experiential learning, mentor opportunity and specialized
classroom settings.

Program Services

2. The mandate of the service is to ensure that the client’s physical, social, medical, emotional, cultural and spiritual
needs are being supported. This service is achieved through a program that provides security and a sense of
belonging as well as developing skills for self sufficiency. The program emphasizes positive interpersonal
relationships, social development, community involvement, life skills and familysupport.

3. The program is to provide a nurturing and safe environment that emphasizes individual growth and development
through positive interactions between the client and the employees. The program promotes and encourages
positive family relationships, daily life skill development, education, recreation and community involvement.

Program Objectives

4. Client’s personal health, safety and general well-being is enhanced.

5. The relationship between the client and their family is enhanced when appropriate.

6. There is an increase in client’s competency in social development skills and emotional regulation.

7. Client’s level of social support and knowledge of community supports are enhanced.

8. Focus on re-engaging education and/or support in gaining full time employment.

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
SCHOOL SUPPORT PROGRAMS – HERA

POLICY: SCREENING AND INTAKES POLICY NO.: I.4.4

DATE ISSUED: ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. The Trellis Hera program follows a formal admission procedure for all clients entering the program.

PROCEDURES

1. Upon the referred client being accepted into the Hera program, the admission procedure will minimally include:

a. An introduction to the other clients at the program;

b. An introduction to program employees;
c. An orientation to the program including all fire and evacuation procedures, transportation options and visitors
and guests;
d. A thorough explanation and a client copy of the Hera program’s services and expectations;
e. The completion of a program intake package and intake meeting with the parents and/or legal guardians, one
Hera program employee, one C.B.E. employee if available and cultural supports when requested;
f. An understanding of the reason for placement and the role and contact information for the Child and Youth
Advocate’s office;
g. Information pertaining to the safeguarding of client personal items and how the program manages items
abandoned by clients;
h. Review of client rights;
i. Information regarding program and community activities and;
j. A clearly defined understanding of the confidentiality policy with regards to client safety and client disclosures.

2. The following admission forms are to be completed at intake:

a. Client Information Sheet;

b. Consent for Services;
c. Consent for Behavior Management;
d. Consent for Release of Information;
e. Grievance Procedures;
f. Client Rights;
g. Permission to Transport Clients;
h. Medication Authorization;
i. Safety Searches;
j. Acknowledgement of Risk;
k. Contract with Youth;
l. Youth Orientation Checklist;
m. Family Connections Worker Confidentiality Agreement;
n. Privacy Statement;
o. Media Consent;
p. Reclaiming Hera.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
SCHOOL SUPPORT PROGRAMS – HERA

POLICY: EMPLOYEE RATIOS POLICY NO.: I.4.5

DATE ISSUED: ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis’ Hera program employs qualified employees to ensure adequate supervision ofthe clients and maintain
safety in the program.

PROCEDURES

1. The supervision of the clients is continuously available. The program must ensure that a minimum of one (1)
TRELLIS employee is available for every ten (10) clients in the program.

2. During day trips and special outings, the program will provide one (1) TRELLIS employee for every (5)
clients inthe program to meet the special or situational needs of the clients.

3. Managers will ensure that adequate supervision is provided to front line employees.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITION

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.5.1

DATE ISSUED: February 16, 1998 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019 CAC

POLICY

1. Clients will be admitted and re-admitted into the Trellis Independent Living and Community Transition Programs
based on the eligibility criteria for the program and program availability. No wait list is maintained for Independent
Living and Community Transition Programs. Notwithstanding this policy, the Program Manager may exercise
some discretion in regards to admissions to allow for special individual cases.

PROCEDURES

1. Client who are admitted into Independent Living and Community Outreach Programs:

a. Are between the ages of sixteen (16) and twenty four (24) unless approval from Contract Manager, Program
Manager, Director and Caseworker; with the exception of the Haven’s Way House Parent side which will
admit females under the age of 16 without Child Intervention status and Aura that accept young people 14-
24.
b. An agreement with Intervention Services is not required for all programs but is required for contracted beds
with the Authority;
c. Are experiencing homelessness or at risk of homelessness, experiencing conflict in the home, community
or at school and for various reasons cannot live at home;
d. Family support and/or community resources are not sufficient to stabilize the client in community without
housing supports;
e. The client is willing to enter into a written agreement with the agency;
f. The client and/or their Caseworker/Guardian have identified the need for supported independent living, and;
g. Have had the opportunity to refuse placement if they feel that the program does not meet their needs.

2. Clients who enter our programs funded by Calgary Homeless Foundation and go through the Coordinated Access
and Assessment (CAC) Committee are assessed by using a Service Prioritization Decision Assistance Tool (VI-
SPDAT) to determine needs and Vulnerability. Clients who have higher acuity scores will receive placement over
clients with a lower score. Once it has been determined that a client is a match for our services, the Housing
Support Worker for the client will be notified within two working days of the match and will make arrangements
for the transfer. The date of the transfer should not exceed ten days from the time the match with the exception
of when the program has a pre-determined move-in date.

3. The referral package should be received and reviewed in reference to the above criteria prior to a decision on
admission being made if there are concerns.

4. In the event the client does not meet the eligibility criteria, the referring source will be advised and a minimum of
3 alternate placements or resources recommended.

5. Trellis advocates for the placement of siblings together when appropriate. If the program is unable to
accommodate this, the program provides opportunities and advocates for regular visits of the siblings.
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: EMERGENCY PLACEMENTS POLICY NO.: I.5.2

DATE ISSUED: February 1, 1997 ASSOCIATED STANDARDS:

CARF – Independent Living
DATE REVISED: May 2019 CARF – Community Transitions

POLICY

1. The Trellis Independent Living and Community Transition programs do not typically accept emergency placements
but may do so under unusual circumstances, specifically if a client has prior involvement with the Agency.

PROCEDURES

1. All emergency placements require that:

a. The client being placed meets the program eligibility criteria for the Agency;
b. If the referral is made by the client’s Intervention Services Caseworker, confirmation of the placement from
a representative of Intervention Services is received;
c. An intake meeting must be scheduled for the day of the intake to review the appropriateness of the
placement;
d. The Program Manager is contacted within twenty four (24) hours of admission;
e. The presence of possible high risk behaviors is assessed upon referral and a High Risk Behavior face
sheet completed and;
f. Appropriate resources are put in place to ensure the safety of the facility and itsclients.

2. In the event that a client does not meet the eligibility criteria, the referring source will be advised and alternate
placements recommended.
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITION

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.5.3

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: April 2018 CAC

POLICY

1. Upon admission to Trellis’ Independent Living and Community Transition programs, an assessment of the
client’s needs/special needs will be completed, and a separate, identifiable and Individual Plan will be developed
within thirty (30) calendar days of admission. The client and their legal guardian * and others relevant to the
Individual Plan are given the opportunity to be fully involved in the development of the client’s Individual Plan.

2. All Indigenous clients, when the family (when applicable) and client agree, have a right to have an Indigenous
Resource Person be involved in the development, implementation and review of the Individual Plan in order to
ensure that the plan is consistent with, and supports the needs of the client and family.

3. The Individual Plan will include:

a. A report based on strengths, needs, abilities and preferences (SNAP) of the client served;
b. the services to be provided, including:

i. the goals to be achieved, as identified by the client;

ii. the tasks/activities/strategies for providing the services and meeting the goals;
iii. individuals involved to support the client;
iv. indicators/measures to determine when goals are met;
v. the effects/involvement of medication and how it affects the individual plan, and
vi. timelines for completion.

4. In the development of Individual Plan, special consideration is given to:

a. the arrangements by which the client’s special needs may be addressed;

b. the services and resources, if any, to be provided by other agencies and the arrangements to be made for
obtaining them;
c. how an effective transition from the program to an alternate program or community setting will be made.

5. The Individual Plan will be reviewed at specific intervals, minimally at 90 days, with the client and the client’s
guardian if applicable, to determine whether the services are adequate or still necessary, or whether another
service or the services of another agency may be needed.

* NOTE: If there is an agreement directly with the client, the client’s involvement in the Individual Plan is to be
sought rather than that of their guardian

PROCEDURES

Service Planning at Admission

1. At intake, a primary assessment is completed. Included, is the determination of the client’s needs and
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITION

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.5.3

recommendations toward the development of their Individual Plan. Information for this report is obtained during
the assessment interview and through contacts with the client, Caseworker (if applicable) and other relevant
support systems where needed and appropriate.

2. The Individual Plan is developed with the client no later than thirty (30) calendar days after the client’s admission
to the program.

3. The client and others relevant to the Individual Plan are given the opportunity to be involved in the development
of the Individual Goal Plan.

4. When a client has Intervention status with Calgary Region Child and Family Services, the Individual Plan is
developed in cooperation with the Caseworker in order to ensure that the plan is consistent with and supports
the goals of the Transition Plan.

5. The Individual Plan and all services provided will give specific consideration to:

a. the client’s culture, language, spirituality, ethnicity, gender identity, sexual orientation and religion are
responsive to the client’s disabilities/disorders or concerns;
b. the resolution of remediation of problems that have necessitated placement;
c. the re-establishment of parental care and maintenance of contact between the family and the client (unless
contraindicated) or the reintegration of the client into the family, natural supports and community;
d. the stability and permanence in the care of the client;
e. the developmental level of the client.

6. The Individual Plan will be signed by the client if 12 or older to indicate participation, as well as by the Caseworker
and parent/guardian. (if applicable)

7. Copies of the Individual Plan are forwarded to the Caseworker and/or guardian (if applicable) with a copy placed
in the client’s personal file. A copy is offered to youth.

Service Plan Reviews/Case Conferences

8. Regular service reviews take place subsequent to the development of the Individual Plan for clients in YTA,
Infinity, Home Fire, Toni’s House and Aura. These reviews will be completed at thirty (30) days and then every
ninety (90) days minimally, dependent on client and program needs.

a. These reviews include those individuals who were involved in the development of the Individual Plan. The
purpose of the review is to evaluate:

i. services and goals;

ii. whether goals are adequate and necessary;
iii. the cultural, religious and spiritual needs of the youth;
iv. tasks/activities/strategies/timelines for meeting goals and providing services;
v. whether another service or the services of another agency may be needed.

A service review may be requested at any time by a client, their guardian or the Caseworker, as well as program
employees.

b. The format will include at a minimum:

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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITION

POLICY: INDIVIDUAL PLANS AND REVIEWS POLICY NO.: I.5.3

i. A review of progress on areas identified in the Individual Plan. Using the information gathered from the
assessment, transition plans and reviews, a brief summary of the goal, work to date, and outcome for
each area is provided;
ii. A review of any new issues or major incidents;
iii. A proposed action plan for the upcoming period based on the review of issues.

The review of progress on identified areas, the proposed action plan and the timelines, together with the minutes
of the meeting, will be given to the Client, Caseworker and/or guardian.

c. To ensure coordination of services outlined in the Individual Plan, communication with other agencies
involved with the client will occur when release of information is obtained.

Assessment and Discharge Planning

9. Following the intake of a client, programs will use an evidence-based assessment tool to inform service planning
goals and priorities. Programs can determine which assessment tool they wish to use to assist in service delivery
planning.
10. An initial assessment will be completed within 30 days of intake). A copy of the completed assessment is kept
on the client file. The client is offered a copy of the assessment upon completion.
11. An assessment will be completed every 90 days following the initial assessment, up to and including 30 days
prior to discharge. If a client is involved in a program for longer than 2 years, assessment may occur every six
months. Copies of the completed assessment are kept on the client file. The client is offered a copy of the
assessment upon completion.
12. If an assessment has not been completed within 30 days prior to discharge a final assessment will be completed
within 10 days. If a final assessment is unable to be completed (e.g. unforeseen, unplanned discharge),
documentation of the reason why is maintained on the client file. A copy of the completed final assessment is
kept on the client file. The client is offered a copy of the final assessment.

13. For Infinity, Home Fire, Toni’s House and Aura clients, in the event of unplanned discharge all efforts will be
made to address behavioral issues and rental arrears, this will be documented, and a copy given to clients.

14. For Infinity, Home Fire, Toni’s House and Aura clients, in the event of unplanned discharge the case manager
will ensure all efforts have been made to facilitate transition to an alternative program. A minimum of 3 appropriate
options will be explored.

Crisis Reviews

15. This review will address either a crisis that has occurred or a proposed adjustment or addition to the current
service or action plan. Consideration of the client’s ability to keep themselves and others safe will be addressed.

