Hospitals operate within a complex legal framework that ensures Ontarians have access to safe and quality care. This framework covers a broad range of topics including, hospital governance and operations, health care funding, regulated health professionals, clinical care, consent and capacity, and public health reporting.
Some of the Acts in this section require certain records to be maintained. Please refer to the OHA Retention Toolkit: A Guide to the Maintenance and Disposal of Hospital Records for specific details on these compliance requirements.
The following Acts are covered in this section:
Child, Youth and Family Services Act, 2017 (CYFSA)
Commitment to the Future of Medicare Act, 2004 (CFMA)
Connecting Care Act, 2019 (CCA)
Coroners Act
Criminal Code (Code) [federal]
Excellent Care for All Act, 2010 (ECFAA)
Fixing Long-Term Care Act, 2021 (FLTCA)
Gift of Life Act (GOLA)
Healing Arts Radiation Protection Act (HARPA)
Health Care Consent Act, 1996 (HCCA)
Health Insurance Act (HIA)
Health Protection and Promotion Act (HPPA)
Laboratory and Specimen Collection Centre Licensing Act (LSCCLA)
Mandatory Gunshot Wounds Reporting Act, 2005
Mental Health Act (MHA)
Patient Restraints Minimization Act, 2001 (PRMA)
Public Hospitals Act (PHA)
Regulated Health Professions Act, 1991 (RHPA)
Safeguarding Our Communities Act (Patch for Patch Return Policy), 2015 (SCA)
Social Work and Social Service Work Act, 1998 (SWSSWA)
Substitute Decisions Act, 1992 (SDA)
Vital Statistics Act (VSA)
The CYFSA governs the provision of services to children and youth in Ontario with the “paramount purpose” of promoting the best interests, protection and well-being of children. In achieving this purpose, the CYFSA contains standard setting and compliance obligations respecting child and youth welfare including, but not limited to, residential services, children’s aid societies, youth justice, and other support programs for children and youth.
Who does the CYFSA apply to?
The CYFSA applies to a variety of organizations operating under the Act. For the purpose of this Guide, the CYFSA applies to “service providers” where service providers include licensees, those prescribed by regulation, and “a person or entity, including a society, that provides a service funded under” the CYFSA. Depending on the programs and services offered, hospitals may be captured by compliance obligations contained in the CYFSA.
What are the key requirements for hospitals under the CYFSA?
Hospitals providing services under the CYFSA must ensure the identified rights of, and regulatory requirements for, children and youth receiving services under the CYFSA are respected, protected, and complied with. (ss 3, 12-13, 15-16; O Reg 156/18, ss 3-6)
Hospitals providing services under the CYFSA cannot use physical or mechanical restraints on children or youth, except as may be authorized, and in compliance with regulatory requirements. (s 6; O Reg 155/18, ss 10-17, 21-21.2)
Hospitals cannot administer or permit the administration of a psychotropic drug to a child or youth without consent in accordance with the requirements of the Health Care Consent Act, 1996. (s 176; O Reg 155/18, s 91)
Hospitals must ensure compliance with consent requirements as may be applicable under the Act. (ss 21-23)
Hospitals must ensure compliance with the duty to report reasonable suspicion of child harm under the Act. (s 125)
Hospitals must comply with regulatory requirements respecting police record checks. (ss 334, 349; O Reg 155/18, ss 116-131)
Hospitals providing services under the CYFSA must ensure those who make decisions that may materially affect a child’s interests have received the required training and have written procedures in place in compliance with regulatory requirements. (O Reg 155/18, ss 7-8)
Hospitals must comply with Ministry of Children, Community and Social Services directives as may be issued and applicable. (s 32)
Depending on the programs and services offered, hospitals may be subject to a number of compliance deadlines respecting procedures and notice provisions under the CYFSA. Careful consideration should be given to the requirements of the CYFSA in specific context.
Directors and/or officers who authorize, permit or concur in an employee’s failure to report suspicion of child harm as required by the Act is guilty of an offence and liable of a fine of not more than $5,000. (s 125) At the time of initial publication, additional director and/or officer liability provisions respecting the use of physical and mechanical restraints were drafted but awaiting in-force proclamation. (s 7.1)
Hospital directors and/or officers may, depending on the programs and services offered, be subject to a number of additional liability provisions under the CYFSA. Careful consideration should be given to the requirements of the CYFSA in specific context.
For more information about the CYFSA, please refer to the following resources:
Commitment to the Future of Medicare Act, 2004 (CFMA)The Canada Health Act establishes criteria and conditions respecting insured health care services and extended health care services that provincial governments must meet in order to receive full health care cash contributions from the federal government. The CFMA sets out various rules and prohibitions with respect to insured services, particularly relating to queue-jumping (“preferences”), extra billing, and charging of block fees, to ensure Ontario’s commitment to and compliance with the requirements under the Canada Health Act.
Who does the CFMA apply to?
Depending on the provision, the CFMA may apply to physicians or other prescribed practitioners, the General Manager of the Ontario Health Insurance Plan (OHIP), the Minister of Health, the Health Services Appeal and Review Board (HSARB), or more generally, to entities (including hospitals) or persons (including persons employed in a hospital).
What are the key requirements for hospitals under the CFMA?
- Hospitals and individuals working in hospitals must not charge or accept payment or a benefit to give preference to an insured person in accessing an insured service. (s 17(1)) Any person employed in a hospital (including privileged health professionals) who performs insured services or services related to the provision of insured services and who has reason to believe someone has violated this prohibition must report it to the General Manager of OHIP. (s 17(2); O Reg 288/04, s 7(1))
- Subject to certain exceptions, physicians and “designated practitioners”, as defined in the Act, must not charge more or accept payment or other benefit for more than the amount payable under OHIP for rendering an insured service to an insured person. (s 10)
- Hospitals must submit information to the General Manager of OHIP, if requested to do so by the General Manager of OHIP for the purposes of determining whether there has been a contravention of or failure to comply with certain provisions of the CFMA or Health Insurance Act. (s 16)
- Mandatory reporting to the General Manager of OHIP must occur “promptly”. (s 17(2))
- If the General Manager requests information, it must be submitted within 21 days of receipt of the request. (s 16)
The Act does not contain any director specific offence provisions.
