Audit of the management of injury-on-duty, 2015

Internal Audit Report

January 19, 2015

Table of Contents

Executive Summary

What We Examined

The Audit of Management of Injury-on-Duty was conducted as part of the Correctional Service of Canada’s (CSC) Internal Audit Sector’s 2013-2016 Risk-Based Audit Plan.

The objectives of this audit were to assess the extent to which:

The audit was national in scope and included all categories of employees. Site visits took place at national headquarters, regional headquarters, and a selection of institutions from all five regions. Although the management control framework that was examined covers all types of injury, emphasis was placed on those elements that were associated with workplace injuries and was limited to those workplace injuries that resulted in leave recorded as injury-on-duty.

Why it’s Important

The audit is linked to CSC’s corporate priorities of efficient and effective management practices that reflect values-based leadership, and safety and security of staff and offenders in our institutions and in the community.

Due to the nature of the work in a correctional environment, CSC employees are regularly involved in challenging and potentially confrontational situations that place them at risk of being exposed to violence and harassment. Given CSC’s environment, and the fact that it employs over 18,000 staffFootnote 1, injury-on-duty is a significant risk to the organization. According to Human Resource Management System data for fiscal year 2013-2014, there were 2,469Footnote 2 workplace injuries at CSC, comprised of both physical and occupational stress injuries. Further, CSC had the highest provincial workers’ compensation board costs of all federal government departments over the past few years, and these costs have been increasing steadily each year.

What We Found

With respect to the first objective, we found that certain aspects of the governance framework were in place to support management of injury-on-duty. A policy framework for management of injury-on-duty exists. In addition, training activities and occupational stress awareness programs are in place.

Overall, the governance framework requires improvement in order to better support management of injury-on-duty. We noted a number of areas that require further consideration by management to ensure that the risks to the organization are better managed:

For the second objective, we found aspects of case management that support efficient and effective case resolution. Case communication, particularly with respect to return to work committee meetings, supported case management. As well, case management plans typically supported efficient and effective case resolution. However, we noted a number of areas related to case management where improvement is needed. Areas of risk that we identified are described below:

Management Response

Management agrees with the audit findings and recommendations as presented in the audit report. Management has prepared a detailed Management Action Plan to address the issues raised in the audit and associated recommendations. The management action plan is scheduled for full implementation by September 30, 2015.

Acronyms & Abbreviations

CSC
The Correctional Service of Canada
CX
Correctional Officer
HRMS
Human Resource Management System
TB
Treasury Board of Canada
UCCO-SACC-CSN
Union of Canadian Correctional Officers - Syndicat des Agents Correctionnels du Canada - Confédération des Syndicats Nationaux
WCB
Workers’ Compensation Board

1.0 Introduction

1.1 Background

The Audit of Management of Injury-on-Duty was conducted as part of the 2013-2016 Risk-Based Audit Plan, and is linked to the Correctional Service of Canada’s (CSC) priorities of efficient and effective management practices that reflect values-based leadership, and safety and security of staff and offenders in our institutions and in the community. We sought to obtain reasonable assurance that a governance framework is in place to support management of injury-on-duty, and that injury-on-duty case management practices support efficient and effective case resolution.

CSC’s Strategic Plan for Human Resource Management reinforces the organization’s values, commitment to, and direction for managing its greatest asset: its people.Footnote 3 Due to the nature of the work in a correctional environment, CSC employees are regularly involved in challenging and potentially confrontational situations that places them at risk of being exposed to violence and harassment. Given CSC’s environment, and the fact that it employs over 18,000 staffFootnote 4, injury-on-duty is a relatively common occurrence and represents a significant risk to the organization.

CSC Workplace Injuries

According to the Human Resource Management System (HRMS) data for fiscal year 2013-2014, there were 2,469Footnote 5 workplace injuries reported at CSC, comprised of both physical and occupational stress injuries. Amongst CSC’s employment categories, the correctional officer (CX) group incurs the greatest number of injuries. The following table lists the number of workplace injury occurrences by category of employee:

Table 1 – Injury Occurrences by Category of Employee (Fiscal Year 2013-2014)
Category of Employee Number of Injury Occurrences Percentage of Total Injury Occurrences
Correctional Officers (CX) 1,606 65%
Welfare Programmes (WP) 185 7%
General Labour and Trades (GL) 149 6%
General Services (GS) 136 6%
Clerical and Regulatory (CR) 135 5%
All other categories (18 in total) 258 10%
2,469 100%Footnote 6

Injury-on-Duty Leave at CSC

Many workplace injuries are relatively minor and do not result in lost time from work. However, when a workplace injury does result in lost time and/or medical attention is required, a claim is filed with the provincial Workers’ Compensation Board (WCB), and if accepted, CSC may approve injury-on-duty leave. Employees covered by a collective agreement are entitled to injury-on-duty leave with full pay for a period of up to 130 days, as determined by the appropriate manager with delegated authority, provided that the claim's initial and ongoing entitlement is supported by the WCB.

It is important to note that sick leave is only used to cover the gap between the time of the accident and the time when the WCB allows the claim. Once the claim is allowed, all sick leave used (or lost salary dollars if insufficient leave credits were available at the time of injury) is credited back to the employee, effectively starting the injury-on-duty leave on the day of injury. Further, the Treasury Board (TB) Policy on Injury-on-Duty Leave states that should “the total period of injury-on-duty leave granted to an employee with respect to an injury or illness reach 130 working days, a special departmental review of the case should be carried out and a decision made as to whether or not the continued provision of such leave beyond this period is warranted.Footnote 7

As indicated in Table 1, there were 2,469 total workplace injuries reported at CSC for fiscal year 2013-2014. Further, there were 1,436 employees on injury-on-duty leave for a combined total of 804,129 hours, or an average of 560 hours per employee in lost time recorded during the scope period of the audit.Footnote 8

The CX classification accounts for most injury occurrences across the organization and there is a unique process in place for the management of these types of claims. The CX Collective Agreement, its associated Global Agreement and the CSC Labour Relations Bulletin on injury-on-duty leave outline this framework. Notably, local, regional, and national return to work committees, comprised of both union and management representation, are in place to discuss CX return to work cases. A new Bulletin on injury-on-duty leave was released in October 2014 and tightens the controls around the mandatory review of injury-on-duty cases that have gone beyond 130 days.