16. The format will include a review of the issue and, when necessary, an addendum to the identified individual issues
listed in the Transition Plan and Individual Plan. Depending on the nature and severity of the issue(s), a Crisis
Service Review can occur by a phone conference or in a meeting.
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: PROGRAM SERVICES POLICY NO.: I.5.4

DATE ISSUED: February 15, 1998 ASSOCIATED STANDARDS:

CARF – Independent Living
DATE REVISED: April 2018 CARF – Community Transitions
CAC
POLICY

1. All Trellis programs providing Independent Living and Community Transition Services (e.g. YTA, Infinity, Home
Fire, Toni’s House and Aura) will deliver their contractual services within the parameters of the service definition.
PROCEDURES
Service Definition
1. The program provides supportive living arrangements in community settings based on the client’s needs and
wants. Clients are provided with the supports and resources that help them develop self-sufficiency and
independence. The goal is to assist clients in acquiring the skills and confidence for successful community living.
Program Services
2. The mandate of the service is to ensure that the client’s physical, social, medical, emotional, cultural and spiritual
needs are being supported. This service is achieved through a program that provides security and a sense of
belonging as well as developing skills for self sufficiency. The program emphasizes positive interpersonal
relationships, social development, community involvement, life and living skills and family support.
3. The program is to provide a nurturing and safe environment that emphasizes individual growth and development
through positive interactions between the client and the employees. The program promotes and encourages
positive relationships with family and natural supports, daily life skill development, education, recreation and
community and cultural involvement. If family reunification is not possible, efforts and resources are then directed
toward assisting the client in achieving independence and adult self-sufficiency.
4. Crisis Support – Scattered Site Supportive Housing. The program offers support to clients 24 hours a day and
7 days a week by providing phone numbers for program employees and emergency on call supervisors that can
assist the clients in accessing the resources required during a crisis situation. Clients are also provided a list of
community crisis resources. Clients are given a copy of these resources and a signed and dated copy is kept on
the client file indicating that this has been completed.

5. Move In / Moving Support – Basic and Necessities. Comprehensive, cost-effective move in / moving supports
is planned for by the case management service or via appropriate referral. The case manager should work with
clients to ensure that they have all the basic furniture and necessities in place upon move-in or relocation
(rehousing) or have a plan in place to ensure acquisition begins at the time of move in and is completed within 5
business days.
5.1. All Youth will have the minimum necessities
i. Bed (bedbug protection as necessary)
ii. Utility set up
iii. Basic cookware and dishes
iv. Telephone / cell phone
v. One week’s worth of groceries and toiletries
vi. Initial cleaning supplies

If this cannot be accommodated, documentation of the efforts made, and reasons why not will be kept in the client
file.
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: PROGRAM SERVICES POLICY NO.: I.5.4

DATE ISSUED: February 15, 1998 ASSOCIATED STANDARDS:

CARF – Independent Living
DATE REVISED: April 2018 CARF – Community Transitions
CAC
6. Relocation / Housing. Prior to relocation and / or rehousing, the case manager will support the client in
accessing moving services to ensure loss is minimized. This should be documented in the client file.

Independent Living Objectives

7. Client’s personal health, safety and general well-being is enhanced.
8. The relationship between the client and their family and natural support enhanced when appropriate.
9. There is an increase in client’s competency in independent living and social development skills.
10. Client’s level of social support and knowledge of community supports are enhanced.
11. Focus on completing education and/or support in gaining part-time/full time employment.
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: EMPLOYEE RATIOS POLICY NO.: I.5.5

DATE ISSUED: September 3, 2001 ASSOCIATED STANDARDS:

CARF – Independent Living
DATE REVISED: May 2019 CARF – Community Transitions

POLICY

1. Trellis believe that the individual needs of clients are the most important factor when determining the employee
support required. Dependent upon identified issues and the strengths of the client, employee to client ratios can
be determined more accurately in order to ensure individual needs are addressed.

PROCEDURES

1. Employee to Client Ratios assigned should not exceed ten (10) clients on a full-time case load. If high risk behaviors
have been identified and more extensive support is required, the number of clients on any given case load may
be reduced.
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: SUPPORTIVE ROOMMATES/ HOUSE POLICY NO.: I.5.6

PARENTS/ HOST HOME PROVIDERS

DATE ISSUED: November 1, 2005 ASSOCIATED STANDARDS:

CARF – Independent Living
DATE REVISED: May 2019 CARF – Community Transitions

POLICY

1. Trellis’ Independent Living Program and Community Transition programs will sometimes employ Supported
Roommates based on the needs clients. The Supported Roommates must meet specific criteria before having a
client placed with them.

PROCEDURES

1. The Program Managers will recruit for, interview and hire candidates for this position as per the Recruiting and
Hiring Policy. Supported Roommates who come as per a recommendation must meet all of the criteria.

2. Programs that place clients in support homes will ensure that the following steps have been completed prior to
moving a client into a support home:

a. A screening interview will be conducted with the adult(s) with whom the client will be living;
b. Verification of criminal record checks or a declaration (signed and dated prior to commencement of interaction
with the person served) that criminal record checks having been conducted on all persons 18 years or older
who reside in the household.
c. Criminal record checks that are no older than 6 months can be considered current, and if the criminal record
check does not come back marked “clear.” There must be written documentation indicating the rationale used
to determine that a person served would not be at risk.
d. Verification of other processes required by the contract or funder. Note the following conditions:

i. in Alberta this means verification of Intervention Record Check or a declaration that Intervention Record
Checks have been conducted for all persons that have direct contact with the client served, must be
signed and dated (prior to first contact with clientserved);
ii. Intervention Record Checks that are no older than 6 months can be considered current;
iii. Intervention Record Checks need to remain current, which means they must be renewed every 3 years,
iv. if the Intervention Record Check does not come back marked “clear,” there must be written
documentation indicating the rationale used to determine that a client served would not be at risk.

e. A declaration of confidentiality signed by all adults living in the home;

f. A facilities check that ensures the following:

i. if any person living in the home has any weapon(s) or article(s) that could be used as a weapon (e.g.
guns, ammunition, bows and arrows, darts, etc.), these are secured in a locked cupboard;
ii. any and all guns must be trigger-locked and stored separately from ammunition; and
iii. a safety checklist is provided to ensure a safe environment and that addresses fire safety, safe storage
of all toxic substances, the locked storage of medications, the functionality of smoke detectors,
emergency and evacuation procedures, and universal precaution procedures.

3. Programs will have written contracts with the Supported Roommate that address the relationship and responsibilities
between the client, the program and any landlords with respect to the following elements:
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: SUPPORTIVE ROOMMATES/ HOUSE POLICY NO.: I.5.6

PARENTS/ HOST HOME PROVIDERS

a. Leases and rental agreements;

b. Damage and inspection reports;

c. The safety and suitability of the accommodations and;
d. Access to the residence.
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: SCREENING AND INTAKES POLICY NO.: I.5.7

DATE ISSUED: September 3, 2000 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019 CAC

POLICY

1. Trellis’ Independent Living and Community Transitions Programs follow a formal admission procedure for all
clients entering the program.

2. Programs funded by the Calgary Homeless Foundation accept referrals and placements through Coordinated
Access and Assessment (CAA) Committee. Programs funded by Calgary Region Child and Family Services
accept referrals and placements through Placement Service Office (PSO).

PROCEDURES

1. Waitlists are not maintained for the program. Referrals will be responded to and documented within 5 working
days. If the program is full, clients will be referred to other community resources. Determining the priority of youth
intake into the program will be based on the following factors:

a. If the client has Child Intervention status or has no status;

b. Their current living situation, and;
c. The appropriateness of the open placement based on the client’s developmental needs.

2. Upon the referred client being accepted and re-accepted into the Program, the admission procedure will minimally
include:

a. An introduction to the other clients at the program; if applicable

b. An introduction to program employees and primary case manager;
c. An orientation to the program including all fire and evacuation procedures, transportation options and visitors
and guests;
d. A thorough explanation and a client copy of the Youth Manual, outlining Program’s services and expectations;
e. The completion of a formal intake package and intake meeting with the Caseworker, parents and/or legal
guardians, one program employee and cultural and natural supports whenrequested;
f. An understanding of the reason for placement, the Intervention Services Agreement (if applicable) and therole
and contact information for the Child and Youth Advocate’s office;
g. Information pertaining to the safeguarding of client personal items and how the program manages items
abandoned by clients;
h. The Agency’s policies around the use of tobacco, alcohol and illegal or legal drugs brought into the program;
i. Review of client rights, and;
j. Information regarding program and community activities.

3. The following admission forms are to be completed at intake:

a. Intake Package
b. Client Face and Information Sheet;
c. Delegation of Authority (if applicable);
d. Risk Assessment;
e. Consent for Services;
f. On-Call Contract;
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PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: SCREENING AND INTAKES POLICY NO.: I.5.7

g. FOIP Consent (Infinity, Home Fire and Aura only);

h. Consent for Behavior Management;
i. Personal Belongings Form;
j. Consent for Release of Information;
k. Consent for Medication Administration;
l. Grievance Procedures and;
m. Child and Youth Advocate’s role (YTA)
n. Criteria for Planned and Unplanned Discharge Form (Infinity, Home Fire and Aura only).
o. Confirmation of rights
p. Youth orientation –welcome package sign off
q. Insurance consent
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
INDEPENDENT LIVING AND COMMUNITY TRANSITIONS

POLICY: WORKING ALONE POLICY NO.: I.5.8

DATE ISSUED: ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019 CAC

The Independent Living and Community Transitions teams work alone with clients in the community as part of their
role. The programs have specific procedures in place to ensure the safety of the employees and clients.

POLICY

1. Trellis’ Independent Living and Community Transitions Programs follow a formal risk assessment procedure when
in-taking new clients and have formal check-ins throughout the day when workingalone in the community.

PROCEDURES

1. When a new client is being intaked into a program, two employees will be present for the first visit and complete a
formal risk assessment form. Based on the results of this assessment of low or high risk, it will be determined by
the Program Manager how many employees will be present when working with this client on anon-going basis. In
the event that the anticipated level of risk for the client changes during their service delivery period, a new
assessment will be completed and a recommendation will be made by the Manager.

2. Employees who are working with clients at any level of risk will be responsible to check in with their Manager a
minimum of twice per day including at the end of their shift. This can be done in the form of a text, email or phone
call and will be documented by the Program Manager. In the event that the employee is working after 6pm, they will
be responsible to check in with the Housing On-Call employee.

3. In the event that a Support Worker does not check in with the Manager, the Manager will attempt to contactthe
employee. If there is no response from the employee within 30 minutes, the Manager will contact the Director or
On-Call system.
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PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.6.1

DATE ISSUED: January 2016 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

POLICY

1. Trellis’ Ready, Set, Go! Program is a play-based preschool program for 3 -5 yearold children. The program
takes advantage of the optimum time in a child’s development to encourage and support early literacy,
socialization, creativity, physical growth, problem solving, and emotional literacy. The program provides a
nurturing and safe environment that emphasizes individual growth and development through positive
interactions between the children and the employees.

PROCEDURES

1. Ready, Set, Go! Preschool program is accessible to all children between theages of 3-5. Acceptance will be
based on the eligibility criteria and program capacity.

2. Children admitted into the program must be toilet trained. Children who are 3 years of age but not yet
successfully toilet trained will be asked to return to the program when they are successful at toilet training.

3. If a child requires additional supports that the program cannot provide, the program employees will consult with
the caregivers of the child and make referrals to other more appropriate preschool settings.

4. Children within the preschool program will exit the program naturally as they age out (over the age of 5) and are
ready to transition to Kindergarten. Employees are available to support parents with this decision andtransition.

5. If a child is over the age of 5 but not yet ready for Kindergarten, program employees will consult with the
parents of the child and make referrals to other more appropriate programs for that child.

6. Parents may cancel registration and withdraw their child from the program at any time if they wish, by speaking
to program employees about their decision. The $25 registration fee will not be refunded.
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PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: PROGRAM SERVICES AND POLICY NO.: I.6.2

SUPERVISION

DATE ISSUED: January 2012 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

POLICY

1. All Trellis programs providing licensed preschool will deliver their services within the parameters of the
service definition. The program is to provide a nurturing and safe environment that emphasizes individual
growth and development through positive interactions between the children and the employees.

PROCEDURES

Service Definition

1. The preschool program provides a physically and emotionally safe environment for children from the
community to be able to develop and their own pace in an inclusive and enriching environment.

2. The mandate of the preschool program is to provide preschool experiences for children and their families who
might not otherwise have access to a quality preschool. The program takes advantage of the optimum time in
a child’s development to encourage and support their learning and socialization. The program focus is to prepare
each child for success in kindergarten.

3. The program also provides a parenting component to support the families.

Program Services

4. Licensed preschool programs will provide for the care of twelve (12) or fewer children per each employee.
Where 7 or more children are present, a minimum of 2 employees shall be in the program.

5. Licensed preschool employees will supervise the children’s play at all times, to ensure their safety, well-being
and development. This is done by employees being in appropriate ratio to provide effective supervision and
ensuring that the layout of the physical space is conducive to effective supervision of the children.

6. Preschool employees regularly inspect and clean indoor physical space including the furniture, toys and play
materials to ensure that they are safe and in good repair, developmentally appropriate and are of sufficient quality
and variety.