For more information about the CFMA, please refer to the following resources:
The CCA creates two organizations, Ontario Health and Ontario Health atHome, and sets out the objects and powers of these organizations as well as requirements with respect to their governance. The CCA also sets out the framework for the funding and oversight of “health service providers”, including hospitals, the framework for the provision of home and community care, and the framework for health system integration, including the creation of Ontario Health Teams (OHTs).
Who does the Act apply to?
Certain parts of the Act apply specifically to the Agency, meaning Ontario Health, the Service Organization, meaning Ontario Health atHome, and/or OHTs. The key provisions for the purposes of hospital compliance apply to “health service providers”, which is defined in the CCA to include all public hospitals in Ontario as well as long-term care (LTC) homes.
What are the key requirements for hospitals under the CCA?
- Each hospital and Ontario Health must negotiate and enter into a service accountability agreement (SAA), which will set out various requirements that the hospital must comply with in order to receive funding from Ontario Health. (s 22) Hospitals are required to comply with their obligations under their SAA, as outlined in the CCA.
- Hospitals must establish mechanisms for engaging with patients, families, caregivers, health sector employees and others as part of their operational planning processes in accordance with the regulations, if any, made by the Minister of Health (Minister). (s 44) (At the time of writing, there were no such regulations applicable to hospitals specifying any particular mechanism(s) for engagement).
- Hospitals that are licensees of LTC homes within the meaning of the Fixing Long-Term Care Act, 2021 must annually submit an audited reconciliation report to Ontario Health. (O Reg 200/21)
- Hospitals must separately, and in conjunction with Ontario Health, OHTs, and other health service providers, identify opportunities to “integrate” services with other health service providers and entities to provide appropriate, co-ordinated, effective and efficient services. (s 30) “Integration” is defined broadly in the CCA. (s 1(1))
- Hospitals that voluntarily integrate have additional compliance requirements under the Act, such as providing notice to Ontario Health of the proposed integration. (s 35) The CCA also provides for integration by Ontario Health. (s 31)
- The timing for specific reporting obligations and other compliance requirements will be set out in each hospital’s SAA.
- The date that reconciliation reports must be submitted will be determined by the accountability agreement between the Minister and Ontario Health as well as the SAA for the LTC home. (O Reg 200/21, s 1(2))
An individual who is convicted of an offence under the CCA is liable for a fine of not more than $50,000 for a first offence, or to imprisonment for a term of not more than 12 months, or to both; and for a fine of not more than $100,000 for a subsequent offence, or to imprisonment for a term of not more than 12 months, or to both. (s 43.8)
Every director of a corporation who commits an offence under the CCA for which the corporation would be liable for prosecution is guilty of an offence and on conviction is liable to the punishment provided for the offence, regardless of whether or not the corporation has been prosecuted or convicted.
For more information about the CCA, please refer to the following resource:
The Coroners Act establishes the framework for investigating deaths in Ontario, especially those that occur under suspicious, unnatural, or sudden circumstances. The Act outlines the duties of coroners, the responsibilities of health care institutions, including hospitals, to report certain types of deaths, and the procedures for conducting inquests to prevent future deaths.
Who does the Act apply to?
The Act applies to deaths that are sudden, unexpected, violent, unexplained, or occur in specific settings, including hospitals, to ensure that any potential systemic issues, medical errors, or risks to patient safety are thoroughly investigated and addressed.
What are the key requirements for hospitals under the Act?
- Hospitals must report deaths to the coroner in specific circumstances, such as when the death is sudden and unexpected, occurs in a suspicious or unnatural manner, or results from medical assistance in dying. (ss 10-10.1)
- Long-term care (LTC) homes must report any resident death to a coroner who will determine if an investigation or inquest is warranted. (s 10)
- Hospitals and LTC homes must not interfere with or alter the body when there is reason to believe the person died under the circumstances specified above. (s 11)
- Hospitals and LTC homes must obtain a coroner's certificate before transporting a dead body from Ontario to another jurisdiction, confirming no further examination is needed, they must pay the prescribed fee for this certificate, and refrain from embalming or altering the body until the certificate is issued. (s 13)
- Hospital and LTC homes must not knowingly hinder, obstruct, or interfere with a coroner, or provide false information or refuse to furnish information required by a coroner or their authorized representative during an investigation. (s 16(6))
- Hospitals must store and dispose of tissue samples when the pathologist is hospital-based and wants to retain tissue samples. (Reg 180, ss 7-10)
Hospitals must notify the police or coroner of qualifying deaths immediately. (s 10)
The Act does not contain any director specific offence provisions.
For more information about the Act, please refer to the following resources:
The Code is the federal legislation that codifies criminal offences in Canada. It defines what conduct constitutes criminal offences, sets out certain defences, and establishes what punishment may be imposed on a person or entity convicted of an offence. The Code additionally sets out powers and procedures with respect to the investigation and prosecution of offences.
Who does the Code apply to?
The Code applies to all individuals in Canada as well as corporations and other legal entities operating in Canada. As such, the Code applies to all employees, staff, officers, and directors of hospital, and to the hospital itself.
What are the key requirements for hospitals under the Code?