While on workers’ compensation direct payment, the affected worker is put on leave without pay by CSC, and thus does not continue to accumulate leave entitlements as would be the case while on injury-on-duty leave. For cases where an injury claim is not approved by the WCB, the employee may pursue alternatives to injury-on-duty leave and workers’ compensation direct payment, such as disability insurance benefits or another type of leave (i.e. sick leave, leave without pay, etc.), if he/she is unable to return to work. In cases where an injury claim has been approved by the WCB, but the affected worker is not granted injury-on-duty leave by CSC due to reasons such as the employee's willful misconductFootnote 9, he or she may receive workers’ compensation direct payment, which is a percentage of regular salary as established by the workers’ compensation legislation of the province in which the injured worker is normally employed.

Once a WCB approves an injury claim, the associated vocational rehabilitation plan, and the medical restrictions for workplace accommodations, CSC’s role with respect to managing and controlling costs and administration of the claims is limited. If CSC decides not to initiate any of the discretionary control activities available to it (i.e. appeal of WCB claim or independent medical assessment), the costs will be set and the timeframe and processes are largely out of CSC’s control. Given that several key steps in the injury-on-duty leave process are managed by external parties, and the significant number of workplace injuries and associated costs, it is of critical importance that CSC exercises as much control as possible to manage its part well.

Costs

CSC has had the highest nominal WCB costs of all federal government departments over the past few years, and these costs have been increasing steadily each year.

Table 2 - CSC’s WCB Costs
Fiscal Year WCB Costs Number of Active Claims Cost per Claim
2013-2014 $13,864,532 2,508 $5,528
2012-2013 $12,166,451 2,485 $4,896
2011-2012 $11,040,891 2,647 $4,171
2010-2011 $9,962,683 2,397 $4,156

These WCB costs and associated administration fees, which are paid out of a corporate budget at National Headquarters include:

However, these costs represent only a portion of what is paid by CSC in relation to injury claims. While on injury-on-duty leave, all salary payments continue to be paid out of the local manager’s budget and are thus not billed to CSC by the WCBs. However, other costs such as the replacement of the affected worker (which could include salary of replacement staff, training, and overtime), workplace accommodations not covered by the WCB, WCB employer-led appeals, and independent medical assessments are also not included.

1.2 Legislative and Policy Framework

There are legislative, government central agency, and internal requirements guiding the management of injury-on-duty throughout the Government of Canada and at CSC.

Provincial Workers’ Compensation Board Legislation protects employees from the financial hardships associated with work-related injuries and occupational diseases. Further, employees of the Public Service of Canada are eligible for benefits provided by the Government Employees Compensation Act, including personal injury benefits resulting from an accident or an occupational disease in the course of their employment. The TB Policy on Injury-on-Duty (the TB Policy) and its Policy on Workers’ Compensation provide direction to federal government departments and agencies over injury-on-duty and workers’ compensation, respectively.

At CSC, Commissioner’s Directive 254 – Occupational Safety and Health and Return to Work Programs provides direction over the return to work program. Guideline 254-2 - Return to Work Program accompanies the Commissioner’s Directive 254 and includes specific direction over injury-on-duty leave. Further, the CSC Labour Relations Bulletin (the Bulletin) on injury-on-duty leave is written in reference to the CX Collective Agreement and the Global Agreement (2013) between CSC and the Union of Canadian Correctional Officers - Syndicat des Agents Correctionnels du Canada - Confédération des Syndicats Nationaux (UCCO-SACC-CSN), and provides direction over the application of injury-on-duty leave for CX staff. Finally, the Instrument of Delegation of Authorities in the Area of Human Resource Management prescribes approval authority for injury-on-duty leave.

1.3 Roles, Responsibilities, and Governance

Based on the legislative and policy framework, there are several organizations that play key roles in the management of injury-on-duty, including the Employment and Social Development Canada Labour Program, provincial WCBs, and the injured employee’s employer. Further details of each organization’s roles and responsibilities are as follows:

Employment and Social Development Canada: Labour Program

Ultimately, the Labour Program serves as the intermediary between WCBs and federal government departments. Once an employer reports a workplace injury, the Labour Program reviews the claim and determines whether the employer is covered under the Government Employees Compensation Act. If the employer is covered, the appropriate provincial workers' compensation authority will officially assess the claim.

Provincial Workers’ Compensation Boards

The role of the WCBs is to gather enough information to adjudicate the claim, that is, decide whether the claim arose from a workplace injury or illness. If the claim is denied, the employee has the opportunity to appeal the decision. If the claim is accepted, the WCB adjudicator monitors the worker's recovery and medical treatment, and attempts to facilitate an early return to work. If it appears that an early return to work will be difficult, a variety of rehabilitative services may be offered to the injured worker to assist in the return to work process.