7. Preschool employees ensure that the children’s safety and well-being are the primary concerns at all times.
Parents are required to sign their child in and out at the beginning and end of each session. Preschool employees
take daily attendance and perform frequent head counts to ensure that all children in attendanceare safe and
accounted for.

8. Parents/guardians are provided with a Parent Handbook upon acceptance in the preschool program. This
handbook provides information specific to the program’s services, policies and procedures. It also outlines the
supervision procedures the teachers utilize to ensure the safety of the children while in the preschool program.
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PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: PROGRAM SERVICES AND POLICY NO.: I.6.2

SUPERVISION

Program Supervision

Observation of children’s play

9. Primary employees will observe children’s play both indoors and outdoors. This will allow employees to learn
about each individual child and their behaviors in order to ensure that they are working proactively with each child
and meeting their individual needs during the time when they are in the program.

Monitoring of the program’s indoor and outdoor environment

10. Primary employees will conduct a thorough inspection at the start of each day to ensure that those areas used
daily or occasionally are clean, safe and ready for use.

Maintaining child safety

11. When children are leaving one area of the program to go to another or to go outside (including entering and
leaving transportation), primary employees will ensure that all children are present by conducting a head count,
using walking leads or conducting a verbal roll call.

Meeting developing needs of children

12. The program will continue to ensure that a play based curriculum is at the forefront of the work by the employees.
This will encompass a combination of teacher initiated activities and free play whilst ensuring that employees are
available at all times for guidance and support and that there are no hazards within the space that will impact the
children or their safety.

Transportation of children from the program

13. If a parent/guardian fails to appear at the designated time for pick up from the program, employees will contact
the guardian/emergency contacted listed on the portable records to have the child picked up from the program.
Employees will remain with the child until they are picked up. If no contact is made the child will remain at the
program and the program procedures for failure to pick up child from program will be adhered to.

Supervision policy information sharing

14. All program policies are available at the program for Parents/guardians to review and ask questions to obtain
clarification. The supervision policy is also included in the parent handbook offered to all parents and is explained
verbally to Parents/guardians during the application and intake process as well as the preschool orientation night.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: CHILD DISCIPLINE POLICY NO.: I.6.3

DATE ISSUED: November 2009 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

POLICY

1. Trellis is designed so that children and families experience an environment where they are safe, secure,
respected and their dignity is protected. The employees/volunteers will use respectful language and
encourage children to solve problems in a positive respectful manner. The children will be encouraged to
understand the consequence of their actions. Problem solving will be part of many activities, notjust discipline
situations.

2. Throughout the year employees and volunteers will continue to work with the children attending the program
regarding behavioral expectations within the preschool. Employees will encourage children to behave
appropriately by having a positive approach in interactions and by providing a stimulating program. At no time
will punitive discipline be used. Disciplinary action taken will be reasonable to the circumstances.

3. TRELLIS prohibits the use of physical restraint, confinement or isolation as a form of child discipline.
Physicalrestraint for the purposes of this policy, is defined as a personal restriction that immobilizes or
reduces the ability of the child to freely move their torso, arms, legs, or head. Brief physical guidance,
instructional prompting, physical support, and comforting are not instances of restraint.

STANDARDS

1. Employees and volunteers in the program will not:

a. deny or threaten to deny any basic necessity;

b. use or permit the use of any form of physical restraint, confinement, or isolation;
c. Inflict or cause to be inflicted any form of physical punishment, verbal or physical degradation or emotional
deprivation.

2. If a child is having behavior difficulty within the program the following steps will be taken:

a. Employees will utilize a strength based approach with the child and discuss what is expected, and give
them positive tools to continue within the program.
b. If the behavior continues, the employee will discuss expectations with the child a second time.
c. If the behavior continues, the child will be removed from the area for a short period of time with an
employee to discuss ways to ensure they will succeed in the program, and to discuss the next steps of
what will happen if they continue with this behavior.
d. If a child continually behaves in a manner that endangers themselves or other children, despite the above
measures, the Program Employee will contact the child’s parents/guardians/emergency contact to pick up
the child from the program. The employee and parents will need to meet together with the child to discuss
the behavior and create a behavior management plan before the child returns to the program.

3. At all times, employees will maintain a fair, consistent and positive approach to children’s behavior. When
children are in conflict with each other, employees will encourage the children to resolve the situation
themselves, but assist as necessary.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: CHILD DISCIPLINE POLICY NO.: I.6.3

4. The child discipline policy is verbally explained to children in the program using developmentally appropriate
terminology. Parents will be made aware of this policy during the registration process and orientation night and
will be included in the program handbook provided to each family.

5. As part of the program orientation process, all program employees will review this policy.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: EMERGENCY EVACUATION POLICY NO.: I.6.4

DATE ISSUED: November 2009 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

Trellis licensed preschool program follows a specific protocol in the event of an emergency evacuation.

POLICY

1. In the event of an emergency within the preschool program, the following steps will be followed:

a. When employees leave the program the emergency contact file will be taken with each child’s personal
information along with the daily attendance sheet.
b. Children are calmly informed to stop all activity and line up by the emergency exit located in the classroom.
c. All children and employees are accounted for.
d. Employees will lead children to the designated location.
e. If need be parents/guardians/emergency contact will be contacted.

2. Under no circumstances will anyone re-enter the building unless otherwise instructed by the Supervisor, or
emergency personnel.

3. Fire and emergency practice drills will be conducted monthly with employees and children within the preschool
program.

4. Practice drill date will be documented on the Monthly Coordinator Report by the Program Coordinator and
submitted to the Program Manager.

5. Emergency protocols and evacuations plans will be posted in all rooms and by all exits.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: HEALTH AND ACCIDENT PROCEDURES POLICY NO.: I.6.5

DATE ISSUED: November 2009 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

POLICY

1. For the health and safety of all the children in the program, children are asked not to attend the preschool
program if the child has ANY of the following symptoms:

a. Fever over 99.5F / 37.5C degrees and is persistent or increasing

b. Head lice
c. Nausea, vomiting or diarrhea
d. Yellow skin or eyes
e. Eye infections, i.e. conjunctivitis (pink eye)
f. Severe cold and/or cough
g. New or unexplained rash with a fever
h. Rapid or difficulty breathing
i. Sore throat with fever or swollen glands
j. Present ear infection
k. Contagious illness such as measles, chicken pox, mumps, etc.
l. If the child requires greater care and attention than can be provided without compromising the care of other
children in the program
m. Having or displaying any other illness or symptoms the employee knows or believes may indicate that the
child poses a health risk to persons on the program premises

2. If a child attends the preschool program and becomes ill, is exposed to or has a contagious disease or is
involved in an accident, a critical incident report will be completed and submitted to the licensing office and the
Program Manager. Employees will perform a visual assessment of a child they suspect is/has become ill and
take their temperature to ascertain for any fever over 99.5F o/37.5C. If there is no clear evidence the child is ill,
employees will continue to watch for changes in behavior of the child and recheck the temperature at a later
time. The critical incident report will minimally include name of child, date and time the child was observed tobe
ill, name of employee identifying the child was ill, time the parent was initially contacted, the name of the
employee who contacted the parent, the time the child was removed from the program and the date the child
returned to the program.

3. Parents are made aware of the program policy around illness during registration, the information is contained in
the parent handbook and the policy is placed on the parent notice board in the classroom.

PROCEDURES

Disease

1. If a child is exposed to or has a contagious disease (as per Schedule 1 of the Communicable Diseases
Regulations, e.g. mumps, chicken pox), they must be immediately removed from the program by a
parent/guardian. All children who become ill or exposed to disease must be symptom free for 48 hours or have
a physicians note prior to returning to program.

2. Employees are required to notify Alberta Health Services and licensing and all other parents of the children who
have been exposed to the disease verbally and/or in written form.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: HEALTH AND ACCIDENT PROCEDURES POLICY NO.: I.6.5

3. Program employees, under direction from the Program Manager, will advise all parents/guardians of any
suspected issues of communicable disease through written and/or verbal communication. Any verbal
conversations with parents/guardians will be documented.

4. A critical incident report will be completed as per policy.

Illness

5. If a child is suspected of becoming ill while in program, employees will assess the child, by using a digital
thermometer to check their temperature, activity level and general physical appearance.

6. If a child becomes ill while at the program, the parent/guardian/emergency contact will be informed immediately
and asked to pick them up immediately.

7. An employee will be assigned to care for the child while ensuring that other children in the program havelimited
exposure to the ill child.

8. If the parent/guardian/emergency contact is unable to arrange immediate removal of the child from program,
the assigned employee will stay with that child until the parent/guardian/emergency contact arrives.

9. All parents/guardians of the children who have been exposed to the ill child will be notified verbally and/or in
writing.

10. The employee must complete a critical incident report for the illness, ensuring that documentation isalso
provided for who contacted the guardian and the time the child was picked up from the program.

11. The employee will document the details of the child and the illness, which will be stored in the child’s file.

12. The child will not be permitted to return to the program until they have been symptom free for 48 hours or a
physician note has been provided by the parent/guardian.

13. If the illness requires emergency medical services and hospitalization, a Government of Alberta incident report
must be completed and faxed to the licensing office. A critical incident report must also be submitted to the
Program Manager.

Accidents

14. In case of emergency or accident, employees will immediately inform the parents/guardian.

15. If the parent/guardian cannot be reached, the emergency contact provided will be informed.

16. The license holder will access medical attention as necessary.

17. All licensed care facilities complete critical incident reports on the individual children in the event of disease,
illness and accidents. These reports are analyzed on an on- going basis to identify trends or issues.

18. Employees will document details of the child and the accident which will be held in the child’s file.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: HEALTH AND ACCIDENT PROCEDURES POLICY NO.: I.6.5

Allergies and Medical Conditions

19. As part of the intake into the program, the parents/guardians will be asked to document any allergies ormedical
conditions that the child has. In the event that there is a child with an allergy or medical condition, program
employees will be made aware and a list of allergies of each individual child will be posted in the employee’s
office.

20. All facilities that house licensed out of child care programs are peanut and nut free.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: OFF-SITE ACTIVITY POLICY NO.: I.6.6

DATE ISSUED: January 2012 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

Trellis licensed preschool program follows a specific protocol in the event of an off- siteactivity.

POLICY

1. All off-site activities are planned in advance as per the Agency’s trip procedures and need written parental
consent in order for the child to participate. This consent will include specifics about the off-site activity
including mode of transportation, supervision arrangements, date of the off-site activity, description of activity,
time of departure from preschool and anticipated time of return.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: NUTRITION POLICY NO.: I.6.7

DATE ISSUED: January, 2012 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

Trellis provide nutritious and balanced snacks and meals to children in licensed preschool facilities.

POLICY

1. Nutritional snacks will be provided on a regular basis in licensed preschool programs.

2. Snack schedules are posted within the licensed preschool that includes time and descriptions of snacks for the
upcoming week.

3. All snacks are required to be conducive with the most current Canadian Food Guide.

4. All meals and snacks will be prepared and stored as per Health and Safety regulations.

5. All meals and snacks are peanut and nut free and take into consideration children’s other allergies and dietary
restrictions.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: PAYMENT FOR LICENSED PRESCHOOL POLICY NO.: I.6.8

DATE ISSUED: November 2009 ASSOCIATED STANDARDS:

Licensed Preschool
DATE REVISED: May 2019

POLICY

1. For licensed preschool programs, families sign a pre-authorized payment agreement, indicating whether they
will be paying on the 1st or the 15th of every month.

2. Families will indicate on the pre-authorized payment agreement if they would like to pay their monthly fees by
cheque, credit card or direct debit.

3. There will be a $25 non-refundable registration fee due at the time of intake.

4. Families are required to apply for subsidy to cover all/some of the costs or pay the monthly fee.

5. Families who do not qualify for subsidy and/or who are unable to pay their fees on a monthly basis must
contact the Program Manager to make alternate arrangements.

6. Invoices are sent to parents on a monthly basis.

7. For those parents who pay fees in whole/part, a receipt will be issued upon payment.

PROCEDURE

1. In the event that a family who does not qualify for subsidy, are late in paying their preschool fees each monthor
the following steps will be taken:

a. Families are sent a reminder invoice stating the amount owing to the program, giving them a month to
either pay the remaining fees, or to contact the Program Manager/Designate to set up a meeting todiscuss
payment options.
b. If the family does not pay their owing fees, or set up a meeting, the Program Manager/Designate will
contact the family via phone or one-on-one conversation to let them know that their fees are overdue. The
Program Manager/Designate and the family will mutually agree upon a time frame within which payment
will be made.
c. In the event that a family isn’t able to rectify the situation finically, and has not been able to come up with a
payment plan that satisfies both the family and TRELLIS, the Program Manager will connect with the Director
of Education and Employment to discuss next steps.