The Code doesn’t set out specific requirements for hospitals to comply with. However, it does set out the following reporting obligations for certain health professionals involved in medical assistance in dying (MAID), which hospitals may facilitate the submission of:
Physicians and nurse practitioners who carry out assessments for or provide MAID, and pharmacists who dispense medication in connection with the provision of MAID must submit reports to Health Canada or the Chief Coroner for Ontario in accordance with the MAID regulation under the Code. (s 241.31; SOR/2018-166)
MAID reporting must occur within the timeframes set out in the MAID regulation under the Code. (SOR/2018-166)
Like other persons, a director may be found criminally liable under the Code if he or she commits an offence, aids or abets a person to commit an offence, or if he or she “knowing that a person has been a party to the offence, receives, comforts or assists that person for the purpose of enabling that person to escape”. (ss 21, 23)
Where a director who "is responsible for the aspect of the organization’s activities that is relevant to the offence departs — or the senior officers, collectively, depart — markedly from the standard of care that, in the circumstances, could reasonably be expected to prevent a representative of the organization from being a party to the offence”, the director may be found criminally liable for the offence. This is a crime of negligence. (s 22.1)
The Code also establishes criminal liability for offences that do not require negligence where senior officers of an organization, which includes directors, act within their scope of authority and are a party to an offence; direct the work of other representatives who commit an offence; or knowing that a representative of the organization is about to be a party to an offence, does not take reasonable measures to stop them from being a party to the offence. (s 22.2)
Additionally, specific obligations related to workplace safety issues are set out in the Code, which provides that everyone who undertakes to direct, or has the authority to direct, how another person works or performs a task must take reasonable steps to prevent bodily harm to that person, or any other person, arising from that work or task. (s 217.1)
The penalties set out in the Code, which may include fines and/or imprisonment, vary depending on the nature of the offence.
For more information about the Code, please refer to the following resource:
ECFAA aims at ensuring that patients interacting with Ontario’s health care system receive high-quality care. In striving toward this stated legislative purpose, ECFAA establishes a baseline framework for patient relations and satisfaction processes; requires the creation of a quality committee responsible for monitoring and board reporting on quality issues; mandates annual quality improvement plans; and includes a bi-annual collection of internal insights into views on the provision of patient care. In addition, ECFAA establishes Ontario’s Patient Ombudsman and sets out an array of powers respecting receipt, review, investigation, and resolution of patient complaints beyond the scope of a health sector organization’s internal processes.
ECFAA applies to “health care organizations” as well as “health sector organizations”; both of which include hospitals within the meaning of the Public Hospitals Act.
What are the key requirements for hospitals under ECFAA?
- Following consultation with the public, hospitals must have a publicly available patient declaration of values. (s 7)
- Hospitals must have a patient relations process that reflects the content outlined in its patient declaration of values, complies with regulatory requirements, and is outlined in a publicly available manner. (s 6; O Reg 188/15)
- Hospitals must establish and maintain a Quality Committee that complies with the requirements of the Act and its according regulations. (ss 3-4; O Reg 445/10)
- Hospitals must develop quality improvement plans that comply with regulatory requirements and make them publicly available. (s 8; O Reg 187/15)
- Hospitals must ensure executive compensation, under a compensation plan, is linked to the achievement of the performance targets outlined in the annual quality improvement plan. (s 9; O Reg 444/10) Careful consideration should also be given to the requirements under the Broader Public Sector Executive Compensation Act, 2014.
- At least once every fiscal year, hospitals must survey patients and their caregivers who had contact with the hospital respecting services provided for the purpose of collecting satisfaction information. (s 5)
- At least once every two years, hospitals must survey employees and professional staff for the purpose of employee and professional staff satisfaction and solicit views about the quality of care being provided. (s 5)
- Hospitals must inform patient relations complainants of the status of their complaint review within five days from the date the complaint is received and whenever the complainant reasonably requests further information. (O Reg 188/15, s 3)
The Act does not contain any director specific offence provisions.
For more information about ECFAA, please refer to the following resources:
The FLTCA establishes the legal framework for providing care, treatment, and services in Ontario’s long-term care (LTC) homes. It outlines requirements to ensure safety, quality of care, resident rights, and compliance with Ministry of Long-Term Care (Ministry) regulations.
Who does the FLTCA apply to?
The FLTCA applies to LTC home licensees, operators, staff, and health professionals who provide care. The Act is relevant to hospitals, particularly those with affiliated LTC facilities or those involved in patient transitions to LTC settings.
What are the key requirements for hospitals under the FLTCA?
- The FLTCA sets out the process that hospitals, placement coordinators and LTC homes must comply with when a patient in a public hospital bed requires an alternate level of care and their discharge destination is a LTC home. (s 60.1)
- LTC home licensees must develop and implement a Resident Bill of Rights, ensuring residents understand and are provided with their rights to respect, dignity, and privacy. LTC home licensees must also establish a Mission Statement that guides all aspects of care and services provided. (ss 3-4)
- LTC home licensees must develop a comprehensive written plan of care for each resident, based on assessments of their needs and preferences, that covers all aspects of care. (s 6)
- LTC home licensees must meet specific staffing requirements, including minimum hours of direct care, per resident, per day, as outlined by the Ministry, as well as in compliance with regulatory requirements. (ss 8-9; O Reg 246/22) LTC home licensees must also ensure all staff of the LTC home have the proper skills and qualifications to perform their duties. (s 79)
- LTC home licensees must provide organized programs and services that meet residents’ needs and promote quality care. (ss 11-22)
- LTC home licensees must implement an infection prevention and control program and must appoint an infection prevention and control lead to oversee the program. (s 23)
- LTC home licensees must establish complaint procedures, forward complaints about resident care or operations to the Director appointed under the FLTCA, and investigate and report incidents of abuse, neglect, improper treatment, or fund misuse. Additionally, suspected harm, abuse, unlawful conduct, or misappropriation must be reported to the Director. (ss 26-28)
