NSMHPCN Annual Policy Review

As part of your terms of employment, an annual review of the organization’s policies is required. As such, please find below a link to the NSMHPCN policies in their entirety for your review. Additionally, below you will find each section that requires a specific acknowledgment. Once you have read each of the sections below, please complete the Acknowledgement form located at the bottom of the page. Upon completion, this form will be saved to your employee file and will be valid for the remainder of the calendar year.

Substance Abuse Policy (Drug and Alcohol)

Type of Policy: Human Resources Policy Number: HR-15
Reviewed by: Executive Director Approved by: Governance Committee
Review Date: May 2, 2022 Date Approved: October 15, 2018
Revision Date: April 8, 2021



North Simcoe Muskoka Hospice Palliative Care Network is committed to the health and safety of its employees and has adopted this policy to communicate its expectations and guidelines surrounding substance use, misuse, and abuse.


Employees under the influence of drugs or alcohol on the job can pose serious health and safety risks to both themselves and their fellow employees. To help ensure a safe and healthy workplace, North Simcoe Muskoka Hospice Palliative Care Network reserves the right to prohibit certain items and substances from being brought on to or present on company premises.


Drug: Any substance which can change or adversely affect the way a person thinks or feels, whether obtained legally or illegally. This could include recreational cannabis, cocaine, opiates, and amphetamines.

Drug paraphernalia: Material or equipment used or intended for use in injecting, ingesting, inhaling, or otherwise introducing a drug, illegal or controlled, into the human body.

Medication: Includes a drug obtained legally, either over the counter or through a prescription issued by an authorized medical practitioner. For this policy, medications of concern are those that inhibit a worker’s ability to perform their job safely and productively.

Alcohol: Any beverage containing any quantity of alcohol, including, beer, wine, and distilled spirits.


The following expectations apply to employees and management alike while conducting work on behalf of the company, whether on or off company property:

  • Employees are expected to arrive to work fit for duty and able to perform their duties safely and to standard;
  • Employees must remain fit for duty for the duration of their shift;
  • Use, possession, distribution, or sale of drugs or alcohol during work hours, including during paid and unpaid breaks, is strictly prohibited;
  • Employees are prohibited from reporting to work while under the influence of recreational cannabis and any other non-prescribed substances;
  • Use and possession of medically prescribed drugs is permitted during working hours, subject to the terms and conditions of the company’s policies and all applicable legislation;
  • Employees on medically approved medication must communicate to management any potential risk, limitation, or restriction requiring modification of duties or temporary reassignment; and
  • Employees are expected to abide by all governing legislation pertaining to the possession and use of cannabis.

Roles and Responsibilities:

North Simcoe Muskoka Hospice Palliative Care Network will:

  • Clearly communicate expectations surrounding alcohol and drug use, misuse, and abuse;
  • Maintain a program of employee health and awareness;
  • Provide a safe work environment; and
  • Review and update this policy regularly

Management will:

  • Identify any situations that may cause concern regarding an employee’s ability to safely perform their job functions;
  • Ensure that any employee who asks for help due to a drug or alcohol dependency is provided with the appropriate support (including accommodation) and is not disciplined for doing so; and
  • Maintain confidentiality and employee privacy.

Employees must:

  • Abide by the provisions of this policy and be aware of their responsibilities under it;
  • Arrive to work fit for duty, and remain so for the duration of their shift;
  • Perform work safely in accordance with established safe work practices;
  • Avoid the consumption, possession, sale, or distribution of drugs or alcohol on company property and during working hours (even if off company property);
  • When off duty, refuse a request to come into work if unfit for duty;
  • Report limitations and required modifications as a result of prescription medication;
  • Report unfit co-workers to management;
  • Seek advice and appropriate treatment, where required;
  • Communicate dependency or emerging dependency to management or human resources; and
  • Follow the after-care program, where established.