2. In the event that a cheque that is cashed through our agency is rejected due to insufficient funds from the bank,
the same stems as above will be followed.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: PARENT/GUARDIAN VOLUNTEERS AND POLICY NO.: I.6.9

CLASSROOM VOLUNTEERS
(PRESCHOOL PROGRAMS)
DATE ISSUED: January 2016 ASSOCIATED STANDARDS
PEER REVIEW
DATE REVISED: May 2019

All parent/guardian volunteers and classroom volunteers will have a clearly identified preschool employee supervisor
who will be responsible for and support them with submission of volunteer paperwork to People Services, and
direction and evaluation.

This Policy applies to all parent/guardian and classroom volunteers who will be working alongside employees in
the preschool to provide support to enhance program outcomes.

Well planned volunteer roles and supervision will help to ensure the volunteer’s experience is positive for both
the individual, employees, children and youth participants with whom they are working.

** A classroom volunteer is one who has completed level one training certification and undergone agency screening
requirements and can be considered part of ratio on a non-regular basis for licensing purposes. A parent volunteer
is one who supports the classroom teachers with activities and cannot be considered part of ratio for licensing
purposes.

POLICY – Classroom Volunteer

1. People Services shall work with the volunteer to ensure all declarations and/or required screenings and agency
documentation are completed and must include child intervention record check, criminal background check,
agency statement of confidentiality and volunteer agreement.

2. Preschool employees will provide an orientation to the program, including outlining the job description and their
specific roles and responsibilities within in the program.

3. Each classroom volunteer will be responsible to the preschool employee designated for supervision.

4. Classroom volunteers can be left alone with the children once they have undergone the required training
certification and have cleared all agency screening requirements.

POLICY – Parent/Guardian Volunteer

5. Each classroom volunteer will be responsible to the preschool employee designated supervisor of the program.

6. Preschool employees will provide an orientation to the program, including outlining the job description and their
specific roles and responsibilities in the program.

7. Each parent/guardian volunteer will be responsible to the preschool employee designated for supervision.

8. Under no circumstances will the parent volunteers be left alone with the children.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
LICENSED PRESCHOOL

POLICY: PARENT/GUARDIAN VOLUNTEERS AND POLICY NO.: I.6.9

CLASSROOM VOLUNTEERS
(PRESCHOOL PROGRAMS)

PROCEDURES

1. The practice and procedures for both classroom and parent/guardian volunteers will be clearly identified
within the program Parent Handbook which is provided to all parents/caregivers at registration.

2. The preschool employees and program supervisor will be responsible for the development of all parent and
classroom volunteer position descriptions (including roles and duties) and schedules.

3. People Services will ensure all necessary declaration and/or cleared screenings and a statement of
confidentiality are signed prior to the classroom volunteer being in the program. In the event that a volunteer
wants to support the program prior to the screenings coming in, employees will provide activities for the
volunteer that will not involve direct contact with children.

4. All classroom volunteer files will be processed and shall remain with People Services.

5. Parent volunteers will sign in and out on the Parent Volunteer Sign-In Sheet which will be provided prior to
commencement of their volunteer shift.

6. Programs will be responsible for Parent Volunteer recognition. Designated supervisors will liaise with People
Services to ensure recognition is in line with agency practice.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY YOUTH DEVELOPMENT

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.7.1

DATE ISSUED: February 16, 1998 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Clients will be admitted and re-admitted into Trellis’ Community Youth DevelopmentPrograms based on the
eligibility criteria for the program and program capacity.

2. No wait list is maintained for Community Youth Development Programs.

3. Notwithstanding this policy, the Program Manager may exercise some discretion in regards to admissions to
allow for special individual cases.

PROCEDURES

1. Client who are admitted into Community Youth Development Programs:

a. Are between the ages of fourteen (14) and twenty-four (24) unless approval from Contract Manager,
Program Manager, Director and Caseworker;
b. Are experiencing homelessness or involved with street life; at risk or involved in sexual exploitation;
c. Are on the trajectory of accumulating risks that may lead to eventual homelessness and street life;
d. Require one-to-one support in key life areas such as housing, basic needs, employment and education,
health, arts, recreation and/or family support;
e. Have a need for case management and system navigation to find and access community supports and
resources.

2. In the event the client does not meet the eligibility criteria, the referring source will be advised and alternate
referrals will be recommended whenever possible.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY YOUTH DEVELOPMENT

POLICY: PROGRAM SERVICES POLICY NO.: I.7.2

DATE ISSUED: February 15, 1998 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

All Trellis programs providing Community Youth Development (Fusion, Unity) will delivertheir contractual
services within the parameters of the service definition.

POLICY

Service Definition

1. The program addresses the needs of street-involved youth and their families/natural supports by providing them
with support, case management, system navigation, connection and opportunities as they increase their
awareness of resources, personal strengths, skills and possibilities. These needs are met in the context of a safe
and supportive environment and through healthy adult relationships and connection to or back into their
family/natural supports. These activities comprise the key interventions that permit street-involved youth to
reintegrate into community living.

2. The program provides care and services to youth and families in a variety of community settings, such as the
street, shelter, drop-in services, youth justice systems, and alternate educational programs to provide support in
ways not addressed by these programs.

Program Services

3. The mandate of the service is to ensure that the client’s physical, social, medical, emotional, cultural and spiritual
needs are being supported. This service is achieved through a program that provides security and a sense of
belonging as well as developing skills for self sufficiency. The program emphasizes positive interpersonal
relationships, social development, community involvement, life and living skills and family support.

4. The program is to provide a nurturing and safe environment that emphasizes individual growth and development
through positive interactions between the client and the employees. The program promotes and encourages
healthy relationships, daily life skill development, education, employment, housing, recreation and community
involvement.

Program Objectives

5. Client’s personal health, safety and general well-being is enhanced.

6. The relationship between the client and their family is enhanced when appropriate.

7. There is an increase in client’s competency in independent living and social development skills.

8. Client’s level of social support and knowledge of community supports are enhanced.

9. Focus on completing education and/or support in gaining full time employment.

10. Support youth to meet their basic and instrumental needs.

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY YOUTH DEVELOPMENT

POLICY: SCREENING AND INTAKES POLICY NO.: I.7.3

DATE ISSUED: September 3, 2000 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

When clients require formal and on-going supports, the Trellis Community Youth DevelopmentPrograms (Fusion,
Unity) follow a formal admission procedure for intake into the program.

POLICY

1. Upon the referred client being accepted into the Community Youth Development Program, the admission
procedure will minimally include:

a. When applicable, an introduction to the other clients at the program;

b. When applicable an introduction to program employees;
c. When on site an orientation to the program including all fire and evacuation procedures, transportation options
and visitors and guests;
d. A thorough explanation and a client copy of the Community Youth Development Program services and
expectations;
e. When applicable, the completion of a form intake package and intake meeting with the Caseworker, parents
and/or legal guardians, one Community Youth Development employee and cultural supports when requested;
f. An understanding of the reason for referral, the Intervention Services Agreement and the role and contact
information for the Child and Youth Advocate’s officewhen applicable;
g. When applicable Information pertaining to the safeguarding of client personal items and how the program
manages items abandoned by clients;
h. Review of client rights, and;
i. Information regarding program and community activities.

2. The following admission forms are to be completed at intake:

a. Information Sheet;
b. Consent for Services;
c. Individual Goal setting in key life areas;
d. Consent for Release of Information;
e. Grievance Procedures and;
f. Client rights.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY CLUBS

POLICY: HEALTH, ALLERGIES AND ACCIDENTS POLICY NO.: I.8.1

DATE ISSUED: November 2009 ASSOCIATED STANDARDS:

Alberta Public Health Act-Communicable
DATE REVISED: May 2019 Diseases Regulations

POLICY

1. For the health and safety of all the clients in the program, clients are asked not to attend the club program if
they have ANY of the following symptoms:

a. Fever over 99.5F / 37.5C degrees and is persistent

b. Head lice
c. Nausea, vomiting and diarrhea
d. Yellow skin or eyes
e. Eye infections, i.e. conjunctivitis (pink eye)
f. Severe cold and/or cough
g. New or unexplained rash with a fever
h. Rapid or difficulty breathing
i. Sore throat with fever or swollen glands
j. Present Ear infection
k. Contagious illness such as measles, chicken pox, mumps, etc.
l. Having or displaying any other illness or symptom the employees know or believe may indicate that the
client poses a health risk to other club members.

2. If a client attends the club program and becomes ill, is exposed to or has a contagious disease or is involvedin
an accident, an incident report will be completed. Employees will perform a visual assessment of a client they
suspect is/has become ill; If there is no clear evidence the client is ill, employees will continue to watch for
changes in behavior of the client. If the staff have evidence that a client is ill they will all guardians so that the
client may go home.
3. Employees will complete a CIR if a child is sent home due to illness.

4. Parents are made aware of the program policy around illness during registration and club orientation, the
information is contained in the parent handbook.

PROCEDURES

Disease

1. If a client has a contagious disease (as per the Alberta Public Health Act, Communicable Diseases
Regulations, Schedule 1, e.g. mumps, chicken pox), they must be immediately removed from the program by a
parent/guardian and quarantined while awaiting pick up.

2. Program employees, under direction from the Program Manager, will advise Alberta Health Services (as per the
Public Health Act) and all parents/guardians of any suspected issues of communicable disease through written
and/or verbal communication. Any verbal conversations with parents/guardians will be documented.

3. A critical incident report will be completed as per policy.

Illness
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY CLUBS

POLICY: HEALTH, ALLERGIES AND ACCIDENTS POLICY NO.: I.8.1

4. If a client becomes ill while at the program, the parent/guardian will be informed and asked to pick them up
immediately.

5. An employee will be assigned to care for the client while ensuring that other clients in the program have limited
exposure to the ill client.

6. If the parent/guardian is unable to arrange immediate removal of the client from program, the assigned
employee will stay with that client until the parent/guardian arrives. Employees will practice universal
precautions.

7. All parents/guardians of the clients who have been exposed to the sick client will be notified verbally and/or in
writing.

8. Employee will document the details of the illness in the client’s file.

9. The client will not be permitted to return to the program until they have been symptom free for at least 24 hours
or a physician note has been provided by the parent/guardian.

Head Lice

10. Clients found to have lice are to be sent home from the program they are participating in.

11. Once the client is completely free of lice and nits for a minimum of 24 hours (this usually takes about 7 days)
they may again participate in club programs.

12. Notification will be made to all participants in the program, client confidentiality must be maintained.

Accidents

13. In case of emergency or accident requiring medical attention;

a. Club employees will seek medical attention as necessary

b. Employees will seek medical attention as necessary

14. If the parent/guardian cannot be reached, the emergency contact provided will be informed.

15. Accident reports will be analyzed on an on-going basis to assess trends and issues as part of the CIR
evaluation process.

16. Parents/guardians will be informed of any accidents requiring first aid upon pick up.

17. Incidents will be documented and stored appropriately.

Allergies and Medical Conditions

18. As part of the club membership process, parents/guardians will be asked to document any allergies or medical
conditions of the client. In the event that a client has an allergy or medical condition, program employees will
be made aware and a list of allergies of each individual client will be kept for quick reference by employees.

19. All community clubs are nut-aware.

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY CLUBS

POLICY: INTOXICATED PARENT POLICY NO.: I.8.2

DATE ISSUED: October 26, 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. If TRELLIS staff have reason to believe the parent or guardian of a client is intoxicated and may endanger
theclient, the staff are not to release the client to the parent/guardian until they deem it is safe to do so.

PROCEDURES

1. Speak to the parent and ask them if they have alternate transportation home or if the program could get a taxi
for the parent/guardian and client.

2. Call the emergency contact or Alternate parent/guardian listed for the client.

3. If the parent refuses, becomes aggravated and/or leaves with the client, call the police as well as notify the
Program Manager or On-Call Coordinator.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY CLUBS

POLICY: LOST, MISSING OR UNCLAIMED CLIENT POLICY NO.: I.8.3

DATE ISSUED: June 1, 2005

DATE REVISED: May 2019

Trellis ensures that a strict protocol for missing and unclaimed clients in community based programs is adhered to.
Lost or missing incidents are situations where participants become separated from the rest ofthe group to the extent
that there is a loss of visual and/or voice communication.

POLICY

1. During any trips or outings clients are given instruction on what to do if they become lost. Once it is determined
that a client is missing employees will establish the likelihood of the client being lost or being AWOL. If the
client is AWOL employees will implement the AWOL procedures as outlined in the AWOL policy. If the client is
lost or unintentionally missing employees will implement the following:

Missing Client

a. One leader assumes responsibility for the other participants and takes a head count.
b. Other leader seeks to establish: last known whereabouts, what they were wearing, what they were doing,
mental/physical/emotional state, and any known plans for that day, any knowledge of current whereabouts.
c. Leader then organizes a search beginning in the obvious areas – washrooms, shelters, surrounding buildings, meeting
areas, last place client was seen, etc.
d. After ten (10) minutes and a thorough search of the area, if the client has not returned, the searching leader will
contact the Program Manager or On-Call Coordinator and notify them of the situation.
e. If there is reason to believe that the client may have had opportunity to contact parents, staff can call them to check in,
otherwise On-Call and police contact should be initiated first.
f. The Program Manager/On-call Coordinator will call the Police immediately, giving details of the incident including point
and time last seen, description of client, including clothing worn, physical condition, medical condition, personality traits
and circumstances. The Manager/Coordinator may ask the employee at the scene to call the police if they determine that
the information will be better conveyed by the employee at the scene.
g. The Program Mangager/On-call Coordinator will contact the Program Director or On-call Manager.
h. The parents/legal guardians will be notified immediately and given details of the incident.
i. The employee at the scene will follow instructions by the Police which may include additional searches. If it is safe and
practical to do so, the remaining clients should be transported back to the program.