- LTC home licensees must ensure the LTC home has an Administrator that is in charge of the LTC home, responsible for its management, and performs any other duties set out in regulation. (s 76; O Reg 246/22, s 249)
- LTC home licensees must ensure the LTC home has a Director of Nursing and Personal Care and a Medical Director who perform the duties set out in the Act and its regulation. (ss 77-78; O Reg 246/22, ss 250-251)
- LTC home licensees must ensure that all required information is posted in a conspicuous and accessible location within the home and communicated to residents who cannot read it in accordance with regulatory requirements. (s 85)
- LTC home licensees must establish written emergency plans that comply with regulations, covering preparedness, response, and evacuation procedures, including those for epidemics, fires, natural disasters, and other emergencies. (s 90)
- LTC home licensees must ensure screening measures are conducted prior to “hiring staff and accepting volunteers” in accordance with the regulatory requirements. (s 81; O Reg 246/22)
- LTC home licensees must submit an annual report to the Director each year, confirming Ministry information, noting any previously omitted notifications, and including additional required details. They must also report the names and contact information of key personnel. (s 91; O Reg 246/22, ss 284-285)
- LTC homes must reassess each resident and revise their care plan at least every six months, or sooner if goals are met, needs change, or care is ineffective. (s 6)
- Suspected incidents of harm, abuse, unlawful conduct, or fund misappropriation must be reported to the Director immediately. (s 28)
Directors and officers of licensee corporations have a duty under the FLTCA to ensure that the corporation complies with all requirements under the Act, and directors and officers who fail to comply are guilty of an offence and can be convicted even if the licensee has not been. (s 75) Directors and officers of a corporation that is the licensee of a non-profit LTC home are liable to a fine of up to $4,000. In other cases, the fine is up to $200,000 for a first offence and up to $400,000 for subsequent offences. (s 192(3))
For more information about the FLTCA, please refer to the following resources:
GOLA establishes the framework for inter-vivos (while living) and post-mortem (after death) tissue transplants in Ontario. In addition, GOLA assigns administrative and oversight responsibilities to Ontario Health and the Minister of Health (Minister), respectively. The Trillium Gift of Life Network, which was transferred to and is now part of Ontario Health under the Connecting Care Act, 2019, is responsible for providing donation and transplantation service coordination and delivery.
GOLA applies to “designed facilities” which, pursuant to O Reg 179/05 (General) under the Act, includes hospitals.
What are the key requirements for hospitals under GOLA?
- Hospitals must obtain written and signed consent in accordance with the requirements of the Act prior to any necessary examination or tissue removal from living humans for the purpose of implantation in the body of another living human (inter-vivos). (ss 2-3)
- Hospitals must obtain either written and signed, or oral, consent in accordance with the requirements of the Act prior to the use of tissue after a person’s death (post-mortem). (s 4)
- Hospitals must comply with additional provisions respecting consent in situations where direct consent cannot be obtained due to incapacity or death. (s 5)
- Hospitals should ensure appropriate procedures are in place respecting physician-coroner interaction and death determinations in compliance with the requirements of the Act. (ss 6-7)
- Hospitals must not buy, sell, or otherwise deal tissue for transplant. (s 10)
- Hospitals must comply with any and all requirements prescribed by either the Minister or Ontario Health, respectively. (ss 8.3-8.17)
Subject to established Ontario Health requirements otherwise, hospitals must notify Ontario Health “as soon as possible” when a patient has died, or the physician is of the opinion that the death of a patient is imminent by reason of injury or death to jointly determine steps for the collection of consent from the patient or their substitute. (s 8.1)
The Act does not contain any director specific offence provisions.
For more information about GOLA, please refer to the following resources:
HARPA governs the use of X-ray technology in Ontario. The Act sets out various requirements and restrictions with respect to the installation and use of X-ray technology, including necessary approvals, authorized uses, safety requirements and standards, and general powers of inspection and enforcement.
HARPA broadly restricts every “person” from installing an X-ray machine without necessary approvals. Additional provisions outline compliance requirements for “owners” and those who “operate” X-ray machines. Due to this, and depending on the context, HARPA may apply to hospitals as either a person, owner or operator.
What are the key requirements for hospitals under HARPA?
- Hospitals must obtain approval from the Director of X-ray Safety (Director) prior to installing an X-ray machine. Written approval from the Director is required before any changes to the installation are made. (s 3)
- Hospitals may not operate an X-ray machine or permit an X-ray machine to be operated unless it has been registered with the Director. The Director must be notified in writing if there are any changes to the details in the registration. (s 4)
- Hospitals that have an X-ray machine must designate a person as the radiation protection officer. Radiation protection officers have various responsibilities, including certain reporting and record-keeping obligations, set out in the Act and regulation. (s 9; Reg 543, ss 7-8)
- Hospitals may not install or operate a computerized axial tomography (CAT) scanner unless the hospital or its class of hospital has been designated by the Minister of Health. (s 23)
- Notice of changes in an X-ray machine registration must be made to the Director within 15 days of the change occurring. (s 4)
- The deadline for radiation protection officer reporting obligations will vary between 5 and 60 days depending on the subject matter of the report. (Reg 543, s 8)
The Act does not contain any director specific offence provisions.
For more information about HARPA, please refer to the following resource:
The HCCA establishes a framework for obtaining consent for health care services. It outlines the requirements for valid consent. The Act also provides guidelines for determining capacity and sets out the role of substitute decision-makers when an individual is incapable of consenting. Additionally, the HCCA establishes the Consent and Capacity Board, which adjudicates disputes related to capacity and consent issues.
Who does the HCCA apply to?
The HCCA applies to health practitioners in Ontario, including those in hospitals, defined as a member of a college as defined under the Regulated Health Professions Act, 1991, or the HCCA regulations.
What are the key requirements for hospitals under the HCCA?
- Health practitioners must ensure that consent is obtained from the patient prior to treatment. Consent must be informed, voluntary, specific to the treatment proposed, and not based on misrepresentation or fraud. (ss 10-11)
- Health practitioners must have procedures to assess a patient’s capacity to consent. If a patient is incapable (unable to understand or appreciate treatment information), consent must be obtained from a substitute decision-maker, selected according to the HCCA’s hierarchy of eligible individuals who are willing, capable, and at least 16 years old. (ss 4(1), 20)
The Act does not contain any compliance deadlines.