CSC

The Assistant Commissioner, Human Resource Management Sector, in consultation with the regions, is responsible for developing the policy and accountability framework surrounding injury and illness, as well as providing national direction for CSC’s return to work program and expert advice regarding workers’ compensation matters. Nationally, the return to work program is managed by the Human Resource Management Sector. The return to work program’s objective is to provide employees who incur an injury or illness the support and assistance to return to fully productive employment, as soon as medically feasible. The key to achieving this objective lies in early and active management of each case.Footnote 10

At the local level, the injured employee, or any other employee (if the injury prevents the injured worker from doing so) shall report all work-related injuries to the employer. The manager is responsible to ensure that the WCB report of accident and the Hazardous Occurrence Investigation Report of Employment and Social Development Canada are properly filled out and forwarded to Employment and Social Development Canada immediately upon learning of the work-related injury.Footnote 11

1.4 Risk Assessment

During the planning phase of the audit, a risk assessment was completed based on interviews with CSC senior management, members of the Workplace Wellness and Employee Wellbeing team, and regional return to work personnel. We also reviewed policies, past audit work, and other documentation related to injury-on-duty to complete the assessment. Some areas of risk, such as training and awareness, effective documentation, accurate, appropriate and timely reporting of injuries, tracking of injury-on-duty leave, fulsome corporate analaysis and reporting were identified for further review as part of the audit in the risk assessment.

Further, an organization-wide fraud risk assessment was conducted in 2012, and it found five key fraud risk areas that could pertain to this audit. In general, they focus on inappropriate and illegitimate claim submissions, inflated absences from the workplace, inflated costs to the organization, as well as collusion.

In response to these concerns, testing plans were developed to ensure coverage of internal audit’s fraud related responsibilities. In particular, two key return to work program activities that control fraud risk (employer-led appeals and independent medical assessments) were closely examined. We did not find any evidence of fraud in the sample of files selected for testing.

2.0 Objectives and Scope

2.1 Audit Objectives

The objectives of this audit were to:

Specific criteria are included in Annex A. The approach and methodology used to assess the criteria are contained in section 6.1.

2.2 Audit Scope

The audit was national in scope and included all categories of employees. Site visits took place at National Headquarters, Regional Headquarters, and at a selection of institutions from all five regions.

Although the management control framework that was examined covers all types of injury, emphasis was placed on those elements that were associated with workplace injuries. For file review purposes, the scope of the audit was limited to workplace injuries that resulted in injury-on-duty leave. Therefore, injuries that occurred outside of the workplace (and associated disability insurance claims) were not included in the scope of this audit.

3.0 Audit Findings and Recommendations

3.1 Governance Framework

The first objective for this audit was to assess the extent to which a governance framework is in place to support management of injury-on-duty. Annex A provides general results for all audit criteria.

The governance framework for management of injury-on-duty was examined from four perspectives: CSC’s policy framework; organizational structure and roles and responsibilities; training activities and awareness; and corporate analysis.

3.1.1 CSC’s Policy Framework

We expected to find that the CSC directive and related guidance is up-to-date, clear, and complies with requirements.

The following area met the audit expectations for this criterion:

The following areas presented in this section did not meet the audit expectations for this criterion.

The national Return to Work Guideline remains relevant; however, it is not up-to-date or clear in certain areas.

CSC’s national Return to Work Guideline (the Guideline) provides direction for management of injury-on-duty. We found that the Guideline is out-of-date as it has not been revised since the creation of the assistant warden operations and correctional manager scheduling and deployment positions. The Guideline, which was last updated in 2002, does not incorporate the roles of these critical positions.

Further, staff indicated that the roles and responsibilities of several other positions (refer to section 3.1.2) require clarification within the Guideline, as each position performs an important role with respect to management of injury-on-duty.

The CSC Labour Relations Bulletin (injury-on-duty leave) updated in October 2014 requires a review to be conducted after 130 working days, which is in-line with the intention of the TB policy on injury-on-duty leave. Given how recently the Bulletin was issued, its impact has yet to be determined.

The CSC Bulletin (the Bulletin) on injury-on-duty leave was written in reference to the CX Collective Agreement and the Global Agreement between CSC and UCCO-SACC-CSN, and provides further guidance for clause 30.16 (injury-on-duty leave) of the CX Collective Agreement. It was found that interpretations provided in the Bulletin differ from the TB Policy in the following areas:

Table 3 – Contrast between CSC’s Bulletin and the TB Policy on Injury-on-Duty Leave
Clause TB Policy on Injury-on-Duty Leave CSC Labour Relations Bulletin*
(injury-on-duty leave)
2006-05 2014-04
Reasonable period of injury-on-duty leave […] employees disabled due to an occupational illness are entitled to injury-on-duty leave with full normal pay for such reasonable period as is determined by the employer […] (section 1) […] the definition of a “reasonable period” is not limited […] […] the definition of a “reasonable period” is not limited […]
Special departmental review of long-term injury-on-duty leave cases Should the total period of injury-on-duty leave granted to an employee with respect to an injury or illness reach 130 working days, a special departmental review of the case should be carried out and a decision made as to whether or not the continued provision of such leave beyond this period is warranted. (section 3.4) […] the 130 day guideline for review of Injury-on-duty Leave no longer applies in Injury-on-duty Leave situations with respect to Correctional Officers […] In all cases, once the period of injury-on-duty leave is anticipated to reach 130 working days, a departmental review must be conducted to determine whether to continue such leave.

*Both Bulletins were written as part of CSC’s continued negotiation processes with UCCO-SACC-CSN, the unions representing CX category employees at CSC and are to be read in conjunction with the TB Policy on Injury-on-Duty Leave.

The impact of these issues is discussed at length in section 3.2.3. Overall, the differences between the two versions of the Bulletin and the TB policy may lead to increased costs as there is no limit to the definition of a reasonable period of injury-on-duty leave for CX staff. Therefore, the Bulletin may have a negative impact on an injured employee’s timely return to work, and does not support effective or efficient case management.

3.1.2 Organizational Structure & Roles and Responsibilities

We expected to find that the organizational structure, roles, and responsibilities are defined, documented, and understood.

The following areas met the audit expectations for this criterion:

The following areas presented in this section did not fully meet the audit expectations for this criterion.

Roles and responsibilities require clarification.