If a client is not picked up from a program at the appropriate time the following will be implemented:

Unclaimed Client

a. The employees will attempt to contact the parent/guardian and notify the Program Manager or On-Call
Coordinator.
b. In the event that the parent/guardian cannot be reached, and fifteen (15) minutes has passed, the
employees will contact the emergency contact listed on the client’s registration form.
c. In the event that the emergency contact AND the parent/guardian cannot be reached, and thirty (30)
minutes has passed, the employees will contact the Program Manager or On-Call Coordinator.
d. The Program Manager or On-Call Coordinator, in consultation with the Director or On-Call Manager, will
determine if a call needs to be made to Children’s Services.
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COMMUNITY CLUBS

POLICY: SEXUAL HEALTH PRESENTATIONS POLICY NO.: I.8.4

DATE ISSUED: April 2000 ASSOCIATED STANDARDS

DATE REVISED: May 2019

POLICY

1. Presentations must be developmentally appropriate for the clients, used for educational purposes only and be
an intentional part of a program.

2. Children aged 12 and under must have parental/guardian written consent prior to participating in presentations.

3. Youth aged 13 and up do not require parental/guardian consent to participate in presentations.

4. Discussions that occur as a normal part of child development, and in the day to day functions of program may
be pursued to a reasonable conclusion without parental consent.

5. If some children/youth are demonstrating acute interest or inquiring about a more complex subject (gender
identification, sexual preference) employees may find it appropriate to refer them to a more specialized
resource such as the TRELLIS LGBTQ2S+ committee ([email protected])
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COMMUNITY CLUBS

POLICY: SLEEPOVERS AND AWAKE-A-THONS POLICY NO.: I.8.5

DATE ISSUED: October 2005 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. During sleepover and/or awake-a-thon events organized by Trellis, it is our responsibility to ensure that all
necessary steps are taken for the safety and comfort of our clients, employees and volunteers. A minimum of 2
employees will be present at ALL times.

2. Planning sleep overs/awake-a must consider staff overtime implications. All plans must be reviewed and
approved by the Program Manager prior to Implementation

3. The minimum required ratio of employees to clients is 1:10 for sleepovers and awake-a-thons. TRELLIS
employees and volunteers will ensure the following planning and precautions are taken prior to hosting such an
event:

a. Written consent from all clients and parent/guardian on file prior to participation.
b. Provision of appropriate private areas for changing.
c. Appropriate supervision and separation for sleeping.
d. Must ensure lights are out to provide the opportunity for a minimum 6 hours sleep forsleepovers.
e. Must ensure parents understand that clients will be awake all night for awake-a-thons and they should
plan accordingly (give the client time to sleep when they get home, etc.).
f. Clients will be provided a list of required items to bring prior to the sleepover (i.e. bedding).
g. Employees/volunteers are to be aware of any bedwetting or sleepwalking concerns and take steps to
address them with the child confidentially.
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COMMUNITY CLUBS

POLICY: BEHAVIOUR MANAGEMENT POLICY NO.: I.8.6

DATE ISSUED: November 2009 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. TRELLIS prohibits the use of physical restraint, confinement or isolation as a form of client discipline.

2. Physical restraint for the purposes of this policy is defined as a personal restriction that immobilizes or reduces
the ability of the client to freely move their torso, arms, legs, or head. Brief physical guidance, instructional
prompting, physical support, and comforting are not instances of restraint.

3. Trellis is designed so that children, youth and families experience an environment where they are safe,
secure, respected and their dignity is protected. The employees/volunteers will use respectful language
and encourage clients to solve problems in a positive respectful manner. Clients will beencouraged to
understand the consequence of their actions. Problem solving is an integral part of all club programming.

4. Employees and volunteers will continually work with the clients attending the program to fully understand
behavior expectations within the club. Employees will encourage clients to behave appropriately by having a
positive approach in interactions and by providing a stimulating program. At no time will punitive discipline be
used. Disciplinary action taken will be reasonable to the circumstances.

PROCEDURES

1. Employees and volunteers in the program will not:

a. Deny or threaten to deny any basic necessity.

b. Use or permit the use of any form of physical restraint, confinement, or isolation.
c. Inflict or cause to be inflicted any form of physical punishment, verbal or physical degradation or emotional
deprivation.

2. If a client is having behavior difficulty within the program the following steps will be taken:

a. Employees will utilize a strength based approach, with the client and discuss what is expected, and give
them positive tools like Social Emotional Learning strategies and skills to continue within the program (this
includes using the client’s name, acknowledging the behavior and stating clear expectations).
b. If the behavior continues, the employee will discuss expectations with the client a second time.
c. If the behavior continues, the employee will discuss expectations with the client a third time.
d. If the behavior continues, the client will cease to participate in the activity for a short period of time and will
discuss with an employee the next steps of what will happen if they continue with this behavior, as well as
ways to ensure they will succeed in the program.
e. If a client continually behaves in a manner that does not meet program expectations, despite the above
measures, the Program employee will contact the client’s parents/guardians to pick up the client from the
program. The employee and parents/guardians will need to meet together with the client to discuss the
behavior and steps/behavior management plan before the client returns to the program.

3. At all times, employees will maintain a fair, consistent and positive approach to clients’ behavior, using SEL
skills and principles. When clients are in conflict with each other, employees will encourage the clients to
resolve the situation themselves, but assist as necessary.
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POLICY: BEHAVIOUR MANAGEMENT POLICY NO.: I.8.6

4. The client discipline policy is verbally explained to clients in the program using developmentally appropriate
terminology. Parents will be aware of this policy verbally during the registration process and it will be included
in the parent handbook provided for each family upon registration.
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COMMUNITY CLUBS

POLICY: SAFE ARRIVAL & DEPARTURE POLICY NO.: I.8.7

DATE ISSUED: November 20, 2013 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Club employees will ensure the safety and well-being of all clients upon arrival and departure.

PROCEDURES

1. Upon arrival to a club program, clients will check in with employees and employees will sign clients in. This
applies to all registered programs.

2. Clients may use the telephone to check-in at home upon arrival to a program at the club.

3. Clients may depart the club once their program is finished.

4. Clients may depart with their parent/guardian or a designate indicated on their membershipform.

5. Parents/guardians may give permission verbally or written for another person to pick up their child from the
program. Permission must be documented with the parent/guardian name, date, and method permission given
(phone, in-person). Such documentation must be kept in the clients file.

6. Employees will ask for identification from any adult picking up a client that is unfamiliar to the staff.

7. If an adult is not a designate or does not have permission to pick up a client, the client will not be permitted to
depart with that adult.

8. If a client has a signed copy of the “Permission to Walk Home Alone” form in their file they may leave the club
without a parent/guardian or other adult present (aside from employees).

9. If an employee deems that it would be unsafe for a client to walk home alone, despite permission to do so,
(e.g. -26C, walk at night in unlighted area, etc.) then the employee will contact the parent/guardian for
guidance.

10. If clients are not picked up on time or it is deemed unsafe for them to walk home alone, and parents are
unreachable, employees will refer to the Missing or Unclaimed Client policy (I.8.5).
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COMMUNITY CLUBS

POLICY: ELIGIBILITY & WAITLIST CRITERIA POLICY NO.: I.8.8

DATE ISSUED: January 2016 ASSOCIATED STANDARDS:

CARF – Screening and Access to Services
DATE REVISED: May 2019

POLICY

1. Clients will access Community Clubs programs based on the eligibility criteria for the specific program and program
availability. Registered programs are generally accessed on a first come first come served basis and once full,
clients may be placed on a waitlist. Drop-in or single session programs are generally accessed until space or
staffing capacity is reached, these programs are not waitlisted. Notwithstanding this policy, the Program Manager
may exercise some discretion in regards to admissions to allow for special individual cases.

PROCEDURES

1. Clients who access Community Club registered programs:

a. Are between the ages of 6 (or in grade 1) and 17 (or in High School) unless an exception is approved by the
Program Manager and Director.
b. Have a current Trellis membership.
c. Have a current registration in one or more specific programs at a Club.
d. Have paid all required fees in full or are current and up to date on their payment plan.

2. Clients who access Community Club drop-in or single session programs:

a. Are between the ages of 12 (or in grade 6) and 17 (or in High School) unless an exception is approved by
the Program Manager and Director.
b. Are accompanied by their parent/guardian if they are between 6 and 11 yearsold.
c. May be required to have a current Trellis membership.
d. Have signed in to the club and provided at minimum emergency contact information.
e. Have paid all required fees of the program in full.

3. Clients may be required to sign in and out (or be signed in and out by a guardian) of the club when attending
specific programs.

4. Clients who may pose a threat to other clients or employees due to uncontrollable anger or aggressive behavior
tendencies will not be eligible for Community Clubs programs without the prior approval of the Program Manager
and a written individual plan for managing behaviors in the Club setting.

5. In the event the client does not meet the eligibility criteria, the client or their parent/guardian will be advised and
alternate programs recommended whenever possible.

6. Whenever possible all attempts will be made to sign clients up as members of Trellis if they are attending
programs more than once in a calendar year.

Waitlists

7. Once the pre-determined maximum number of clients have registered in a specific program the next subsequent
client to register will be first on the waitlist, the next subsequent client to register will be second on the waitlist,
and so on.

8. Waitlists for any specific program will be capped at a maximum of 8 clients.

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COMMUNITY CLUBS

POLICY: ELIGIBILITY & WAITLIST CRITERIA POLICY NO.: I.8.8

9. If a registered client withdraws from the program the first client on the waitlist will be contacted and offered the
vacant spot, provided they meet all eligibility requirements for that program.

10. If the first client on the waitlist cannot fill the vacant spot for any reason, the next client on the waitlist will be
contacted, and so on until the vacant spot is filled.

11. If after contacting all clients on the waitlist the spot remains vacant it may be filled by the next client to inquire
about registering in that specific program.

12. Waitlists will be maintained for the duration of the specific program, once it is completed no record of the waitlist
will be maintained.

13. Being on the waitlist does not entitle the client to any special registration privileges for future offerings of the
specific program or any other Community Club program
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COMMUNITY CLUBS

POLICY: PROGRAM SERVICES POLICY NO.: I.8.9

DATE ISSUED: January 2016 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. All Trellis Community Clubs programs will deliver their services within the parameters of the service definition.

PROCEDURES

Service Definition

1. Community Clubs provide services to clients between the ages of 6 (or currently in Grade One) and 17 (or
currently attending High School) in safe, supportive and supervised environments. Services emphasize age-
appropriate growth and development through positive interactions between clients and employees. Services
focus on engaging clients in positive pursuits during critical out of school time.

2. Community Clubs foster a positive sense of self and healthy Social and Emotional development through learning
and discovery programs, health and well-being, leadership development opportunities and positive connections
to community, as well as family support.

Program Services

3. Community Clubs programs will provide services for clients at a maximum 1:15 ratio, in addition numbers will be
dependent on the capacity of the space available and the type of program being offered (some may be as low as
1:6), and the needs of clients.

4. Learning and Discovery: Community Clubs offers programs and opportunities for clients to develop an affinity
for learning and a sense of curiosity. The program offers support with homework and numeracy and literacy
development, as well as creative expression.

5. Health and Well-Being: Community Clubs offers programs that provide information on physical literacy and
emotional health, and nutrition and basic needs. Programs are also offered that model healthy stress
management and self-regulation.

6. Leadership Development: The program provides leadership development for youth in the program, opportunities
are found in both the Agency and in community settings.

7. Positive Connection to Community: Clubs promote awareness of community issues and resources and support
engagement opportunities that enhance feelings of value and contribution in the community.

8. Family Support: The program provides opportunities for families to be together, and to develop social capital and
community connections. Clubs may also provide referrals to community-based programs that can benefit families
by addressing basic needs, relationships, crisis, growth, and empowerment.
Service Objectives

9. To support children and youth to live a healthy, active lifestyle.

10. To support children and youth through positive relationships with peers, family, positive adults, and other natural
and community supports.
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POLICY: PROGRAM SERVICES POLICY NO.: I.8.9

11. To help children and youth develop self-esteem through engagement in creative arts, recreation, and leadership
development opportunities.