The Act does not contain any director specific offence provisions.
For more information about the HCCA, please refer to the following resources:
The HIA establishes the framework for providing insured health services to Ontario residents, including billing, reporting, and the scope of services covered under the Ontario Health Insurance Plan (OHIP). It outlines the responsibilities of hospitals and health care providers in the preparation and submission of accounts for insured services, the reporting of patient information, and compliance with Ministry of Health (Ministry) regulations.
Who does the HIA apply to?
The HIA applies to physicians, practitioners, health facilities and hospitals providing insured services to Ontario residents.
What are the key requirements for hospitals under the HIA?
- Hospitals must prepare accounts for all insured services provided, ensuring they are properly documented by physicians, practitioners, and the hospital itself. (s 17(1))
- Hospitals must not charge insured persons for in-patient services, out-patient services, and medication that insured persons are entitled to without charge. (ss 7-9)
- Hospitals must report specific patient information to the Ministry, including in-patient admissions with details of any ambulance services used, in-patient death or discharge notifications also including ambulance service details, if applicable, lists of outpatients, long-stay reports, operating statements, financial and statistical returns, and accident reports for admissions or discharges due to accidents. (Reg 552, s 36)
- Hospitals must provide a written statement to the General Manager of OHIP regarding the condition of an insured patient who received services, prepared by the attending physician or relevant health care provider, explaining the necessity of insured services and any ambulance services provided. (Reg 552, s 37(2))
- Hospitals must submit accounts for insured services within 3 months of service or 12 months of discharge for in-patient care. (O Reg 22/02, s 2)
- Hospitals must provide in-patient admission notifications within 24 hours and death or discharge notifications within 96 hours. Additionally, monthly lists of out-patients must be submitted when the form is filled in, or by the 25th day of the month, whichever is sooner. (Reg 552, s 36)
The Act does not contain any director specific offence provisions.
For more information about the HIA, please refer to the following resource:
The HPPA creates the framework for the organization and delivery of public health programs and services, the prevention of the spread of disease, and the promotion and protection of the health of people in Ontario. Through this framework, regional boards of health are established, which are responsible for ensuring that certain health programs and services are provided. The HPPA also provides the Minister of Health, Chief Medical Officer of Health and regional boards of health with various powers to enforce the administration of the Act.
Who does the HPPA apply to?
The HPPA applies to a wide range of entities, including but not limited to boards of health, hospitals, long-term care (LTC) homes, school boards, child care centres, operators of food premises, and owners and operators of public pools. Hospitals are named directly in a number of provisions and also may be subject to additional obligations depending on what other services they provide, such as operating a LTC home or operating a “food premise” (as defined in the Act).
What are the key requirements for hospitals under the HPPA?
The HPPA sets out a number of reporting obligations, including:
- Hospitals and LTC homes must report to the medical officer of health of the Public Health Unit (PHU) in which the hospital or LTC home is located when an in-patient, out-patient, or LTC home resident has or may have a disease of public health significance or a communicable disease. The list of relevant diseases is set out in regulation. (s 27; O Reg 135/18; Reg 569, ss 1, 5.2-5.3)
- Hospitals that operate a laboratory must report positive laboratory findings for a disease of public health significance to the medical officer of health of the PHU in which the person from whom the specimen was taken resides. (s 29; Reg 569, ss 3-3.1)
- Physicians, registered nurses in the extended class or any other person, including a hospital, who has information about a mammal bite or contact with a mammal that could transmit rabies must notify the medical officer of health. (Reg 557, s 2(1))
Other reporting obligations apply to physicians and/or other health professionals practicing in a hospital, rather than to the hospital itself. (ss 26, 30, 34, 38; Reg 557)
- Hospitals may also be the subject of certain orders under the HPPA. (ss 29.2, 35)
- If a hospital intends to commence operating a food premise, it must give notice of the intention to the medical officer of health of the PHU in which the food premise will be located. (s 16(2))
- Hospitals operating a food premise must do so in accordance with the HPPA and its regulations, including keeping the prescribed records for the premise for the prescribed period of time. (s 16; O Reg 493/17)
- Hospital or LTC home reports on diseases of public significance or communicable diseases must be made as soon as possible after an entry with respect to a prescribed disease is made in the patient’s or resident’s record. (s 27(3))
- Hospitals that operate a laboratory must report positive laboratory findings within 24 hours of making the finding. (s 29; Reg 569, ss 3-3.1)
- Notices regarding potential rabies exposure must be made as soon as possible. (Reg 557, s 2(1))
The HPPA sets out a number of offences, including contravening a requirement to make a report of a disease of public health significance, a communicable disease or a reportable event following the administration of an immunizing agent. (s 100)
Where a corporation is convicted of an offence, each director (and each officer, employee or agent who was responsible for the conduct that gave rise to the offence) of the corporation is guilty of an offence unless they can satisfy the court that they took all reasonable care to prevent the commission of the offence. A person who is guilty of an offence is liable on conviction to a fine of not more than $5,000 for every day or part of a day on which the offence occurs or continues. (s 101)
For more information about the HPPA, please refer to the following resource:
The LSCCLA creates the framework for the licensing and oversight of laboratories and specimen collection centres in Ontario. This framework sets out the licensing process as well as rules with respect to staffing qualifications, laboratory location and equipment, requisitions, recordkeeping, and reporting.
Who does the LSCCLA apply to?
The LSCCLA applies to all entities, including hospitals, that establish, operate or maintain a “laboratory” (as defined in the Act). While the LSCCLA also applies to places where specimens are taken or collected from the human body for examination, known as “specimen collection centres”, section 34 of O Reg 45/22 (General) exempts hospitals from the provisions applicable to these centres. The Act also sets out who is authorized to requisition laboratory tests and perform specimen collections or point-of-care tests.
What are the key requirements for hospitals under the LSCCLA?