The national Return to Work Guideline is the primary tool for communicating roles and responsibilities related to management of injury-on-duty. As indicated in section 3.1.1, some of these roles and responsibilities are not well defined or documented within the Guideline. Further, staff indicated that roles and responsibilities are not clearly defined or documented for the correctional manager scheduling and deployment, regional manager labour relations, and labour relations advisors. Staff interviewed also indicated that the roles and responsibilities of managers and injured employees are not always well understood.

The risk associated with unclear roles and responsibilities is that there may be varying levels of service provided to injured employees, unequal workloads for CSC staff, and administrative responsibilities such as approval of injury-on-duty leave can be overlooked. Given that there are various parties involved with management of injury-on-duty, it is important that roles and responsibilities are clearly defined, documented, and understood in order to ensure sound, consistent, return to work program management and service delivery.

The organizational structure for the return to work program is inconsistent.

Implementation of the return to work program has been delegated to the regions through the Guideline. In each region, a return to work advisor is in place to provide functional guidance and support to managers and staff. Three regions have implemented a decentralized structure such that the institutions have a labour relations advisor on-site to oversee return to work program delivery. The other two regions have a centralized model whereby the regional return to work advisor provides service to each location remotely from Regional Headquarters, without the assistance of a labour relations advisor on-site.

There are implications to be considered with each approach. We found inconsistency in roles and responsibilities, inequitable workload for the same group and level, and varying support provided to sites.

3.1.3 Training Activities and Awareness

We expected to find that training activities have been developed, provided, and taken; and that CSC contributes to the awareness of occupational stress injuries. This criterion was met.

3.1.4 Corporate Analysis

We expected to find that corporate analysis is being performed and facilitates organizational improvement.

The following areas met the audit expectations for this criterion:

The following areas presented in this section did not fully meet the audit expectations for this criterion.

Limited corporate analysis is being performed to quantify and qualify injury-on-duty information in a way that identifies issues, facilitates improvement, and helps ensure sound financial stewardship.

Monitoring and Reporting

Return to Work Program Monitoring

Overall, we found that return to work program monitoring is insufficient to facilitate organizational improvement.

The national policy centre indicated that there are no performance indicators in place for the return to work program, and as a result, there is limited national monitoring of overall program performance. For example, we found that CSC is unaware of the total volume of activity, associated costs, and/or outcomes of the following key program activities:

Reporting

CSC’s external reporting activity provides basic information regarding workplace injuries to the workers’ compensation boards and Employment and Social Development Canada. Internal reporting activity is primarily derived from HRMS, but is generally done on an ad-hoc basis.

Data collected by the local and regional level includes basic tombstone information such as:

While this basic information is available across the organization, it is not being consolidated, reported upon, or assessed at an in-depth level to facilitate effective management of injury-on-duty. Regular reporting on the following information would be useful for trending of activity and effective oversight:

Limitations of the details of information restrict management’s ability to conduct meaningful analysis of the data. For example, of the 2,469 workplace injuries identified in HRMS for fiscal year 2013-2014Footnote 12, the most frequently recorded injuries were “unidentified” (408) or “other” (341). These ‘injuries’ accounted for 30% (749) of all injuries recorded in the system.

As well, a key component of external reporting is not being met. As per the TB Policy on Workers Compensation, government departments and agencies have three days to submit the Employer’s Workers Compensation Accident Report following a workplace injury. For the 2013-2014 fiscal year, CSC’s average time to submit a claim was 23 days. It should be noted that CSC has improved its reporting time is recent years and is outperforming the average for the core public administration, which was 30 days during the same time period. Nonetheless, non-compliance with this reporting deadline is of particular concern for CSC given its high volume of workers’ compensation claims.

These monitoring and reporting deficiencies are in part due to a lack of definition around: information needs and performance indicators, which medium (i.e. hard copy file, HRMS, other electronic software) should be used for collecting and reporting information, and how analysis of information will be used to improve practices.

Financial Analysis

Overall Costs to CSC

Injury-on-duty costs that are readily available for analysis by CSC senior management are the WCB costs which totaled $13.9 million for fiscal year 2013-2014 (see Table 2). However, there are other injury-on-duty related costs that are incurred by CSC which are not captured in the billing from the WCBs. These additional costs are not consistently tracked or consolidated, and are thus not reported upon collectively. These costs are comprised of:

As a result, CSC is unaware of the overall costs of injury-on-duty; a value that figures to be substantially higher than the known costs of $13.9 million that are billed from the WCBs.

Cost implications of the Bulletin

We found that national analysis has not been done to determine the financial implications of the current Bulletin. To illustrate, from a national perspective CSC has not calculated the cost implications of maintaining an employee on injury-on-duty leave beyond 130 days, rather than transferring the employee to workers’ compensation direct payment. However, one region conducted such an assessment and estimated that it could cost CSC a signficiant amount of salary dollars each year to keep one employee on injury-on-duty leave rather than workers’ compensation direct payment. The cost difference in most cases may be substantial due to the different provisions (refer to section 3.1.1) associated with injury-on-duty leave and workers’ compensation direct payment.

Cost/Benefit of Program Activities

No cost/benefit or similar analysis has been done for WCB appeals or independent medical assessments; two key discretionary program activities available to CSC. Although utilization of these activities is low (refer to section 3.2.4), CSC is unable to assess if the appeals and independent medical assessments provide value due to a lack of analysis over associated costs.

Conclusion

We found that certain aspects of the governance framework were in place to support management of injury-on-duty. A policy framework for management of injury-on-duty exists, and training activities and occupational stress awareness programs are in place.

Overall, the governance framework requires improvement in order to better support management of injury-on-duty. We noted a number of areas that require further consideration by management to ensure that the risks to the organization are better managed:

Recommendation 1

The Assistant Commissioner Human Resource Management should:

  • Review the efficiency and effectiveness of Bulletin 2014-04 within one year to ensure its consistent application, given the flexibility extended to the regions;
  • Update the national Return to Work Guideline to ensure roles and responsibilities are updated, clearly defined and where missing, documented, to ensure consistent and appropriate resolution of injury-on-duty files; and
  • Conduct a cost-benefit analysis of the various regional organizational structures for the return to work program. Determine which approach is the most efficient and effective, and implement accordingly.
Management Response

We agree with this recommendation. By September 30, 2015, the ACHRM will:

  • Review the efficiency and effectiveness of Bulletin 2014-04;
  • Complete Guidelines 254-2 taking into account changes to the return to work program; and
  • Review the organizational structure for the return to work program.
Recommendation 2

The Assistant Commissioner Human Resource Management should establish and implement a monitoring and reporting plan that includes:

  • Conducting an analysis of which quantitative and qualitative information is necessary to make informed decisions with regard to the management of injury-on-duty; and
  • Developing key performance and financial indicators, collecting and analyzing information, and subsequently reporting to the appropriate decision makers to allow for better understanding of injury-on-duty when making decisions.
Management Response

We agree with this recommendation. By September 30, 2015, the ACHRM will:

  • Implement a reliable systematic reporting and monitoring approach for IOD; and
  • Report to EXCOM annually on IOD (quantitative and qualitative data analysis).

3.2 Case Management

The second objective for this audit was to assess the extent to which case management practices support efficient and effective case resolution. Annex A provides general results for all audit criteria.

Case management practices were examined from five perspectives: communication; leave decisions; return to work plans; vocational rehabilitation and workplace accommodations; and recourse including appeal mechanisms and independent medical assessments.

3.2.1 Communication

We expected to find that return to work committee meetings, return to work file documentation, and ongoing dialogue with the injured employee support case management. This criterion was met.

Good Practice

At some locations, a WCB representative(s) attends, and participates in, return to work committee meetings. This practice provides an opportunity to enhance the relationship between all parties, and increases the WCB’s knowledge and understanding of the correctional environment.

3.2.2 Case Management Plans

We expected to find that return to work plans, vocational rehabilitation plans, and workplace accommodations comply with requirements and support case management. This criterion was met with some exceptions.

Case management plans support efficient and effective case resolution.

Developing a return to work and accommodation plan (see Glossary for a description) for the employee following a workplace injury is an important component of case management. It helps ensure a safe, timely, and successful return to work.

Return to Work Plans

In practice, return to work plan creation is dependent on several factors, including the nature of the injury, medical limitations, and amount of lost time from the workplace. For example, a plan may not be necessary for an injured employee returning from an absence of only a few days to his or her regularly scheduled substantive position. With this in mind, the auditors noted that 57 of the 126 files reviewed included information that return to work activities (i.e. modified work, accommodation, etc.) were undertaken. We expected to find plans in these 57 files. However, only 70% (40/57) included a documented return to work plan, and of these, 80% (32/40) were captured on CSC’s prescribed form 1390-1e. Improper documentation of the return to work plan may hinder the injured employee’s progress towards a successful return to work, will limit CSC’s ability to hold all parties accountable for their respective roles in the return to work process, and will make it difficult to demonstrate to the WCB the instances when an employee is not participating with an agreed upon plan. In cases where an employee does not participate in the return to work process, the WCB may choose to discontinue their support for his or her entitlement. In turn, it is important that CSC be able to demonstrate, through a previously agreed upon return to work plan, that the employee is or is not participating as this may have important implications on WCB decisions, an employee’s motivation to follow the plan, and CSC’s financial costs.

Workplace Accommodations

According to the CSC national Return to Work Guideline “the provision of modified work is a sound rehabilitative step that improves recovery times and results in lower financial and human costs to the Service and the employee. The manager shall make every effort to provide accommodated (modified) work.” Both file reviews and interviews with staff indicated that there are inconsistent strategies in place for workplace accommodations. Some managers will create work or assign an employee to a role that is not their substantive position, while other managers will simply allow the employee to remain at home until a return to regular full time duties is feasible. A failure to provide modified work leads to non-compliance with the national Return to Work Guideline, reduces organizational productivity, and does not support the employee’s successful return to work.

File review was conducted to determine if workplace accommodations that resulted from injury-on-duty respected the medical limitations provided by the employee’s treating practitioner and/or the WCB. Forty-two of the 126 files reviewed included information that a workplace accommodation had occurred. Five of the files could not be assessed due to incomplete documentation. Of the files that could be assessed, 100% (37/37) were found to be compliant with medical limitations.

Overall, significant efforts are being made by institutional management to ensure appropriate accommodations for injured employees when they are able to return to work.

3.2.3 Leave Decisions and Injury Tracking

We expected to find that leave decisions are timely and assessed against requirements; and leave is properly recorded and credits reinstated as appropriate. This criterion was not met.

Leave decisions are not always timely or assessed against requirements.

Approval authority for injury-on-duty leave is outlined in CSC’s Instrument of Delegation of Authorities in the Area of Human Resource Management. Initial approval must be granted by the employee’s manager, and if the case is long-term in nature, the approval authority escalates to higher levels of management depending on the length of the absence. Further, the TB Policy indicates that a special departmental review should be conducted if the injury-on-duty leave reaches 130 working days.

Initial Approval of Injury-on-Duty Leave

We found that unlike other types of leave, the employee’s manager does not approve injury-on-duty leave transactions within HRMS. Rather, injury-on-duty leave is typically entered into HRMS by compensation personnel or a Labour Relations Advisor. However, as per CSC’s Instrument of Delegation of Authorities in the Area of Human Resource Management, the employee’s manager is still required to approve the injury-on-duty leave. When conducting audit testing within HRMS, it was found that neither the name of the person entering the leave in the system, nor the name of the manager is recorded next to the transaction as is customary for other types of leave. The system does not indicate the names in these instances because an injury-on-duty leave request is not initiated by the employee. Therefore, we could not assess compliance rates for injury-on-duty leave approval at the transactional level due to a lack of an audit trail within HRMS and on file. Further, interviews indicated that the initial approval of injury-on-duty leave is not always compliant with these requirements as it is not always approved by the appropriate delegated authority prior to making the entry in HRMS. Improper approval of injury-on-duty leave increases the risk that an employee is granted injury-on-duty leave without entitlement, the employee’s leave credits within HRMS are not accurate, and reporting from the system will be unreliable for decision making.

Ongoing Approval of Injury-on-Duty Leave

Another example of non-compliant leave approval relates to the Bulletin. In our audit sample, several cases, including cases involving non-CX staff, extended beyond 130 days without being subjected to a special departmental review. HRMS leave data for the audit time periodFootnote 13 was assessed in order to estimate the number of employees on injury-on-duty leave for more than 130 working days. We found that during this timeframe, 265 employees were on injury-on-duty leave for more than 130 working days. Of the 265 employees, 75% (199/265) were CX staff and 25% (66/265) were non-CX staff. Although the national policy centre does not support application of the Bulletin to non-CX staff, it has yet to issue formal guidance to the regions in this regard. The regions have therefore been left to determine application of the Bulletin, and in turn, reported to us that they have been applying it to non-CX staff as a way to reduce the inequality in benefit application across employment categories. Given that the injury-on-duty leave benefit (full salary payments and accumulation of leave credits) is typically more lucrative for injured employees than WCB direct payment, application of the Bulletin could provide a disincentive for employees to return to work. This also leads to increased costs for long-term cases, and has a negative overall impact on case management. Following completion of the audit testing work, CSC issued an updated Bulletin, which provides more clarity around injury on duty leave application as well as requirements for managing individual cases. However, it is too early to determine whether or not the updated Bulletin will adequately address the issues listed in this paragraph and in consequence, we suggest that CSC takes measures to evaluate the success of the new Bulletin once it has been in effect for an appropriate period of time.

Leave and injury information is not properly recorded or tracked.

Sick Leave Reinstatement

The national RTW Guideline states: “sick leave is only used to cover the gap between the time of accident and the time when the WCB allows the claim. Once the claim is allowed, all sick leave used is credited back to the employee.” We found that when sick leave credits are reinstated in HRMS following injury-on-duty leave approval, the original sick leave entry is removed from the system, and thus we could not determine if accurate amounts of sick leave were reinstated. Without proper documentation of sick leave transactions, there is an increased risk that improper reinstatement of sick leave credits is not detected, thus potentially increasing the financial liability for CSC.

Injury Recording in HRMS

There is the potential for incurring multiple injuries from one incident, and this may impact the recording of injuries in HRMS. For example, a staff member could be involved in an incident that leads to multiple physical injuries, an associated occupational stress injury, or both. We found that the nature of injury on file was recorded accurately in HRMS 66% (83/126) of the time. Of the errors noted, the most common (ten files) were due to an absence of complete injury information in HRMS for an incident. Improper recording of injuries in HRMS increases the risk that reporting from the system will be unreliable for decision making, particularly with respect to injury prevention and trending of injury information.

3.2.4 Employer-led WCB Appeals and Independent Medical Assessments

Approval of workers’ compensation benefits (for a description of benefits see the Glossary) is dependent upon medical information provided by a treating practitioner and a subsequent approval by the WCB. Given that adjudication is made by an external party, we expected to find that mechanisms are in place to support CSC’s position if it does not agree with an employee’s claim or the subsequent WCB approval.

The following areas presented in this section did not fully meet the audit expectations for this criterion.

The importance of employer-led appeals and independent medical assessments is elevated due to the perception that there are unethical claims.

We found that management and staff in the regions question the validity of some WCB injury claims, often citing a lack of ethics on the part of the employee submitting a claim. For example, employee submission of a WCB claim for a non work-related injury, and employee attempts to use injury-on-duty leave when other types of leave have been exhausted.

When used appropriately, employer-led appeals support case management.

A total of 3,389 WCB claims were submitted during fiscal years 2011-2012 and 2012-2013. A report from the national policy centre for this time period indicated that only 18 of these claims were appealed by CSC; five from one region and 13 from another. The report indicated that six of these appeals were ruled in CSC’s favour by the WCB, one was ruled partially in CSC’s favour, and the remaining were pending review. Audit site visits occurred after the policy centre report was issued, and we found that some of the appeals that were pending review had not been ruled in CSC’s favour. However, the national policy centre could not provide current results as they do not prepare reports on a regular basis.

We found that decisions to initiate employer-led WCB appeals are ultimately left up to the local manager, and are based upon his or her discretion, which is consistent with requirements in the national Return to Work Guideline. Sites that were not active with employer-led appeals were unfamiliar with the process in place to facilitate the appeal, did not have confidence that decisions would be ruled in CSC’s favour, and/or were concerned that challenging an employee’s claim would have a detrimental impact on the employee-manager relationship.

Although CSC is not tracking the amount of cost savings from successful appeals, outcomes in its favour would lead to significant cost and leave recovery in several cases, and would contribute to the mitigation of possible fraud. Conversely, inappropriate or unsuccessful appeals have the potential to further exacerbate an employee’s injury particularly if it is a stress-related injury, and can lead to labour relations actions against the employer. As well, initiation of employer-led WCB appeals that are inappropriate or unsuccessful lead to unnecessary expenditures.

The current framework for independent medical assessments does not support case management.

As per the national Return to Work Guideline: “The employer can request workers to undergo an independent medical examination by a medical practitioner or advisor of the employer's choice. An examination can be conducted to confirm the employee's limitations, to prepare for an appeal, or to ensure that the employee is fit to return to work.” Staff indicated that formal independent medical assessments are no longer being used due to their costs, poor timeliness and results, and a perceived lack of independence when performed by Health Canada. Rather than initiating a formal assessment, the typical approach is to contact the WCB and/or treating practitioner informally for additional information regarding medical limitations when an injured employee is able to return to work.

Without a mechanism in place that would better serve CSC’s needs, there is an increased risk that funds are spent on an activity with limited value-added, and that medical limitations are not respected when injured employees are able to return to work.

Conclusion

Overall, we found aspects of case management that support efficient and effective case resolution. Case communication, particularly with respect to return to work committee meetings, supported case management. As well, case management plans typically supported efficient and effective case resolution. However, we noted a number of areas related to case management where improvement is needed. Areas of risk that we identified are described below:

Recommendation 3

The Assistant Commissioner, Human Resource Management should:

  • Address deficiencies identified within HRMS that lead to poor tracking of injury-on-duty leave; and
  • Ensure accurate and complete injury information in HRMS through increased supervision, monitoring and reporting of data on a frequent basis.
Management Response

We agree with this recommendation. By September 30, 2015, the ACHRM will:

  • Implement a consistent approach to ensure accurate recording and reporting of injury-on-duty information.
Recommendation 4

The Assistant Commissioner, Human Resource Management should improve oversight of injury-on-duty claims to ensure they are fully scrutinized including measures to:

  • Reinforce compliance with return to work plan requirements;
  • Enhance guidance for employer-led appeals, and consider the need to have appeals led by an authority external to the site in order to protect the employer-employee relationship; and
  • Improve the framework for medical assessments, including guidance and options for managers.
Management Response

We agree with this recommendation. By June 30, 2015, the ACHRM will:

  • Implement a consistent approach for documenting return to work initiatives;
  • Review internal WCB appeal process; and
  • Clarify process for managers to obtain relevant medical information from the WCB to assist with return to work solutions.

4.0 Conclusion

With respect to the first objective, we found that certain aspects of the governance framework were in place to support management of injury-on-duty. A policy framework for management of injury-on-duty exists. In addition, training activities and occupational stress awareness programs are in place. Overall, the governance framework requires improvement in order to better support management of injury-on-duty. We noted a number of areas that require further consideration by management to ensure that the risks to the organization are better managed:

For the second objective, we found aspects of case management that support efficient and effective case resolution. Case communication, particularly with respect to return to work committee meetings, supported case management. As well, case management plans typically supported efficient and effective case resolution. However, we noted a number of areas related to case management where improvement is needed. Areas of risk that we identified are described below:

Recommendations have been issued in the report to address the root cause of our observations.

5.0 Management Response

Management agrees with the audit findings and recommendations as presented in the audit report. Management has prepared a detailed Management Action Plan to address the issues raised in the audit and associated recommendations. The management action plan is scheduled for full implementation by September 30, 2015.

6.0 About the Audit

6.1 Approach and Methodology

Audit evidence was gathered through a number of methods such as: review of documentation; analytical review, and interviews.

Review of Documentation: relevant documentation that was reviewed included: legislation; internal and external policies and related guidelines; job descriptions; organizational charts; training and awareness materials; monitoring and reporting information; HRMS records; and return to work files.

Analytical Review: was performed as part of the assessment on corporate analysis; leave decisions; return to work plans; vocational rehabilitation and workplace accommodations; and appeal mechanisms and independent medical assessments.

Sampling Strategy: In order to develop a sampling approach that addressed the audit criteria identified in Annex A, a sample was selected from the following populations:

These populations were stratified by location, file type (injury-on-duty leave and WCB direct payment), category of employee, and injury type. Random samples were chosen from these stratified populations. The sampling approach allowed us to review files that had gone through the return to work process in its entirety, and long-term files that had not been resolved within one year. In total, 126 files were reviewed.

Sites were selected based on a number of factors that included: volume of reported injury-on-duty leave cases; geographical location; classification of institution; and financial and time constraints for completing the audit testing.

Interviews: A total of 73 interviews were conducted with management at National and Regional Headquarters, institutional management, human resources personnel, and union representatives.

Site Visits: This audit included on-site testing in all five regions and National Headquarters (refer to Annex B for a complete list of sites visited).

6.2 Previous Audit Work

We reviewed internal and external audit reports for areas where CSC was identified as having weaknesses or risk exposures and for recurring risk areas to assist with the scoping of this audit. The following audits were deemed relevant:

6.3 Statement of Conformance

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed on with management. The opinion is applicable only to the area examined.

The audit conforms to the Internal Auditing Standards for Government of Canada, as supported by the results of the quality assurance and improvement program. The evidence gathered was sufficient to provide senior management with proof of the opinion derived from the internal audit.

_
Sylvie Soucy, CIA
Chief Audit Executive

Glossary

Employee Assistance Program
A voluntary and confidential program designed to provide assistance to employees, and their family members, who are experiencing personal or work related problems that may impair their well-being and productivity. Assistance, referral and short term counselling will be provided to any employee or family member who seeks it.
Commissioner’s Directive 253
Critical Incident Stress Management
A program designed primarily for employees who are likely to be involved in critical incidents. The emphasis of the program is twofold: First, it is preventive, aimed at educating and preparing employees to deal with potential hazards of being exposed to very stressful events. Second, it focuses on providing support, assistance and follow-up services to individuals who have been involved in critical incidents.
Commissioner’s Directive 253
Human Resource Management System
A PeopleSoft, Inc. software product that is endorsed by the Treasury Board Secretariat and used by Correctional Service Canada.
Injury-on-Duty Leave
Employees covered by a collective agreement are entitled to injury-on-duty leave with full pay for a period of up to 130 days, as determined by the appropriate manager with delegated authority, provided that the claim's initial and ongoing entitlement is supported by the WCB. Sick leave is only used to cover the gap between the time of accident and the time when the WCB allows the claim. Once the claim is allowed, all sick leave used is credited back to the employee, effectively starting the injury-on-duty leave on the day of injury.
A manager or his/her designate is responsible for determining injury-on-duty leave for such a reasonable period.
CSC Guideline 254-2
Return to Work Committee
A workplace or regional advisory group formed to review workplace injuries or illnesses and their resulting conditions with the goal of assisting the manager to identify opportunities for reintegration into the workplace. This committee will include representation from union, management and staff to review WCB cases and facilitate a return to work.
CSC Guideline 254-2
At the local level, meetings are to occur on a monthly basis. At the regional and national levels, meetings are to occur not less than quarterly.
Return to Work Committee Terms of Reference
Return to Work Plan
The individual written return to work plan is key to the concept of shared responsibility and joint commitment to common goals. It is the road map back to employment for the worker. Like a road map, the return to work plan identifies the destination and the specific route to be taken.
CSC Guideline 254-2
Vocational Rehabilitation
Programs and services designed to re-establish, as much as possible, a worker’s pre-injury earnings profile or maximum earnings potential.
CSC Guideline 254-2
WCB Employer-led Appeal
Employers who disagree with a decision made in a WCB claim have the right to discuss the decision with the WCB decision maker and request a formal appeal when the disagreement is unresolved.
In general, most provincial WCBs have two to three different levels of appeal. The initial level of appeal is most frequently known as a review or reconsideration as it occurs at the operating level. When a manager or employee disagrees with a decision made in the claim, the first step is to request the decision maker “review or reconsider” their decision. Some WCBs provide a formal second level of appeal which is impartial but an internal review of the WCB decision for employees and employers who continue to challenge the WCB decision. A final level of appeal for employees and employers dissatisfied with decisions is the Workers’ Compensation Appeal Tribunal (WCAT), separate and independent of the WCB. The WCAT is an external quasi-judicial body authorized to hear final level appeals on compensation claim matters. WCAT decisions are final with no further avenue for appeal.
CSC Fact Sheet: “Workers’ Compensation Appeals Information”
Workers’ Compensation Benefits
The Government Employees Compensation Act provides for employment injury benefits (workers' compensation).
Such benefits include:
  • compensation for loss of earnings (if an injured employees is not entitled to injury-on-duty leave);
  • medical, hospital, and related services;
  • rehabilitation services;
  • a pension, if an injury results in a permanent disability; and
  • pensions to dependants of employees who are fatally injured in the course of their employment.
Treasury Board Policy on Workers’ Compensation
Workers’ Compensation Direct Payment
In cases where the affected worker is not granted injury-on-duty leave, he or she may receive direct payment of workers' compensation benefits (salary replacement) which is a percentage of regular salary as established by the workers' compensation legislation of the province in which the injured worker is normally employed.
CSC Guideline 254-2
Workplace Accommodation
The changing of work or work methods in order to permit a person to return to productive employment.
CSC Guideline 254-2

Annex A: Audit Criteria

The following table outlines the audit criteria developed to meet the stated audit objectives and audit scope:

Objective Audit Criteria Met/Met with Exceptions/Partially Met/Not Met
  1. Assess the extent to which a governance framework is in place to support management of injury-on-duty.
1.1 CSC Policy Framework: The CSC directive and related guidance is up-to-date, clear, and complies with requirements. Partially Met
1.2 Organizational Structure & Roles and Responsibilities: The organizational structure, roles, and responsibilities are defined, documented, and understood. Partially Met
1.3 Training Activities and Awareness: Training activities have been developed, provided, and taken; and CSC contributes to the awareness of occupational stress injuries. Met
1.4 Corporate Analysis: Corporate analysis is being performed and facilitates organizational improvement. Not Met
  1. Assess the extent to which case management practices support efficient and effective case resolution.
2.1 Communication: Committee meetings, file documentation, and ongoing dialogue with the injured employee supports case management. Met
2.2 Leave Decisions: Leave decisions are timely and assessed against requirements; and leave is properly recorded and credits reinstated as appropriate. Not Met
2.3 Return to Work Plans: Return to work plans support case management and comply with requirements. Met with Exceptions
2.4 Vocational Rehabilitation and Workplace Accommodations: Vocational rehabilitation and workplace accommodations support case management. Met with Exceptions
2.5 Appeal Mechanisms and Independent Medical Assessments: Appeal mechanisms and independent medical assessments support case management. Partially Met

Annex B: Location of Site Examinations

Region Sites
Atlantic Dorchester Penitentiary
Springhill Institution
Nova Institution for Women
Regional Headquarters
Québec Regional Headquarters
Ontario Millhaven Institution
Collins Bay Institution
Regional Headquarters
Prairie Saskatchewan Penitentiary
Regional Psychiatric Centre
Regional Headquarters
Pacific Matsqui Institution
Fraser Valley Institution for Women
Regional Headquarters
National Headquarters National Headquarters

Footnotes

Footnote 1

2014-15 CSC Report on Plans and Priorities

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Footnote 2

Any workplace injury that requires medical attention must be reported to the workers’ compensation board. This figure includes both reported and non-reported injuries.

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Footnote 3

12-13 to 14-15 Strategic Plan for Human Resource Management

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Footnote 4

2014-15 CSC Report on Plans and Priorities

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Footnote 5

Any workplace injury that requires medical attention must be reported to the workers’ compensation board. This figure includes both reported and non-reported injuries.

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Footnote 6

Percentages do not add due to rounding

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Footnote 7

http://www.tbs-sct.gc.ca/pol/doc-eng.aspx?id=12139&section=text

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Footnote 8

As per HRMS data for audit scope period April 1, 2012 to December 31, 2013

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Footnote 9

Correctional Services (CX) Collective Agreement (2013)

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Footnote 10

CSC Guideline 254-2 Return to Work Program

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Footnote 11

ibid

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Footnote 12

These included all CSC injuries, not only those that resulted in a WCB claim.

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Footnote 13

The audit time period covered employees on injury-on-duty leave between April 1, 2012 and December 31, 2013.

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