12. To increase clients’ positive sense of self through developing self-efficacy and building hope and optimism.

13. To increase social competencies by developing skills like collaboration, communication and problem solving.

14. To develop healthy emotional competencies such as self-regulation, self-awareness, coping skills and empathy.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

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COMMUNITY CLUBS

POLICY: EMPLOYEE RATIOS POLICY NO.: I.8.10

DATE ISSUED: January 2016 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

1. Trellis Community Clubs employs qualified employees to ensure adequate supervision of clients and maintain
safety in programs.

PROCEDURES

1. The supervision of clients is continuously available. Clubs must ensure that one (1) employee is available for
every fifteen (15) clients in the Club as a minimum standard.

2. Specific programs may reduce this ratio depending on the technical requirements of the program, the space
available, and the needs of the clients.

3. Additional employees will be made available for peak activity periods and specialized programs according to the
needs of clients and employees, and the type of activity. Extra staffing must also be accessible to provide special
or situational needs for clients on a short term, limited engagement basis. For example, those who are aggressive,
struggling to manage their emotions, or who pose a threat to others.

4. Managers will ensure that adequate supervision is provided to front line employees.
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SHELTER SERVICES

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.9.1

DATE ISSUED: February 16, 1998 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Clients will be admitted and re-admitted to the Trellis youth shelter programs based on eligibility criteria.

2. The Shelter programs do not wait list clients but assist clients with securing alternate, appropriate shelter when
they are unable to accommodate them.

Avenue 15

1. Youth experiencing homelessness, ages 12 to 17, with or without Intervention status;

2. Are assessed as having a need for the program;

3. Are willing to contract with the shelter so as to abide by behaviors which prohibit the endangering of self or others,
are willing to follow program expectations and are willing to work on an Individual Goal Plan for services that
develop Individual plans;

4. The client’s health, substance abuse profile if any, and behavior are reasonably within the parameter of the
program’s ability to manage.
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SHELTER SERVICES

POLICY: INDIVIDUAL GOAL PLANS AND POLICY NO.: I.9.2

REVIEWS

DATE ISSUED: June 1, 2005 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Upon admission to Trellis’ Shelter Services, an assessment of the client’s needs/special needs will be completed
and a separate, identifiable and Individual Plan will be developed within seven (7) calendar days of admission.
The client and their legal guardian * and others relevant to the Individual Plan are given the opportunity to be fully
involved in the development of the client’s Individual Plan.

2. All Indigenous clients have a right to have an Indigenous Resource Person be involved in the development,
implementation and review of the Individual Plan in order to ensure that the plan is consistent with, and supports
the needs of the client and family.

3. The Individual Plan will include:

a. A report based on strengths, needs and desires (SNAP) of the client served;
b. the services to be provided, including:

i. the goals to be achieved;

ii. the tasks/activities/strategies for providing the services and meeting the goals;
iii. individuals involved to support the client;
iv. indicators/measures to determine when goals are met;
v. the effects/involvement of medication and how it affects the individual plan, and;
vi. timelines for completion.

4. In the development of the Individual Plan, special consideration is given to:

a. the arrangements by which the client’s special needs may be addressed;

b. the services and resources, if any, to be provided by other agencies and the arrangements to be made for
obtaining them;
c. how an effective transition from the program to an alternate program or community setting will bemade.

5. The Individual Plan will be reviewed at specific intervals, minimally at 30 days, with the client and the client’s
guardian, to determine whether the services are adequate or still necessary, or whether another service or the
services of another agency may be needed.

* NOTE: If there is an agreement directly with the client, the client’s involvement in the Individual Plan is to be
sought rather than that of their guardian.
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SHELTER SERVICES

POLICY: INDIVIDUAL GOAL PLANS AND POLICY NO.: I.9.2

REVIEWS

PROCEDURES

Service Planning at Admission

1. At intake, a primary assessment is completed. Included is the determination of the client’s needs and
recommendations toward the development of their Individual Plan. Information for this report is obtained during
the assessment interview and through contacts with the client, Caseworker and other relevant support systems
where needed and appropriate.

2. The Individual Plan is developed with the client at the Case Conference no later than thirty (30) calendar days
after the client’s admission to the program.

3. The client and others relevant to the Individual Plan are given the opportunity to be involved in the development
of the Individual Goal Plan.

4. When a client has Intervention status with Calgary Region Child and Family Services, the Individual Plan is
developed in cooperation with the Caseworker in order to ensure that the plan is consistent with and supports
the goals of the Transition Plan.

5. The Individual Plan and all services provided will give specific consideration to:

a. the language, spirituality, ethnicity, religious and cultural needs of the clients are met in relation to their
disabilities/disorders or concerns;
b. the resolution of remediation of problems that have necessitated placement;
c. the re-establishment of parental care and maintenance of contact between the family and the client (unless
contraindicated) or the reintegration of the client into the family and community;
d. the stability and permanence in the care of the client;
e. the developmental level of the client.

6. The Individual Plan will be signed by the client if 12 or older to indicate participation, as well as by the Caseworker
and parent/guardian.

7. Copies of the Individual Plan are forwarded to the Caseworker and/or guardian with a copy placed in the client’s
personal file.

Service Plan Reviews/Case Conferences

8. Regular service reviews take place subsequent to the development of the Individual Plan. These reviews will be
completed at thirty (30) days and then every ninety (90) days minimally, dependent on client and program needs.

a. These reviews include those individuals who were involved in the development of the Individual Plan. The
purpose of the review is to evaluate:

i. services and goals;

ii. whether goals are adequate and necessary;
iii. the cultural, religious and spiritual needs of the youth;
iv. tasks/activities/strategies/timelines for meeting goals and providing services;
v. whether another service or the services of another agency may be needed.
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SHELTER SERVICES

POLICY: INDIVIDUAL GOAL PLANS AND POLICY NO.: I.9.2

REVIEWS

A service review may be requested at any time by a client, their guardian or the Caseworker, as well as program
employees.

b. The format will include at a minimum:

i. A review of progress on areas identified in the Individual Plan. Using the information gathered from the
assessment, transition plans and reviews, a brief summary of the goal, work to date, and outcome for
each area is provided;
ii. A review of any new issues or major incidents;
iii. A proposed action plan for the upcoming period based on the review of issues.

The review of progress on identified areas, the proposed action plan and the timelines, together with the minutes
of the meeting, will be given to the Caseworker and/or guardian.

c. To ensure coordination of services outlined in the Individual Plan, communication with other agencies
involved with the client will occur when release of information is obtained.
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SHELTER PROGRAMS

POLICY: PROGRAM SERVICES POLICY NO.: I.9.3

DATE ISSUED: February 15, 1998 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Programs providing youth shelter services will deliver their contractual services within the parameters of the service
definition.

POLICY

Service Definition

1. The programs provide safe, supportive and supervised environments for clients who are experiencing
homelessness or at risk of homelessness. The programs assist clients with determining their goals and supports
the reintegration of the client with their family and natural supports whenever possible. When reunification is
neither appropriate nor practical, the programs support skill development associated with adult self-sufficiency to
promote integration into independent community living.

Program Services

2. Crisis Shelter: The shelter offers a safe and supportive environment for clients that provides access to basic
needs.

3. Crisis Support: All clients using services will receive support to assist them through the crisis situation. Clients
whose emotional needs exceed that of the program employees will be assisted in finding appropriate community
resources.

4. Family Mediation and Support: All clients and families will be supported with family reunification and preservation
when deemed appropriate and safe.

5. Education and Employment: The shelter will assist clients in returning to school or finding employment. The
employees will advocate on the client’s behalf around issues pertaining to gaining entrance into school,
suspensions and supports needed.

6. Referral Resource: The shelter will assist clients and families in locating appropriate community resources to best
suit the needs for community living. Employees will also advocate for services in our continuum of care when
appropriate to do so.

7. Repatriation: The shelter will assist clients who have become separated from their home and family. The shelter
will provide shelter for these clients until they can be safely repatriated to their permanent home.

Service Objectives

8. To provide short and medium term living arrangements for youth who are experiencing homelessness.

9. To enhance positive relationships with family and other natural and community supports.

10. To increase client’s knowledge and access to resources appropriate to their individual circumstance.

11. To identify and work towards the client’s goals.

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YOUTH SHELTERS

POLICY: SCREENING AND INTAKES POLICY NO.: I.9.4

DATE ISSUED: September 3, 2000 ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Trellis’ Shelter Programs follow a formal admissions procedure for clients entering the program.

2. Clients entering the program do so voluntarily and must agree to be an active participant in the program. Access
to programs are based on a first-come, first-serve basis unless otherwise directed by the Placement Services
Office of Calgary Region Child and Family Services for contracted beds.

PROCEDURES

1. Employees will assess the youth’s present circumstances using admin/re-admit information.

2. Employees will provide the youth with information pertaining to the expectations of the program. This shall include,
but not be limited to:

a. Program expectations;
b. Routines and responsibilities;
c. Evacuation and emergency procedures;
d. Safeguarding personal items and how the program manages items abandoned by clients;
e. The Agency’s policies around the use of tobacco, alcohol and illegal or legal drugs brought into the
program;
f. Grievance procedure;
g. Access to Child and Youth Advocate’s office or other advocates, and;
h. Client rights to be involved in their case planning.

3. Employees will provide assistance with obtaining alternate resources should the youth not be admitted into the
program.

4. Intake package completed with the client and consent for services obtained. Employees will ensure that any
cultural or spiritual practices of the client are supported and will assist the youth in accessing these supports in
the agency or the community.

5. Clients are provided with a program orientation.

6. The employees will notify parent/legal guardians within 24 hours of the client’s admission. In addition, SACIS
(Southern Alberta Children Intervention Services) 403-297-2995 will be notified so that they can determine if the
client has status or is in need of support with CFSA. The program employees will share any pertinentinformation
with the parent/legal guardian relating to the client’s admittance, or as soon as possible after admittance when
appropriate and safe to do so.

7. If employees have doubts about the identity of client, they should notify SACIS or the Calgary Police in an attempt
to verify identity.
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YOUTH SHELTERS

POLICY: EMPLOYEE RATIOS POLICY NO.: I.9.5

DATE ISSUED: September 3, 2001 ASSOCIATED STANDARDS:

DATE REVISED: May 2019

Trellis’ Youth Shelter programs employ qualified employees to ensure adequate supervision of the clients and
maintain safety in the program.

POLICY

1. The supervision of the clients in the shelter is continuously available. The program must ensure that a minimum
of one (1) employee is available for every twelve (12) clients staying at the shelter.

2. Additional employees may be made available for peak activity periods according to the needs of the clients and
the employees. If a client enters the program that requires additional support due to situational, behavioral or
medical needs, every effort will be made to ensure extra staffing is available, either through the program, a
community resource or Calgary Region Child and Family Services.

3. Managers will ensure that adequate program orientation, training and on-going development is provided to front
line employees.
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BUILDING YOUTH CONNECTIONS

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.10.1

DATE ISSUED: ASSOCIATED STANDARDS:

CARF – Screening and Access
DATE REVISED: May 2019

POLICY

1. Clients accessing Building Youth Connections (BYC) must be between the ages of 12 and 24 years old. Youth
under the age of 12 and over the age of 24 are ineligible for Building Youth Connections services. All efforts will
be made to refer ineligible youth to an appropriate community program that addresses their needs.

2. When a current BYC client turns 25, they age out and become ineligible for BYC services. TRELLIS and
BYC encourage youth who have turned 25 to continue to stay connected with TRELLIS. Youth are invited to
learn about volunteer opportunities and other ways to be involved with TRELLIS and BYC, in accordance
with agencypolicy C.4.1 section 5.d Previous Client Volunteers.

3. Immigrant and refugee youth with permanent resident (PR) status of landing papers must provide their
immigration, Refugees, and Citizenship (IRCC) identification number (UCI/FOSS ID). In order to receive one on
one settlement coaching services youth must have PR status with IRCC and provide their card number.

4. All new clients will complete a program intake package in order to obtain program membership; information
gathered in entered onto the program database. In addition, members will be introduced to the program
welcome package which outlines important information. Employees will provide the youth with an overview of
this information. This shall include:

a. Intake Form
b. Consent to Release Information (as needed)
c. Permission to Transport ( when required)
d. Grievance Procedure
e. Confirmation of Youth Rights
f. Privacy and FOIP Statement
g. Safety Search Form
h. Program Specific Contract
i. Acknowledgement of Risk
j. Media Consent Form
k. Emergency Procedure Guidelines
l. Consent for Services
m. Program Orientation

5. Program membership is required for regular access to the program. Prior to membership, new clients must
sign in and provide emergency contact info in order to access services.

6. After a membership is obtained, clients will be asked to sign in upon every visit.

7. Clients of the program will also be asked to complete satisfaction surveys and Pre and Post Surveys for both
the Agency and funders at regular intervals throughout the year, as well as participate in intermittent file
reviews in order to ensure that information is up to date.