- A laboratory established, operated or maintained by a hospital must have a licence issued by the Director of Laboratory and Specimen Collection Centre Licensing (Director) and the laboratory must be operated in accordance with the terms and conditions of the licence. The licence will indicate the date on which it will expire and an application for renewal must be submitted to continue operating the laboratory after the expiry date. (ss 9, 14; O Reg 45/22, s 2) An initial licensing fee and annual fee must be paid for the licence. (O Reg 45/22, ss 5-8)
- Hospitals that own and/or operate a laboratory must post certain licence details and evidence that the laboratory has met the requirements of Accreditation Canada’s quality management program in a conspicuous and easily accessible location in the laboratory. (O Reg 45/22, s 40)
- Hospitals that own and/or operate a laboratory must notify the Director in writing of any changes in the officers or directors of the hospital. (s. 9(19))
- A laboratory director that holds one of the prescribed qualifications must be employed in the laboratory at all times. (O Reg 45/22, ss 12-13)
- Hospitals that own and/or operate a laboratory must make reports in accordance with any policies that the Ministry of Health may publish and must report laboratory test results in accordance with the regulation. (O Reg 45/22, ss 23-24.1)
- Initial licensing fees must be paid at the time of issuance or renewal of a licence. Annual fees must be paid each year on or before the day and month that correspond with the expiry date set out in the licence. (O Reg 45/22, ss 5, 8)
- Notices to the Director regarding changes in the hospital’s officers or directors must be provided within 15 days of the change occurring. (s 9(19))
Any person who contravenes the LSCCLA is guilty of an offence and liable on conviction for a fine of not more than $25,000 per day or imprisonment for a term of not more than 12 months, or both for the first offence; and not more than $50,000 per day or imprisonment for a term of not more than 12 months, or both, for subsequent offences. (s 22(1))
Whether or not a corporation has been convicted of an offence, each director of the corporation who authorized, permitted, acquiesced in or participated in the commission of an offence by the corporation or failed to take reasonable care to prevent the commission of the offence is a party to and guilty of the offence. (s 22(3))
For more information about the LSCCLA, please refer to the following resource:
The Mandatory Gunshot Wounds Reporting Act sets out when and how gunshot wounds must be reported by certain entities.
Who does the Act apply to?
The Act applies to certain “facilities”, which is defined to include all public hospitals.
What are the key requirements for hospitals under the Act?
Every hospital that treats a person for a gunshot wound must orally disclose to the local police service or the local Ontario Provincial Police detachment the fact that a person is being treated for a gunshot wound, the person’s name, if known, and the name and location of the hospital. (s 2)
Disclosure must be made as soon as it is reasonably practicable to do so without interfering with the person’s treatment or disrupting the regular activities of the facility. (s 2(2))
There are no provisions in the Act making directors personally liable for acts or omissions of the hospital, and the Act explicitly indicates that no action or other proceeding will be instituted against directors for acts done in good faith. (s 4)
For more information about the Act, please refer to the following resource:
The MHA sets the responsibilities and obligations of designated psychiatric facilities. It provides the legal framework that governs admissions, assessments, and treatment of individuals with mental health disorders in Ontario.
Who does the MHA apply to?
The MHA applies to designated psychiatric facilities as well as health care professionals and law enforcement in Ontario. Psychiatric facilities are defined as facilities for the observation, care and treatment of persons suffering from mental disorders. Additionally, the MHA guides physicians in issuing forms for psychiatric assessments and law enforcement in taking individuals into custody to psychiatric facilities.
For a hospital to be designated as a psychiatric facility, it must offer in-patient, out-patient, day care, emergency, and consultative and educational services to local agencies. For the list of psychiatric facilities and their designations, please see the Ontario Ministry of Health’s website.
What are the key requirements for hospitals under the MHA?
- Hospitals that are designated psychiatric facilities must ensure that involuntary admissions are conducted in accordance with the criteria set out in the Act, including the necessity for a physician's certificate (Form 1). (s 15)
- Hospitals that are designated psychiatric facilities must inform patients of their rights upon admission, including the right to legal counsel and the right to appeal their detention to the Consent and Capacity Board (CCB). (s 38)
- Hospitals that are designated psychiatric facilities must clearly document the use of restraint on a patient in the patient's personal health information record, detailing the restraint and the behavior that necessitated it. (s 53(1))
- Upon admission to a designated psychiatric facility, a physician shall examine the patient to determine their capability of managing property. This determination, along with reasons, must be recorded in the patient's personal health information record. A certificate of capacity must be issued and transmitted to the Public Guardian and Trustee. (ss 54(1)-(4))
- Observation and treatment of patients must be under the direction and supervision of a psychiatrist. (Reg 741, s 5)
The Mental Health Act includes various requirements for hospitals related to patient admissions, detentions, and community treatment orders (CTOs). There are also specific requirements for Officers in Charge, usually the CEO of the hospital. Please refer to the OHA's Guide to Mental Health and the Law in Ontario (4th edition) for a more comprehensive overview of these topics.
Compliance Deadlines
Hospitals that are designated psychiatric facilities must ensure that Form 1 detentions do not exceed 72 hours without further assessment or discharge. (s 15 (5)(b))
The Act does not contain any director specific offence provisions.
For more information about the MHA, please refer to the following resources:
Patient Restraints Minimization Act, 2001 (PRMA)
The PRMA aims to ensure that the use of restraints in health care settings is minimized and only applied when necessary for the safety of patients and staff. The Act establishes guidelines for the appropriate use of restraints, mandates the development of policies and procedures, and requires training for health care providers on alternative methods to manage patient behaviour.
Who does the PRMA apply to?
The PRMA applies to all public hospitals in Ontario that are approved under the Public Hospitals Act, private hospitals licensed under the Private Hospitals Act, and any other facilities or organizations prescribed by regulation. However, the Act does not apply in situations where the Mental Health Act governs the use of restraints in psychiatric facilities.