Suspicion of Impairment

The following procedure may be enacted if there is reasonable belief that an employee is impaired at work:

  1. If possible, the employee’s manager or supervisor will first seek another manager’s or supervisor’s opinion to confirm the employee’s status.
  2. Next, the manager or supervisor will consult privately with the employee to determine the cause of the observation, including whether substance abuse has occurred. Suspicions of an employee’s ability to function safely may be based on specific personal observations. If the employee exhibits unusual behaviour including but not limited to slurred speech, difficulty with balance, watery or red eyes, or dilated pupils, or if there is an odour of alcohol, the employee should not be permitted to return to their assigned duties in order to ensure their safety and the safety of other employees or visitors to the workplace.
  3. If an employee is considered impaired and deemed “unfit for work,” this decision is made based on the best judgement of two members of management and DOES NOT require a breathalyser or blood test. The employee may be advised that North Simcoe Muskoka Hospice Palliative Care Network has arranged a taxi or shuttle service to safely transport them to their home address or to a medical facility, depending on the determination of the observed impairment. The employee may be accompanied by a manager or supervisor or another employee if necessary.
  4. An impaired employee will not be allowed to drive. The employee should be advised if they choose to refuse North Simcoe Muskoka Hospice Palliative Care Network organized transportation and decide to drive their personal vehicle, the company is obligated to and will contact the police to make them aware of the situation.
  5. A meeting may be scheduled for the following work day to review the incident and determine a course of action which may include a monitored referral program as part of a treatment plan.

Possession at Work:

Possession of alcohol, drugs, and drug paraphernalia on company property is prohibited. Company property encompasses all company owned or leased property used by employees, including without limitation parking lots, vehicles, lockers, desks, and closets.

Possession of alcohol, drugs, and drug paraphernalia is also prohibited while employees are acting on behalf of the organization off of company premises. This includes attending events as a company representative.

Substance Dependency:

North Simcoe Muskoka Hospice Palliative Care Network understands that certain individuals may develop a chemical dependency to certain substances, which may be defined as a disease or disability. Employees are not excused from their duties as a result of their dependencies. North Simcoe Muskoka Hospice Palliative Care Network promotes early diagnosis. Any employee who suspects that they might have an emerging drug or alcohol problem is expected to seek appropriate treatment promptly.

The company will work with the individual who requests accommodation in an effort to ensure that the measures taken are both effective and mutually agreeable, up to the point of undue hardship. Employees are encouraged to communicate any need for accommodation to their immediate supervisor, and to work with them in addressing the concern.

Voluntary Identification:

Employees are encouraged to communicate if they have a dependency or have had a dependency so that their rights are protected and they can be accommodated appropriately. Employees will not be disciplined for requesting help or due to current or past involvement in a rehabilitation effort.

All medical information will be kept confidential by North Simcoe Muskoka Hospice Palliative Care Network, unless otherwise authorized by law. 

Agreement for the Continuation of Employment

North Simcoe Muskoka Hospice Palliative Care Network reserves the right to invoke an agreement for the continuation of employment in accordance with an employee’s commitment to become and remain alcohol- and drug-free. The agreement will outline the conditions governing the employee’s return to the job and the consequences for failing to meet the conditions.

An agreement for the continuation of employment may include a requirement for drug or alcohol testing.

Disciplinary Action

Employees may be subject to disciplinary action up to and including termination of employment for failure to adhere to the provisions of this policy, including but not limited to:

  • Failure to meet prescribed safety standards as a result of impairment from alcohol or drugs; and
  • Engaging in illegal activities (for example, selling drugs or alcohol while on company premises)

Conflict Resolution Policy

Type of Policy: Human Resources Policy Number: HR-28
Reviewed by: Governance Committee Approved by: Board of Directors
Review Date: January 11, 2024 Date Approved: March 22, 2021
Revision Date:



North Simcoe Muskoka Hospice Palliative Care Network is committed to providing a workplace free of conflict, where employees are treated with fairness, dignity and respect. North Simcoe Muskoka Hospice Palliative Care Network has instituted this policy to provide employees with an outlet to raise concerns regarding any conflict in the workplace or dissatisfaction with respect to issues related to their employment in an open and fair manner with provisions made to ensure their prompt and reasonable resolution. Under no circumstance should any employee fear discrimination or reprisal in the workplace as a result of the filing of a complaint.



The following conflicts should be reported, and North Simcoe Muskoka Hospice Palliative Care Network shall strive to address them with reasonable resolutions.