8. Trellis is designed so that children, youth, and families experience an environment where they are safe,
secure, respected, and their dignity is protected. The employees and volunteers will use
respectful language and encourage clients to solve problems in a positive and respectful manner. Clients will
be encouraged to understand the consequences of their actions. Problem solving is an integral part of all
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BUILDING YOUTH CONNECTIONS

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.10.1

programming.

9. Employees and volunteers will continually work with youth to fully understand behavior expectations within the
program. Employees will encourage client to behave appropriately by having a positive approach in interactions
and by modelling respectful behavior. At no time will punitive discipline be used. Disciplinary action taken will be
reasonable to the circumstances.

PROCEDURES

1. If a client is having behavior difficulty or acts in a way that is contrary to the BYC guidelines set out, the
following steps will be taken:

a. Employees will utilize a strength based approach with the client and discuss what is expected and give
them positive tools to continue with the program. All conflict events are documented by following CIR
procedure and are stored electronically.
b. If the behavior continues, or if there are reoccurring infractions of the guidelines, employees and/or
program manager will discuss expectations with the client a second time. Access to services may be
suspended for the remainder of the day.
c. In the event of extreme or severe violent and/or illegal behavior that puts our members and employees at
risk, we reserve the right to revoke service privileges for BYC and youth will no longer be permitted to
participate in program, or be in program space. In this event, all efforts to refer youth to an appropriate
resource for their continued needs, will be made. For all youth who are ineligible for continued service a
CIR will be completed and a form submitted on Sharevision under “Clients Turned Away,” with a
description of the unacceptable behavior and efforts to maintain services for the youth.

2. All children and youth being served by Trellis are encouraged to express to a third partyany concern or
disagreement they have in regards to treatment by any of the program employees. In their role as advocate,
program employees will act promptly to ensure that children/youths are assisted through the process to
expedite resolution of the situation. The procedure for voicing concerns is outlined in the Grievance Procedure
form which is provided by the program to youth upon intake; additional copies are available at any time by
request.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
BUILDING YOUTH CONNECTIONS

POLICY: PROGRAM SERVICES POLICY NO.: I.10.2

DATE ISSUED: ASSOCIATED STANDARDS:

DATE REVISED: May 2019

POLICY

Service Definition

1. The program provides supportive services and programs for clients who are ages 12 to 24 with specific support
services for youth who are new to Canada. The program assists clients to determine their goals and the supports
they require to successfully integrate into their community. Building Youth Connections (BYC) specifically
provides support for education, employment, social emotional learning, community connections and well-being.

Program Services

2. Educational Support and Tutoring: BYC offers support and advocacy for youth to experience academic success.
The program offers support with homework and will assist clients in finding an educational setting that meets their
needs.

3. Pre-Employment Resources and Support: Clients can access support with resume building, job searching,
interview skills and employment standards information. The Employment Facilitators assist youth to develop the
skills and supports required for successful transition into an employment setting.

4. Health and Well-Being: BYC offers clients access to community referrals for basic needs. In addition, the
program provides information on physical, emotional and sexual health as well as referrals to community-based
programs that may benefit the clients.

5. Creative Arts and Recreation: BYC offers structured drop-in programming that focuses on creative expression
through the arts, including a music studio. In addition, the program offers access to positive recreational activities
that engage the clients in social emotional learning.

6. Leadership Development: BYC provides leadership development and volunteer opportunities for youth in the
program, in both the Agency and community settings.

7. Advocacy and One to One Support: BYC provides one on one settlement coaching for newcomer youth and
referrals to other programs and services that support the youth and families with basic needs, system navigation,
and translator/interpreters for court appearances, school registration, police, worker’s compensation, and other
areas as needed that reduce the barriers to successful integration.

Service Objectives

8. To support clients with education, employment and community connections and to assist in identifying and
working towards the client’s unique goals and integration.

9. To enhance positive relationships with peers, family and other natural and communitysupports.

10. To increase client’s self-esteem and social emotional learning through their engagement in creative arts,
recreation, community connections and leadership development opportunities.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
WORK EXPERIENCE PROGRAM - STAMPEDE

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.11.1

DATE ISSUED: ASSOCIATED STANDARDS:

Peer Review
DATE REVISED: May 2019

POLICY

1. Trellis’ Stampede Work Experience Program is offered in partnership with the Calgary Exhibition and Stampede.
The program focuses on providing the opportunity for youth to learn valuable work experience skills in a supportive
environment. The Stampede Work experience program focuses on interviewing techniques, resume and
application writing, employability skills and work ethic. Youth will be accepted into Trellis’ Stampede Work
Experience Program based on eligibility criteria for the program and program availability. A waitlist may exist to
access this work experience program.

PROCEDURES

1. Youth who are admitted into the Work Experience Program:

a. Must be 12 years or older by a date that precedes the first orientation as determined by the Stampede
Committee;
b. All applicants must have a Social Insurance Number or a receipt (proof that they have applied for a
number);
c. Youth under 18 must have parent/guardian permission to work. This permission is documented on the youth’s
application form. For youth between the ages of 13 and 15 this may also require a work permit through Labor
Standards as determined by the provincial government.
d. All successful applicants must be available to work all 11 days of Stampede, including Sundays;
e. Are looking for a work experience opportunity to gain employability skills, such as interviewing, resume
writing, teamwork, respect, goal setting, responsibility and work ethics;
f. Wages are set in collaboration with both Trellis and Stampede.

2. In the event that a youth is selected for an interview but is not successful in obtaining a position in the Work
Experience Program, they will be given feedback as to why they are not suitable and be encouraged to reapply
again for the following year. Youth may also be placed on a waitlist for the current year in the event that a position
becomes available.

3. Due to the volume of applicants, only those selected for an interview will becontacted.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
WORK EXPERIENCE PROGRAM - STAMPEDE

POLICY: RECRUITMENT POLICY NO.: I.11.2

DATE ISSUED: ASSOCIATED STANDARDS:

Peer Review
DATE REVISED: May 2019

POLICY

1. Youth will go through a standardized employment recruitment process to be accepted into Trellis’
Stampede Work Experience Program.

PROCEDURES

1. Stampede Community members give informational recruiting and job skills talks at locations across the city. The
talks are designed to inform youth about the Stampede Work Experience Program, the requirements to apply,
how to fill out an application form as well as provide interview hints. Youth who attend a talk will receive an
advanced application, which may provide a benefit when interview selections are made.

2. Applications must be in the Stampede mail box at Renfrew according to the date put forth by the Stampede
Committee.

3. All applications must be filled out in full and include a youth resume to be considered complete. Incomplete
applications will not be considered.

Application Forms

1. Supervisors will receive the application forms from their Manager prior to the interview dates.

2. Selected applicant will be contacted and an interview time arranged.

3. All youth must ensure that they have a valid Social Insurance Number and that the employee and
parent/guardian declarations and release forms have been signed accordingly.

4. If supervisors wish to refer applicants, they must do so through their Manager. Outside referrals cannot be
given priority over agency referrals.

5. Youth must apply for positions as per the ages indicated on the application form. Youth cannot request different
positions or work times. The Stampede Committee may move successful applicants from crew to crew may
occur in order to fill all positions on all crews.

6. All application forms that are not selected for an interview are not kept on file but destroyed according toTRELLIS
standards and FOIP.

Interview Schedule

1. A predetermined date and set of times will be given to each supervisor and interviews must be held within that
time frame. If a youth is unable to make the interview, a phone interview may be an option.

Arranging the Interview

1. Supervisors will contact each successful applicant to arrange a fifteen minute interview. The interviews should be
conducted on the date and between the times arranged by the respective manager.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
WORK EXPERIENCE PROGRAM - STAMPEDE

POLICY: RECRUITMENT POLICY NO.: I.11.2

Assessment of the Applicant

1. Each applicant will be assessed according to the following criteria:

a. Completion of the application form and inclusion of resume

b. Professional appearance
c. Amount of work or volunteer experience
d. Involvement in extra-curricular activities, including TRELLIS program membership and involvement
e. Prior work experience with the Stampede and applicable supervisors references
f. Responses to situational questions
g. Employment readiness
h. General

Hiring

1. Youth who are offered a position must be able to work all 11 days and attend training. Youth who are unable to
commit to these days cannot be hired.

2. All successful applicants will receive an email of confirmation detailing the position, hours of work, TD-1 form,
date, time and location of training, and, when required, work permit. These documents must be completed in full
and returned to their supervisor on training night.

3. Interviewed youth who are not successful in obtaining a position will be informed by their supervisor. Feedback
will be given to the applicant about why they were not successful and what they can do to improve chances to
be considered for the following year.

Waiting List

1. Unsuccessful applicants may be asked to be part of the waitlist in case a position opens becomes available.
Waitlist candidates will be those who have been assessed as meeting the criteria for the position.

2. Waitlist applicants are not guaranteed a position.

3. Waitlists are managed by Stampede Committee members. Information regarding the size and specific position
of individual applicants is not available to supervisors, applicant, or anyone outside of thecommittee.

Email

1. All confirmation of hire and required documentation will be sent by email. Youth are responsible for creating
and checking a valid email address regularly.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
WORK EXPERIENCE PROGRAM - STAMPEDE

POLICY: SUPERVISION POLICY NO.: I.11.3

DATE ISSUED: ASSOCIATED STANDARDS:

Peer Review
DATE REVISED: May 2019

POLICY

1. Trellis Stampede Work Experience Program employs qualified adult supervisors to ensure adequate
supervision of the youth and to maintain safety in the program.

2. Supervisors must be eighteen (18) years of age or older before a date that precedes the first supervisor
orientation, as determined by the Stampede Committee.

PROCEDURES

1. Youth aged thirteen (13) will be in groups of five (5); youth aged fourteen (14) will be working in groups of six
(6), and will be in constant audio and visual contact with their Supervisor.

2. Youth fifteen (15) years of age will be working in groups of eight (8), and will be in regular audio and visual
contact with their Supervisor, but permitted to work in pairs independently until 9 pm.

3. Youth aged sixteen (16) to seventeen (17) will be working in pairs, and remain in constant radio contact with their
Supervisor. Eight (8) youth are assigned per Supervisor. After 9 pm, these youth will be in constant audio and
visual contact with their Supervisors until the end of their shift.

4. Night Crew Employees, aged eighteen (18) and over will be working in pairs, but remain in constant radio
contact with their Supervisor. Up to fifteen (15) Night Crew Employees may be assigned to one Supervisor.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY OUTREACH PROGRAMS

POLICY: ELIGIBILITY CRITERIA POLICY NO.: I.12.1

DATE ISSUED: January 2016 ASSOCIATED STANDARDS:

Peer Standards
DATE REVISED: May 2019

POLICY

1. Clients will be admitted and re-admitted into Trellis’ Community Support Programs based on the eligibility
criteria for the program and program capacity.

2. A waitlist may be maintained for the Pursuit program, when program has reached capacity.

3. Notwithstanding this policy, the Program Manager may exercise some discretion in regards to admissions to
allow for special individual cases.

PROCEDURES

1. Client who are admitted into Community Outreach Programs will meet the following criteria:

a. All In for Youth

Eligible youth can be referred into this program by Calgary Board of Education, Calgary Catholic School
Division, other TRELLIS Programs, community members, guardians, by peers or may make self-referrals.
Youth must be eligible for enrollment in high school classes at the school where the referral is made to,
attending that school in the upcoming semester (or have recently transitioned out of that school). Youth meet
with the Success Coach on an as needed basis. Current youth exit the program by completing or leaving
high school. Youth can also exit the program by choice at any time. Youth may also transition out of the
program to another community service provider.

b. Raise the Grade

Youth accepted into this program must be in junior high or high school and have the willingness to participate
in tutoring and mentoring. Acceptance into RTG will be based on availability and program capacity.

c. Pursuit
The goal of the Pursuit program is to prevent youth homelessness and ensure that previous experiences of
homelessness are the last through meaningful employment. Therefore, youth accepted into this program
must be referred by another TRELLIS program, and be supported by a key worker. Youth must be willing to
meet with their employment coach and set and work towards long term employment goals. Youth must be
between the ages of 15 and 24 years.

d. HireUp
Youth must be referred by an Alberta youth serving agency, supported by a youth worker-and may be
between 16 to 29 years of age. Youth must be interested in making and working towards employment goals.

2. In the event the client does not meet the eligibility criteria, the referring source will be advised and alternate
referrals will be recommended whenever possible.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
COMMUNITY OUTREACH PROGRAMS

POLICY: PROGRAM SERVICES POLICY NO.: I.12.2

DATE ISSUED: January 2016 ASSOCIATED STANDARDS:

Peer Standards
DATE REVISED: May 2019

All Trellis’ programs providing outreach services will deliver their contractual services within the parameters of the
service definition.

POLICY

Service Definition

1. The programs address the needs of children, youth and families as per the eligibility criteria. Community Outreach
programs provide support to meet the individual needs of the clients by providing them with case management,
system navigation, connection and opportunities as they increase their awareness of resources, personal
strengths and skills. These needs are met in the context of a safe and supportive environment and through healthy
adult relationships. These activities comprise the key interventions that permit children, youth and families to build
their own capacity and work towards self-sufficiency.

*The programs provide care and services to children, youth and families in a variety of community settings,
such as in schools, Clubs and community settings.

Program Services

2. The mandate of the services is to ensure that the client’s physical, social, medical, emotional, cultural and spiritual
needs are being supported. This service is achieved through programs that provide security and a sense of
belonging as well as developing skills for self sufficiency. The programs emphasize positive interpersonal
relationships, social development, community involvement, life and living skills and family support.

3. The programs provide nurturing and safe environments that emphasizes individual growth and development
through positive interactions between the client and the employees.

Program Objectives

4. Client’s personal health, safety and general well-being is enhanced.

5. The relationship between the client and their natural supports are enhanced where appropriate.

6. There is an increase in client’s competency in school completion and social development skills.

7. Client’s level of social support and knowledge of community supports are enhanced.

8. Support youth to meet their basic and instrumental needs.

9. Be a strong advocate for the youth within their respective program placements.

10. Youth are connected to meaningful employment and/or volunteer opportunities when appropriate.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
IIYIKA’KIMAAT

POLICY: ELIGIBILITY AND WAITLIST CRITERIA POLICY NO.: I.13.1

DATE ISSUED: July 20, 2016 ASSOCIATED STANDARDS:

CARF – Screening and Access to Services
DATE REVISED: May 2019

POLICY

1. Clients will have access to the Iiyika’kimaat based on eligibility criteria for the specific program and program
availability. Program starts in September of each calendar year and is based on a first come first serve basis and
is based on continuous intake. Based on identified number for that program, once the program is full, client(s) will
be placed on a waitlist.

PROCEDURES

1. Notwithstanding this policy, the Program Manager may exercise some discretion in regards to admissions to
allow for special individual cases.

2. Clients who access the Iiyika’kimaat program:

a. Are between the ages of 12 – 21 years of age unless an exception is approved by the Program
Manager and Director;
b. Self-identify at First Nations, Métis or Inuit descent;
c. Have signed in and at minimum provided at a minimum emergency contact information.

3. Clients are required to sign in and out (or be signed in and out by a guardian) of the Lodge when attending
Program.

4. Clients who may pose a threat to other clients and employees due to uncontrollable anger or aggressive behavior
tendencies will not be eligible for the Iiyika’kimaat program without the prior approval of the Program Manager and
a written individual plan for managing behavior’s in the Lodge setting.

5. In the event the client does not meet the eligibility criteria, the client or their parent/guardian will be advised and
alternate program recommendations will be made whenever possible.

6. If a client transitions out of the Iiyika’kimaat program (i.e. ages out of the program), the client will be asked to
complete relevant program completion forms and be offered information about available community supports or
volunteer opportunities.

7. Wherever possible all attempts will be made to sign clients up as members of Trellis,if they are attending
programs more than once in a calendar year.

8. If a client choses to exit the specific Iiyika’kimaat program delivery, clients will be asked to complete relevant
completion forms and be offered information about relevant community supports and referrals.

Waitlists

9. Once the pre-determined maximum number of clients have been registered in the Iiyika’kimaat program, a
waitlist will be established on a first come first serve basis.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
IIYIKA’KIMAAT

POLICY: ELIGIBILITY AND WAITLIST CRITERIA POLICY NO.: I.13.1

10. If a registered client withdraws from the program, the first client on the waitlist will be contacted and offered the
vacant spot, provided they meet all eligibility requirements for Iiyika’kimaat.

11. If the first client on the waitlist cannot fill the vacant spot for any reason, the next client on the waitlist will be
contacted, and so on until the vacant spot it filled.

12. Waitlists will be maintained for the duration of the current Iiyika’kimaat year program, once it is completed no
record of the waitlist will be maintained.

13. Being on the waitlist does not entitle the client to any special registration privileges for future offerings of the
specific program or any other Indigenous Initiatives program.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
IIYIKA’KIMAAT

POLICY: PROGRAM SERVICES POLICY NO.: I.13.2

DATE ISSUED: July 20, 2016 ASSOCIATED STANDARDS:

CARF –
DATE REVISED: May 2019

POLICY

1. Iiyika’kimaat will deliver their services within the parameters of the service definition below.

PROCEDURES

Service Definition

1. Iiyika’kimaat provides services to clients between the ages of 12-21 years of age in a safe, supportive and
supervised environment. Services emphasize age-appropriate growth and development and culturally
appropriate practices through positive interactions between clients, elders and employees. Services focus on
engaging clients in positive, culturally appropriate activities during critical hours, during school breaks, and during
evenings.

2. Iiyika’kimaat fosters positive social and emotional development through cultural mechanisms via ceremony,
health and well-being, intentional learning and leadership development that is integrated into programming to
provide youth with a sense of identity, resiliency, self-esteem, coping skills, knowledge, and healing. The majority
of activities will be delivered at the “Lodge”, with field trips to cultural sites in Calgary and the surrounding area,
with exceptions.

Program Services

3. The Iiyika’kimaat program will provide services for clients at a maximum 1:15 ratio, in addition, numbers will be
dependent on the capacity of the space available and the type of program being offered (some may be as low
as 1:6) and the needs of the clients.

4. The Iiyika’kimaat program is delivered in four phases through a 10 month timeframe (based on Dr Martin
Brokenleg’s Circle of Courage). Each phase has a traditional principle being: Belonging, Generosity, Mastery,
and Independence. Program components include (but may not be limited to): Fall Solstice teachings, leadership,
responsibilities and roles with regular Turtle teachings (girls) and Wolf Den teachings (boys), language, regalia
and traditional dress/responsibilities; animal teachings (medicine bear, kinship wolf), sweat lodge protocols,
smudge, sharing circles (debriefs) and peer mentoring. All teachings and cultural aspects include strong Elder,
culture and family involvement.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
IIYIKA’KIMAAT

POLICY: ACCIDENT PREVENTION FOR POLICY NO.: I.13.3

CLIENTS

DATE ISSUED: July 20, 2016 ASSOCIATED STANDARDS:

CARF –
DATE REVISED: May 2019

POLICY

1. It is the responsibility of the employees to ensure that the environment is safe and free of hazards.

PROCEDURES

1. Employees are required to have a First Aid kit available at all times. The contents of the First Aid kit must meet
the requirements provided in the TRELLIS Emergency Response Manual.

2. To ensure the safety and wellbeing of all young people associated with Trellis,all direct service employees will
hold the required certifications for their position as per their job description, thatincludes First Aid and CPRC
training (as per policy C.3.13).

3. It is the employee’s responsibility to be aware of each client’s medical history.

4. Employees must have access to a complete list of clients with the following information: Name, address, phone
numbers of parents/guardians, Alberta Health Care number and alternate contact person.

5. Clients whereabouts, while in program (on and off site), should be known at all times.

6. Sign in and sign out from programming is required by clients.

 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
IIYIKA’KIMAAT

POLICY: HEALTH AND ACCIDENT POLICY NO.: I.13.4

PROCDEDURES

DATE ISSUED: July 20, 2016 ASSOCIATED STANDARDS:

CARF –
DATE REVISED: May 2019

POLICY

1. For the health and safety of all the clients in the program, clients are asked not to attend the Iiyika’kimaat
program if they have ANY of the following symptoms:

a. Fever over 99.5F / 37.5C degrees and is persistent;

b. Head lice;
c. Nausea, vomiting and diarrhea;
d. Yellow skin or eyes;
e. Eye infections, i.e. conjunctivitis (pink eye);
f. Severe cold and/or cough;
g. New or unexplained rash with a fever;
h. Rapid or difficulty breathing;
i. Sore throat with fever or swollen glands;
j. Present ear infection;
k. Contagious illness such as measles, chicken pox, mumps, etc.;
l. Having or displaying any other illness or symptom the employees know or believe may indicate that the
client poses a health risk to other program members.

2. If a client attends the Iiyika’kimaat program and becomes ill, is exposed to or has a contagious disease or
is involved in an accident, an incident report will be completed. Employees will perform a visual assessment of
a client they suspect is/has become ill; take their temperature to ascertain for any fever over 99.5F/37.5C. If
there is no clear evidence the client is ill, employees will continue to watch for changes in behavior of the client
and recheck the temperature at this time. This report will minimally include name of client, date and time the
client was observed to be ill, name of employee identifying the client was ill, time the parent/guardian was
initially contacted, the name of the employee who contacted the parent/guardian, the time the client was
removed from the program and the date the client returned to the program.

3. Clients and Parents/Guardians are made aware of the program policy around illness during registration
and program orientation, the information is contained in the parent handbook.

PROCEDURES

Disease

1. If a client is exposed to or has a contagious disease (as per Schedule 1 of the Communicable Diseases
Regulations, e.g. mumps, chicken pox), they must be immediately removed from the program and quarantined
while awaiting pick up by a parent/guardian.

2. Employees are required to notify Alberta Health Services and all other parents/guardians of clients who may
have been exposed to the disease, verbally and/or in written form.

3. Program employees, under direction from the Program Manager, will advise all parents/guardians of any
suspected issues of communicable disease through written and/or verbal communication. Any verbal
conversations with parents/guardians will be documented.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
IIYIKA’KIMAAT

POLICY: CLIENT DISCIPLINE POLICY NO.: I.13.5

DATE ISSUED: July 20, 2016 ASSOCIATED STANDARDS:

CARF –
DATE REVISED: May 2019

POLICY

1. TRELLIS prohibits the use of physical restraint, confinement or isolation as a form of client discipline.
2. Physical restraint for the purposes of this policy is defined as a personal restriction that immobilizes or reduces
the ability of the client to freely move their torso, arms, legs, or head. Brief physical guidance, instructional
prompting, physical support, and comforting are not instances of restraint.
3. Trellis is designed so that children, youth and families experience an environment where they are safe,
secure, respected and their dignity is protected. The employees/volunteers will use respectful language
and encourage clients to solve problems in a positive respectful manner. Clients will beencouraged to
understand the consequence of their actions. Problem solving is an integral part of all Lodgeprogramming.
4. Employees and volunteers will continually work with the clients attending the program to fully understand
behavior expectations within the Lodge. Employees will encourage clients to behave appropriately by
having a positive approach in interactions and by providing a stimulating program. At no time will punitive
discipline be used. Disciplinary action taken will be reasonable to the circumstances.

PROCEDURES

1. Employees and volunteers in the program will not:

a. Deny or threaten to deny any basic necessity.
b. Use or permit the use of any form of physical restraint, confinement, or isolation.
c. Inflict or cause to be inflicted any form of physical punishment, verbal or physical degradation or emotional
deprivation.
2. If a client is having behavior difficulty within the program the following steps will be taken:
a. Employees will utilize a strength based approach with the client and discuss what is expected, and give them
positive tools to continue within the program (this includes using the client’s name, acknowledging the
behavior and stating clear expectations).
b. If the behavior continues, the employee will discuss expectations with the client a second time.
c. If the behavior continues, the employee will discuss expectations with the client a thirdtime.
d. If the behavior continues, the client will cease to participate in the activity for a short period of time and will
discuss with the employee the next steps of what will happen if they continue with this behavior, as well as
ways to ensure they will succeed in the program.
e. If a client continually behaves in a manner that does not meet program expectations, despite the above
measures, the employee will contact the client’s parents/guardians to pick up the client from the
program. The employee and parents/guardians will need to meet together with the client to discuss the
behavior and steps/behavior management plan before the client returns to the program.
3. At all times, employees will maintain a fair, consistent and positive approach to clients’ behavior. When clients
are in conflict with each other, employees will encourage the clients to resolve the situation themselves, but
assist as necessary.
 TRELLIS SOCIETY – LEGACY BGCC PROGRAMS

PROGRAM SPECIFIC
IIYIKA’KIMAAT

POLICY: EMPLOYEE RATIOS POLICY NO.: I.14.6

DATE ISSUED: July 20, 2016 ASSOCIATED STANDARDS:

CARF –
DATE REVISED: May 2019

POLICY

1. Iiyika’kimaat will deliver their services within the parameters of the service definition.

2. Trellis’ Indigenous Initiatives employs qualified employees to ensure adequate supervision of clients
and maintain safety in programs.

PROCEDURES

1. Iiyika’kimaat provides services to clients between the ages of 12-21 years of age in a safe, supportive and
supervised environment. Services emphasize age-appropriate growth and development and culturally
appropriate practices through positive interactions between clients, elders and employees. Services focus on
engaging clients in positive, culturally appropriate activities during critical hours, during school breaks, and during
evenings.

2. The supervision of clients is continuously available. Indigenous Initiatives must ensure that one (1) employee is
available for every fifteen (15) clients in the program/Lodge.

3. Specific programs may reduce this ratio depending on the technical requirements of the program, the space
available, and the needs of the clients.

4. Managers will ensure that adequate supervision is provided to front line employees.