What are the key requirements for hospitals under the PRMA?
- Hospitals must ensure that restraints, confinement, or monitoring devices are only used on a patient if authorized by a treatment plan with consent, necessary to prevent serious bodily harm, or in accordance with prescribed regulations. (ss 4-6)
- Hospitals must establish policies that prioritize alternative methods over restraints whenever feasible and ensure public accessibility and compliance with these policies. (s 7)
- Hospitals are required to monitor restrained patients, provide staff training on restraint alternatives, and implement quality control measures to comply with the Act. (s 8)
- Detailed records and reports on the use of restraints and monitoring devices must be maintained and submitted as specified by regulations. (s 9(3))
The Act does not contain any compliance deadlines.
The Act does not contain any director specific offence provisions.
For more information about the PRMA, please refer to the following resource:
The PHA establishes the primary regulatory framework for the operation of public hospitals in Ontario. This framework includes the approvals required to establish or make certain decisions related to a hospital; governance and accountability requirements for hospitals; the framework for physician privileging; and the rules relating to the provision of care in a hospital, such as admission, treatment, orders, clinical record-keeping, discharge, and report of death. The PHA also sets out the authority of the Ministry of Health (Ministry) in the oversight of public hospitals, and the mechanism for hospital classification.
Who does the PHA apply to?
The PHA applies to all public hospitals in Ontario.
What are the key requirements for hospitals under the PHA?
- Hospitals must receive approval from the Minister of Health (Minister) before certain actions are taken, including filing articles under the Not-for-Profit Corporations Act, 2010, applying to incorporate a hospital or amalgamate two or more hospitals, adding buildings or facilities to a hospital, and selling, leasing, mortgaging or otherwise disposing of land, buildings or other premises used by a hospital. (s 4)
- If the Minister issues an operational or policy directive to a hospital board, the board must carry out the directive. (s 8.1)
- The Lieutenant Governor in Council may appoint investigators or supervisors and the Minister may appoint inspectors with powers to inspect or oversee a hospital, which hospitals must comply with. (ss 8, 9, 18)
- Hospitals must be governed and managed by a board of directors that is established and continued in accordance with the PHA. (s 12; Reg 965, s 2) Additionally, every hospital board must establish a fiscal advisory committee and a medical advisory committee (MAC) in accordance with the PHA. (s 35; Reg 965, ss 5, 7) For compliance with physician privileging requirements, see the OHA’s Professional Staff Credentialing Toolkit.
- Hospitals must pass by-laws as prescribed by Reg 965 (Hospital Management). The by-laws must set out, among other things, the rules and requirements for the hospital’s governance, the organization and duties of the medical staff, and the establishment and operation of an occupational health and safety program and a health surveillance program. (Reg 965, s 4)
- In certain enumerated circumstances where a hospital takes disciplinary action against a physician, the hospital must prepare and forward a report to the College of Physicians and Surgeons of Ontario (CPSO). (s 33)
- Hospitals must establish a system for addressing “critical incidents” (as defined in Reg. 965) that includes certain prescribed steps, such as disclosure and review of all incidents. Aggregated critical incident data must also be provided to the hospital’s Quality Committee (established under the Excellent Care for All Act, 2010). (Reg 965, s 2) Additionally, hospitals must report all critical incidents related to medication or intravenous (IV) fluids through the National System of Incident Reporting (NSIR). (Directive)
- Hospitals must publicly report on certain public safety indicators, as specified by the Minister of Health, that relate to diagnoses of hospital-acquired infections, activities undertaken to reduce hospital-acquired infections, and mortality. The results for each indicator must be disclosed on the hospital’s website. (Reg 965, s 22.2)
- The PHA does not set out a specific timeframe for when a report must be forwarded to the CPSO following disciplinary action against a physician.
- Disclosure of a critical incident to the MAC, hospital administrator and affected patient must occur as soon as is practicable after the incident occurs. (Reg 965, s 2(4)) The provision of aggregated critical incident data to the hospital’s Quality Committee must occur at least two times per year. (Reg 965, s 2(5.2)) Reporting to NSIR must occur within 30 days following the disclosure of the critical incident. (Directive)
- The timing of patient safety indicator reporting will vary depending on the indicator.
The PHA contains no provisions making directors personally liable for acts or omissions of the hospital, and the Act explicitly indicates that no action or other proceeding will be instituted against directors for acts done in good faith. (s 13)
For more information about the PHA, please refer to the following resources:
The RHPA is “umbrella legislation” containing general provisions which govern all regulated health professionals in Ontario, including those working in a hospital setting. There is companion legislation relating to each profession which details their scope of practice, controlled acts and issues relating to delegation. The RHPA provides a framework for regulating the scope of practice for regulated health professionals and outlines the manner in which regulatory colleges operate with regard to health care professionals.
The Health Professions Procedural Code, a Schedule to the RHPA, creates obligations for public hospitals, particularly with respect to reporting (e.g., revocation/resignation of hospital privileges, sexual assault).
Who does the RHPA apply to?
The RHPA applies to all regulated health professionals in Ontario, including physicians, nurses, pharmacists, dentists, and other health practitioners. It also applies to “facilities” where one or more regulated health professionals practise, which includes hospitals. Hospitals must comply with both the RHPA and the specific Acts applicable to the health professionals they employ or offer privileges to.
What are the key requirements for hospitals under the RHPA?