  • Disputes with co-workers or managerial staff with unwanted, and unresolved consequences
  • Perceived unfair or inequitable treatment
  • Harassment whether sexual, discriminatory, or personal in nature
  • Abuse of authority
  • Administration of company policies

Conflict Reporting Procedure


  • Employees are encouraged to discuss the unwanted behaviour or actions with the offending party as the situation dictates
  • Under ideal circumstances, the two parties shall reach a reasonable resolution without the necessity of the filing of a formal complaint
  • In the event that a discussion is not feasible or fails to reach a reasonable resolution, a formal complaint may be filed


  • Complainants should record the details of the unwanted circumstance(s), the names of any applicable witnesses, and any attempts made to resolve the issue heretofore
  • Formal complaints stemming from unresolved employee or managerial conflicts shall be submitted in writing with any pertinent documentation to the Executive Director or designate
  • Formal complaints shall be reviewed and investigated
  • Formal complaints must be submitted within 14 days from the date of the alleged incident(s)
  • In all cases where formal complaints have been lodged, it is important to maintain a policy of strict confidentiality. For investigative purposes, the offending party will be notified
  • Anonymous complaints shall not be reviewed

Employee Expectations


  • Employees are required to fully comply with the Conflict Resolution Policy
  • Shall be treated fairly throughout the process, as either a complainant, or alleged offending party
  • Shall be responsible for maintaining confidentiality regarding their involvement, and the complaint itself
  • Shall co-operate with any investigations in relation to complaints

Executive Director or Designate

  • The Executive Director or designate will be responsible for enacting preventative measures to ensure a workplace that is free from harassment, and for the communication of policy and procedures contained herein
  • The Executive Director or designate shall receive and address properly filed complaints in an appropriate fashion
  • In the event that the complainant and the offending party are engaged in a subordinate-supervisor relationship, they may be physically removed from each other on a temporary basis, and may require a change in their reporting relationship
  • Investigate, or co-investigate any complaints, claims and documentation therein.
  • Attempt to reach a reasonable resolution to the conflict.
  • Inform the complainant and the offending party of possible resolutions available.


  • If an apology is made by the offending party, and the complainant accepts the apology, this may be viewed as a reasonable resolution
  • All attempts shall be made to reach a reasonable resolution through mediation of the complaint with both parties involvement

Where the complaint is substantiated:

In the event that a complaint is substantiated and a reasonable solution to halt the unwanted behaviour or action through mediation is not possible, the following actions shall be taken for the offending party:

  • Written warning/reprimand
  • Transfer or demotion, and in some instances both a transfer and a demotion
  • Education and training
  • Suspension
  • Termination of Employment

Where the complaint is not substantiated:

In the event that a complaint is not substantiated due to lack of evidence or other reasons, both parties shall be informed with the rationale used. The complainant shall be notified first.

Both parties should be reminded that an unsubstantiated complaint does not necessarily mean that it was filed under false or frivolous pretenses.

A complainant may request that the investigation be re-opened in the event that pertinent new evidence can be provided, or a reprisal due to the allegation has occurred.


North Simcoe Muskoka Hospice Palliative Care Network shall keep on file all formal complaints, and the accompanying documentation, and the findings of any investigation.

Information from a previous investigation resulting in a substantiated complaint may be used for review and consideration purposes in the event of a new allegation.

False or Frivolous Complaints

  • Employees should be cognizant of the fact that a formal complaint against another employee is a serious allegation with repercussions
  • Where a complaint is found to be either false or frivolous, or where supporting documentation for a complaint has been falsified, the complainant or witness may be subject to disciplinary measures up to and including termination of employment

Confidentiality Agreement

Confidentiality Form


I understand that in the course of my employment or affiliation with the North Simcoe Muskoka Hospice Palliative Care Network (NSMHPCN), I may have access to confidential information, including personal health information of patients, employee information (i.e. employment records, salaries) or business information about NSMHPCN (i.e. financial and statistical information, internal reports) (“Confidential Information”). I understand that I have a professional, ethical and legal obligation to protect the confidentiality and privacy of this information, and this is a condition of my employment or affiliation with NSMHPCN. I understand that my failure to comply with these obligations may result in the termination of my employment or affiliation with NSMHPCN and I may be subject to legal or professional disciplinary proceedings.

In consideration of being provided with access to Confidential Information at NSMHPCN, I agree as follows:

  • I will comply with all policies and procedures of the North Simcoe Muskoka Hospice Palliative Care Network relating to Confidential Information, and applicable professional guidelines and laws (including, but not limited to the Personal Health Information Protection Act, 2004). I will treat all Confidential Information, regardless of form, in accordance with NSMHPCN’s Vision, Mission and Values.
  • I will not collect, use or disclose Confidential Information except as necessary in order to perform my job responsibilities. Under no circumstances may Confidential Information be communicated either within or outside of NSMHPCN, except to other persons who are authorized by NSMHPCN to receive such Confidential Information.
  • I agree that I will not alter, destroy, copy or interfere with any Confidential Information, except with authorization of NSMHPCN in accordance with its policies and procedures. I will observe NSMHPCN’s policy prohibiting the temporary or permanent removal of Confidential Information from the premises of the NSMHPCN without specific authorization by Administration.
  • I agree to immediately notify the Executive Director or designate or designate if I become aware that personal health information has been lost, stolen or accessed by unauthorized persons.
  • I agree to keep any computer access codes (e.g. passwords) confidential and secure and will promptly log out when leaving my workstation. I will protect physical access devices (e.g. keys, badges) and take reasonable steps to protect the security of any Confidential Information in my possession.
  • I understand that as a safeguard to confidentiality, random and targeted audits will be conducted on the use of my computer access to Confidential Information and that I will be held accountable for documented access to information not required by me in the performance of my duties. Should a potential breach of confidentiality be suspected, a formal breach investigation will be initiated and my access rights to Confidential Information may be temporarily suspended pending the outcome of the investigation.
  • I will not lend my access codes or devices to anyone, nor will I attempt to use those of others. I understand that access codes come with legal responsibilities and that I am accountable for all work done under these codes. If I have reason to believe that my access codes or devices have been compromised or stolen, or if I become aware of any potential security of privacy breaches, I will immediately contact the Executive Director or designate.

I acknowledge that I have ready and understood North Simcoe Muskoka Hospice Palliative Care Network’s policies and procedures on privacy, confidentiality and security.

Criminal Record Annual Declaration

Criminal Records Check Declaration


I hereby declare that I have not been charged with a criminal offense during the past year of my employment with the North Simcoe Muskoka Hospice Palliative Care Network.

I agree to allow the North Simcoe Muskoka Hospice Palliative Care Network to perform a subsequent criminal records check if required.

Cell Phone Agreement

Cell Phone Agreement


Use of NSMHPCN Cell Phone and Corporate Cell Phone Plan

North Simcoe Muskoka Hospice Palliative Care Network Policy requires that Employees who regularly work outside of the NSMHPCN office have a personal cell phone to ensure their safety and in order to conduct their work remotely.

The Corporate cell phone plan for 2023-2024 will cover basic costs adding up to $56.00 per month. Any costs above the $56.00 per month will be the responsibility of the employee and will be deducted from their payroll.

The HR-17 Policy on Use of Organization Property also requires all NSMHPCN mobile devises (including cell phones) to be password protected; Employees must submit passwords to the Administrative Assistant for storage.

Further, the HR-17 Policy on Use of Organization Property requires the safeguarding of equipment and entails that employees are responsible for damaged or lost equipment unless circumstances are beyond the employee’s control. The network will review such circumstances and determine if equipment will replaced at no cost to the employee. No equipment will be replaced more than once a year at expense of the network.

Employees Acknowledgment

I acknowledge that cell phones provided by NSMHPCN are the property of NSMHPCN and are entrusted into my care. As such I acknowledge that the cell phone in my care will be password protected at all times.

I also acknowledge that cell phone costs above the corporate cell phone plan amount will be my responsibility and I agree to have them deducted from my payroll.

I also acknowledge that I am responsible for damage or loss of the cell phone entrusted to me unless it is due to circumstances beyond my control.

I further acknowledge that the NSMHCPN cell phone must be returned at the conclusion of the employment relationship or any time requested by NSMHPCN.

Equipment Agreement

Equipment Agreement

The items mentioned in my acknowledgment have been entrusted in my care for the duration of my employment with North Simcoe Hospice Palliative Care Network (NSMHPCN). The items listed are the property of NSMHPCN and are to be returned to the Network should the employment relationship come to an end.

The employee is responsible for these items while in his/her possession and will be responsible for their replacement if they are lost or damaged and is responsible for informing his/her manager immediately of lost or stolen equipment. All laptops, cell phones and USB drives must be password protected and passwords kept on file with the Executive Director or designate. All the above statements are in accordance with HR-17 Policy on Use of Organizational Property.

NSMHPCN also reserves the right to request these items be returned at any point during the employment relationship (for maintenance, upgrades, etc.)

NSMHPCN Policy Acknowledgement Form