2022 Edition

Group Living Services (CA-GLS) 16: Privacy Provisions

The organization provides for resident comfort, dignity, privacy, and safety.




Group Living Services allow individuals who need additional support to regain, maintain, and improve life skills and functioning in a safe, stable, community-based living arrangement.
Related Standards:
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Privacy policy
  • Privacy procedures
  • Judicial order, law, or contract, as applicable
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Residents
  • Review case records
  • Observe facility

Fundamental Practice

CA-GLS 16.01

The organization ensures residents’ comfort, dignity, privacy, and safety by:
  1. prohibiting the use of surveillance cameras or listening devices in bedrooms;
  2. maintaining doors on sleeping areas and bathroom enclosures;
  3. providing one- or two-person rooms to residents who need extra sleep, protection from sleep disturbance, or extra privacy for clinical reasons; and
  4. requiring employees and residents to knock before entering an individual's room unless there is an immediate health or safety concern.


When organizations are required to employ alternate practices, documentation must be provided to justify the practice. Documentation may include a judicial order, law, contract, copy of the province's safety plan for a resident, or clear, clinical written justification for a resident.

Sensitivity should always be taken to ensure that all residents, especially abuse or trauma survivors and the LGBTQ population, feel safe and not violated.
Note: Please see the Facility Observation Checklist for additional guidance on this standard.

Fundamental Practice

CA-GLS 16.02

Searches of residents or their property are conducted in a trauma-informed manner that respects people's rights, dignity, and self-determination and include, as appropriate to the frequency and invasiveness of searches:
  1. communicating policies for searches of individuals or their property to residents in writing;
  2. timely notification of a parent and/or legal guardian, when applicable;
  3. definition and documentation of reasonable cause and assessed risk of harm to self or others;
  4. trained, qualified staff; and
  5. an administrative review process including documentation, notification, and the timetable for review.


Search procedures should correspond directly to the invasiveness of the search to be conducted. For example, more invasive searches should be reserved for higher risk situations with reasonable cause, should only be conducted by highly qualified personnel, and always require an administrative review.

Fundamental Practice

CA-GLS 16.03

The organization communicates policies that respect residents’ privacy for reviewing mail and only does so when a previous incident involving the resident indicates that:
  1. the mail is suspected of containing unauthorized, dangerous, or illegal material or substances, in which case it may be opened by the resident in the presence of designated personnel; or
  2. receipt or sending of unopened mail is contraindicated.


Programs serving individuals with substance use conditions may require personnel to review mail without incident due to the reason for which residents are seeking treatment. If an organization employs this approach, it must provide justification for taking such measures, which may include health, safety, and other security concerns.
Examples: Examples of mail include letters, packages, emails, and other forms of correspondence via social media and electronic communication.

Fundamental Practice

CA-GLS 16.04

All residents can have private telephone conversations, and any restriction is:
  1. based on contraindications and/or a court order;
  2. approved in advance by the program director or an appropriate designee;
  3. documented in the case record; and
  4. reauthorized weekly by the immediate supervisor of the direct service provider.