- Hospitals must report to a regulated health professional’s respective college if the hospital has reasonable grounds to believe a health professional practicing at the hospital is incompetent, incapacitated, or has sexually abused a patient. (Schedule 2, ss 85.2-85.3)
- When a hospital terminates the employment of a regulated health professional, or revokes, suspends, or imposes restrictions on their privileges, the hospital must file a written report with the registrar of the health professional's respective regulatory college. This report must set out the reasons for the actions taken. (Schedule 2, s 85.5)
- Hospitals must ensure that regulated professionals that perform “controlled acts,” as defined by section 27(2), only do so within the scope of their practice. (ss 42(1), 27(1); O Reg 107/96)
- When a hospital terminates the employment of a regulated health professional, or revokes, suspends, or imposes restrictions on their privileges, the hospital must file a written report with the registrar of the health professional's respective regulatory college within 30 days. (Schedule 2, s 85.5)
- A report to a college with respect to incompetence, incapacity, or sexual abuse must be filed within 30 days, unless the circumstances set out in the Act require urgent intervention, in which case the report must be filed “forthwith”. (s 85.3)
The Act does not contain any director specific offence provisions.
For more information about the RHPA, please refer to the following resources:
The Health Supportive Care Providers Oversight Authority Act, 2021 (HSCPOAA) is a legislative framework in Ontario that governs the oversight of registered personal support workers (PSWs). It establishes the Health and Supportive Care Providers Oversight Authority as the oversight authority responsible for registering and overseeing PSWs. The HSCPOAA does not create any direct compliance obligations for hospitals. For more information about this framework, please see the OHA's Frequently Asked Questions Resource.
Aimed at combatting the misuse and diversion of prescription fentanyl, the SCA creates a series of specific requirements respecting the prescribing and dispensing of fentanyl patches. In doing so, it creates a ‘patch for patch’ framework mandating dispensers to, subject to certain exemptions, require the return of a used fentanyl patch prior to dispensing a subsequent patch.
Who does the SCA apply to?
The SCA contains compliance obligations for “prescribers”, “dispensers”, and/or the “operator of a pharmacy”. For the purpose of this Guide, hospitals operating a pharmacy may be subject to “dispenser” and/or “operator” obligations.
What are the key requirements for hospitals under the SCA?
Hospitals operating a pharmacy must ensure “every dispenser employed or retained by the pharmacy complies” with the obligations outlined in section 3 of the SCA, unless fentanyl patches are being dispensed for a patient of the hospital and the hospital has a “written policy establishing a medication management system for the collection and administration of fentanyl patches used in the hospital, long-term care home or institution that safeguards the patches from misuse, abuse and diversion”, in which case, a hospital should ensure dispenser compliance with such written policy. (s 3; O Reg 305/16, s 6)
The Act does not contain any compliance deadlines.
The Act does not contain any director specific offence provisions.
For more information about the SCA, please refer to the following resources:
The SWSSWA establishes the regulatory framework for social workers (SWs) and social service workers (SSWs) in Ontario. It mandates the creation of the Ontario College of Social Workers and Social Service Workers (OCSWSSW), which is responsible for regulating these professions to ensure public protection and high standards of practice.
Who does the SWSSWA apply to?
The SWSSWA applies to SWs and SSWs. The Act also applies to hospitals that employ SWs and SSWs.
What are the key requirements for hospitals under the SWSSWA?
- Every hospital that is an employer of SWs and SSWs is required to report to the Registrar of the OCSWSSW any instances of professional misconduct, incompetence, or incapacity involving their social work staff who they intend to terminate. If the staff member resigns before the hospital can terminate employment, the hospital must also file a written report. (s 41)
- Hospitals must notify the OCSWSSW in writing when they become aware that their social work staff has been convicted of an offence under the Criminal Code (federal) involving sexual conduct. (s 42)
- Hospitals must submit the termination or intention to terminate for misconduct report within 30 days of termination or resignation. (s 41)
- Hospitals must notify the OCSWSSW “promptly” upon becoming aware of a sexual conduct conviction. (s 42)
The Act does not contain any director specific offence provisions.
For more information about the SWSSWA, please refer to the following resources:
The SDA governs the appointment and responsibilities of substitute decision-makers (SDMs) for individuals who are incapable of making certain decisions for themselves. The Act provides a framework for making decisions about personal care and property on behalf of individuals who are not able to do so due to incapacity.
Who does the SDA apply to?
The SDA applies to individuals deemed incapable of making decisions about their property or personal care, and the SDMs and guardians appointed to act on their behalf. The SDA also applies to “facilities”, which is defined in the Act to include public hospitals, psychiatric hospitals and long-term care homes.
What are the key requirements for hospitals under the SDA?
- Hospitals must disclose personal health information upon request to a Power of Attorney for Property, a Guardian of the Person with express authority, and a Power of Attorney for Personal Care with access rights. (ss 31.1, 59.1, 59(2), 67(2))
- Hospitals must comply with specific rules for access and disclosure of records to the Public Guardian and Trustee (PGT) when the PGT is conducting investigations. (ss 82-83)
The Act does not contain any compliance deadlines.
The Act does not contain any director specific offence provisions.
For more information about the SDA, please refer to the following resources:
The VSA establishes the legal framework for registering and certifying vital events in Ontario, including births, still-births, marriages, and deaths.
Who does the VSA apply to?
The VSA applies to the Registrar General who is responsible for maintaining and managing vital statistics records, as well as individuals reporting vital events such as physicians, nurses, or midwives.
The Act also applies to certain “institutions”, like hospitals, that have certain duties around vital statistics information.
What are the key requirements for hospitals under the VSA?
- Hospitals must assist the Registrar General by providing information from their records upon request to verify information or determine if any document issued under the VSA is being, or may be, improperly used. The Registrar General may disclose information as necessary, but institutions receiving such information are prohibited from using it for commercial purposes. (s 53.1)
- Physicians, midwives, and nurses working in a hospital (some of whom are hospital employees) have specific obligations under the Act, including preparing and signing a Notice of Live Birth or Notice of Still-birth for reporting births and still-births, and completing and signing a Medical Certificate of Death to document the cause of death. (ss 8-9.1, 21; Reg 1094, ss 1-17, 19-29, 35-48) The VSA also provides specific definitions for births and still-births. (s 1)
The Act does not contain any compliance deadlines.
The Act does not contain any director specific offence provisions.
For more information about the VSA, please refer to the following resource:
