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Audit Report
Audit for
Covenant Health – St. Michaels Health Centre
October 20, 2014
2012 CCSA Audit Report
2
Table of Contents Executive Report 3
Employer Information 4
Contact Information 4
Scope of Audit 4
Auditor Information 5
Company Profile / Explanation of Audit Scope 6
Scoring Summary Results 7
Conclusion 8
Appendix – Organization ChartError! Bookmark not defined.
Appendix – Summary Site and Interview Sampling Information Sheet 12
Appendix – Site Information Sheet 14
Appendix – Pre-Audit Meeting Minutes 16
Appendix – Post-Audit Meeting Minutes 17
Detailed Audit Report 18
1. Management Leadership and Organizational Commitment 19
2. Hazard Identification and Assessment 29
3. Hazard Control 37
4. Ongoing Inspections 48
5. Qualifications, Orientation and Training 56
6. Emergency Response 63
7. Incident Investigation 68
8. Program Administration 77
Observation Report 85
2012 CCSA Audit Report
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Executive Report
Employer Information
Employer Name:
(As registered with WCB)
Covenant Health - St. Michael’s Health Centre
Employer Trade Name:
(If applicable)
Billing Address: 1400 9th Avenue South, Lethbridge, Alberta T1J 4V5
Contact Information
Name: Geoff Hoeppner Phone: 780-342-8736
Email: Geoff.Hoeppner@covenanthealth.ca Fax: 780-342-8744
Scope of Audit
COR No.: 20090810-2435 COR Expiry:
Audit Type:
☐ External / COR Certification
X Internal / COR Maintenance
Audit Purpose:
☐ External / Renewal
X Internal
☐ Qualifying Audit
Total Facilities: 2 Facilities Audited: 2
WCB Account No(s). 3156836 WCB Industry Code(s):
Start Date: End Date:
Report Date:
2012 CCSA Audit Report
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Auditor Information
Privacy, Confidentiality, Conflict of Interest and Disclaimer Statement:
The Audit will be conducted with the utmost integrity, confidentiality and no conflict of interest. The facts
stated in the audit will be recorded accurately and according to the information received at the time of the
audit. The intent of the audit is to give guidance, enhance current programs, and suggestions for
improvement, not to undermine any current processes in place, or assume liability for changes or use of
the document for any reason other than the original intent. I agree to submit my audit within an
acceptable time frame and address all deficiencies in a timely manner. I hereby certify that I participated
in at least one (1) of the three (3) key areas of conducting the audit (documentation review, interviews
and observations). Additionally, if this is my qualifying audit I certify that I have written the Audit Report in
my own words.
Lead Auditor: Name: Matthew Godarzi Phone: 780-342-8733 Company: Covenant Health Fax: 780-342-8744 Address: 11111 Jasper Avenue, Certification: 094-13 Edmonton, Alberta T5K 0L4
X Documentation x Interviews x Observations Date: October 20, 2014
Audit Team Members:
Name: Phone:
Company: Fax:
Address: Email:
Certification:
Address: Email:
Certification:
☐ Documentation ☐ Interviews ☐ Observations Date:
2012 CCSA Audit Report
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Company Profile / Explanation of Audit Scope
Covenant Health is Canada's largest Catholic provider of healthcare, serving 12 communities across Alberta. Their facilities provide a range of healthcare services, including acute care, continuing care, assisted living, hospice, rehabilitation and respite care, and seniors' housing. Serving people of all faiths, cultures and circumstances, Covenant health builds on a 150-year legacy of providing compassionate, quality care in Alberta. Included in the scope of the audit were two of the Covenant Health facilities in Lethbridge, including the St. Michaels Health Centre and St. Therese Villa
St. Michael’s Health Centre Built on the legacy of the Sisters of St. Martha of Antigonish, who founded St. Michael’s Hospital in 1929, St. Michael’s Health Centre was opened in 2001 and serves those in Southern Alberta who need continuing care, inpatient and outpatient rehabilitation programs and services, and palliative care. It is a state of the art residential-style facility was constructed on the historic 13th Street site of the old St. Michael’s Hospital. The residential model ensures personal choice, dignity and respect for the patients and residents who are accommodated in individual and personalized rooms in smaller home-like groupings. St. Michael’s Health Centre offers a multi-faceted range of rehabilitation, palliative and
continuing care services. St. Therese Villa, Lethbridge The new Villa opened April 15th, 2008 as part of the St. Martha’s Care Group, St. Michael’s Housing Association, whose roots go back to 1929 and St. Michael’s Hospital, founded by the Sisters of St. Martha of Antigonish. St. Therese Villa provides Designated Assisted Living (DAL) combining accommodation services with other supports and care with 196 staff, and has a 200 bed capacity. Nursing staff work 3 shifts that cover the 24 hour period. The facility meets the needs of a wide range of people, but not those who have highly complex and serious health care needs. St. Therese Villa offers their residents requiring assisted living a place where they are treated with kindness and compassion and an environment in which their dignity is preserved
2012 CCSA Audit Report
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Scoring Summary Results
Element Number
Total
Points
Possible
Points not
Applicable
(N/A)
Total
Points
Points
Scored
Final
Score
1. Management Leadership and
Organizational Commitment 115 0 115 108 94%
2. Hazard Identification and
Assessment 170 0 170 148 87%
3. Hazard Control 160 0 160 114 71%
4. Ongoing Inspections 95 0 95 87 92%
5. Qualifications, Orientation and
Training 100 0 100 92 92%
6. Emergency Response 110 0 110 73 66%
7. Accident and Incident
Investigation 125 0 125 97 78%
8. Program Administration 125 0 125 112 90%
Total Audit Points
1000
0
1000
831
83%
2012 CCSA Audit Report
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Conclusion
It was a pleasure to conduct this audit for Covenant Health. On-site activities were conducted on all two
sites included in the scope of the audit between September 9 and September 12. A total of 68 interviews
were conducted, sampling staff from a wide variety of departments, positions, shifts, experience, etc. The
auditor would like to thank all employees for their co-operation and participation in bringing this audit to a
successful completion. Managers, Supervisors and Workers from all work areas and shifts did their best
to supply all the required documentation and interview information.
Areas of Key Strength:
Employees had a good overall awareness of their specific health and safety responsibilities, as
well as hazard and incident reporting requirements.
All work areas had very consistent and up to date hazard assessment documentation in place.
All workplace inspections were completed as quarterly required within the Units/departments.
All employees received job specific training and completed orientation within the first week of
employment.
All investigations reports are reviewed by Manager and Supervisors.
There is a system is in place to communicate health and safety issues with employees, provide
feedback opportunities, and ensure follow up on health and safety issues.
The health and safety system is evaluated annually through the use of an audit process
Areas of Key Suggestions:
A hard copy of Current Alberta OH&S Legislations wasn’t readily available in the sites. It is
suggested to ensure a current copy of Alberta OH&S Legislations is kept at all units /departments
which is readily accessible to the all staff, and the staff are made aware of the legislation copy.
Some health and safety hazard had not been identified for job and task in the Units/departments
(included cytotoxic drugs, O2 cylinder, etc.). It is suggested that all units/department, to review
their hazard assessments to ensure that each sampled position specific Task Hazard assessment
systematically identified the health and safety hazards related to the position’s key tasks.
There are lack of some measures and procedures to control some of the risks in facilities. These
risk included violence (patient abuse) airborne pathogen, cytotoxic and hazardous drugs, etc. It is
suggested to
Review the existing control measures and determine whether they are adequate.
Consultant with OHS team to identify other controls which may be needed to reduce the risk.
(Examples: N95 mask, cryogenic gloves, safety procedures, buddy system, training, panic
alarms, security cameras…)
2012 CCSA Audit Report
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Observation indicated employees are using surgical mask during their work activity and also that
PPE were kept in locking room and weren’t readily available to employees in the care Units that.
Documentation verified that most of the employees have been not fit tested for N95 mask at both
sites. Ensure all employees are using proper PPE in their work are as outline in Alberta OHS
codes (Part 18 Section 228) and Covenant Health policy and procedures regarding. In addition,
all PPEs must be readily available within the Units/departments.
Worker participation and involvement in key OHS activities such as hazard assessments, formal
safety inspections, and incident investigations is inconsistent and lacking in areas. It is suggested
to foster enhanced worker participation in these activities, as well as increase the communication
of such participation and the outcomes of the activities to all affected staff. This will ensure that
workers’ perspectives are sufficiently addressed and included, and contribute to the overall buy-in
and promotion of a positive health and safety culture. It is further suggested consider keeping a
hard copy of updated hazard assessments (with sign-off sheet) and completed work place
inspection in the binders within the units.
Some of the employees who did not believe that they received appropriate OHS training (include
hazard assessment, work place inspection, incident investigation, and emergency response,
etc.). And also, they unaware if key employees who conducting incident investigation, hazard
assessment and work place inspection have received training had not received on these
techniques. It suggested encouraging all employees to complete Covenant Health OHS online
training courses (included OHS awareness for workers awareness, and workplace abuse &
harassment, etc). It is further suggested to create a spreadsheet and transfer all training
activities into the spreadsheet in order monitor all employees training activities (included online
OHS training courses, annual and refresher training, job specific training).
The generic Workplace Inspection Checklist mainly represents patient care areas, and although it
can be modified, little customization was observed in the sampled documentation in the units /
departments. It is suggested to develop area / operation specific inspection checklist templates
for each of the main departments / types of work areas (i.e. dietary, housekeeping, maintenance,
etc.), and to make those available to all locations.
Although there are some supplies and equipments available in the both sites, both sites do not
meet all legislature requirements for First Aid as outlined in Alberta OHS cods, part 11. This
requirement included provision of first aid services supplies and equipment ( lack of first aid kid’s
#3), first aid kit are not visible readily available, first aid provider (LPN and RN completed online
supplementary first aid course), designated first aid area, first aid signage etc. It is suggested to
implement Covenant Health first aid plan in both sites to comply with Legislations.
23% of interviews indicated that some employees have not been able to participate in emergency
drill. Also, employees stated that some of the emergency response drills had not been conducted
after OHS representative left the site. It is suggested to conduct regularly emergency drill with all
units and all shifts to ensure employees is kept up-to-date on emergency procedures for the site.
It is further suggested to continue with the practice of reviewing the code of the month with all
staff members.
Only 40% of sampled incident investigation reports properly identified direct, indirect and root
causes, and had appropriate recommended corrective actions documented. It is suggested that
thorough root cause analysis is applied to all investigations to determine the most effective
preventative measures, and that this be properly and fully documented in the investigation reports
or other attached information. It is further suggested to ensure that all recommended corrective
action be also properly and fully documented on the investigation report forms. This ensures that
investigations result in the most effective recommendations to prevent recurrence, and that these
recommendations can be tracked more effectively.
2012 CCSA Audit Report
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Although an action plan had been developed as a result of the previous audit, several item of
action plan had not been completed. Also, some employees interviewed were unaware of
previous audits results and action plan. It is suggested to ensure that an action plan is developed
and systematically implemented over the next year. It is further suggested to ensure all
employees are aware of audit process and action plan results. This can be done by discussing
the audit with the employees through the OH&S meetings and Staff meeting, and also posting
action plan on OHS board
Overall the both sites have a comprehensive health and safety management system in place. It is very apparent that a large amount of work has gone into the development and implementation of the health and safety program and preparation for this audit. Congratulations on a good score which is well deserved by the ongoing, consistent dedication and efforts of all staff. To maintain the Certificate of Recognition and to receive the WCB PIR incentives an external audit will again be required to renew the COR prior to the date stated on the Certificate of Recognition in 2015. Thank you once again and keep up the good work. Please contact myself if you have any questions, comments, or require further assistance. Sincerely, Matthew Godarzi
2012 CCSA Audit Report
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Appendix – Organization Chart
2012 CCSA Audit Report
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Appendix – Summary Site and Interview Sampling
Information Sheet
Employer: Covenant Health – St. Michael’s Health Center
BC Account #: 3156836 Industry Code: 82705 – Health Units
Total Number of Sites: Minimum Number of Sites: Total # of Sites included in
Audit:
Contractors and volunteers? X Yes ☐ No # Interviewed: 4
Total 71
Detailed Representative Sampling Information:
Interview Sampling Details
Department Shift Total #
Interviewed Department
Shift Total # Interviewed D E N D E N
Senior Managers 1 n/a n/a 1 Rehabilitation 2 1 0 3
Managers 4 n/a n/a 4 Education 2 1 0 3
RN 3 2 1 6 Social Services 0 0 0 0
LPN 4 3 3 10 Administration 7 0 0 7
HCA 3 2 6 11 Pharmacy 1 0 0 1
RA 3 4 4 11 Laundry 1 0 0 1
Maintenance 3 0 0 3 Housekeeping 2 1 0 3
Dietary Services 2 1 0 3 Others:
Recreation 2 1 0 3
Total Number of Employees Interviewed: 67
Role
Number of Employees Total # of Employees Per
Role
Total # of Employees
Interviewed / Role Full-Time
Part-Time
Casual
Senior Managers 1 0 0 1 1
Managers 6 0 0 6 4
Supervisors 5 0 0 5 3
Workers 167 186 179 532 59
Total # of Employees: 544
Minimum # of Interviews Required: 64
Total # of Employees Interviewed: 67
2012 CCSA Audit Report
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Work Site Sampling Details
List each site under the WCB Account #
Included in Audit
Scope?
Total Number of Employees
Number Interviewed
St. Michael’s Health Centre Yes 333 42
St. Therese Villa Yes 211 29
NOTE: if there is more than one site included in the audit, one Site Sampling Sheet must also be
completed for each site and included in the Audit Report.
Additional Explanation of sampling if required:
2012 CCSA Audit Report
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Appendix – Site Information Sheet Site Name: St. Michael’s Health Centre
Account #: 3756836 Industry Code: 82705 – Health Units
Site Specific Detailed Interview Sampling:
Interview Sampling Details
Department Shift Total #
Interviewed Department
Shift Total # Interviewed D E N D E N
Senior Managers 1 n/a n/a 1 Recreation 1 0 0 1
Managers 3 n/a n/a 3 Rehabilitation 2 1 0 3
RN 1 2 1 4 Education 1 0 0 1
LPN 2 2 1 5 Social Services 0 0 0 0
HCA 1 0 3 4 Administration 6 0 0 6
RA 1 1 2 4 Pharmacy 1 0 0 1
Maintenance 2 0 0 2 Laundry 1 0 0 1
Dietary Services 3 1 0 4 Other:
Housekeeping 1 1 0 2 13
Total Number of Employees Interviewed: 42
Additional Explanation of sampling if required:
Role
Number of Employees Total # of Employees Per
Role Full-Time
Part-Time
Casual
Senior Managers 1 0 0 1
Managers 4 0 0 3
Supervisors 3 0 0 2
Workers 19 12 4 35
Total # of Employees: 333
2012 CCSA Audit Report
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Appendix – Site Information Sheet Site Name: St Therese Villa
WBC Account #: 3756836 Industry Code: 82705 – Health Units
Site Specific Detailed Interview Sampling:
Interview Sampling Details
Department Shift Total #
Interviewed Department
Shift Total # Interviewed D E N D E N
Senior Managers 0 0 0 0 Education 0 0 0 0
Managers 1 n/a n/a 1 Social Services 0 0 0 0
RN 2 0 0 2 Administration 1 0 0 1
LPN 2 1 2 5 Pharmacy 0 0 0 0
HCA 2 2 3 7 Others:
RA 2 3 2 7 Housekeeping Aramark Contract
Maintenance 1 0 0 1 Dietary services Aramark Contract
Recreation 1 0 0 1 Landry Aramark Contract
Rehabilitation 0 0 0 0 Aramark Contractors
3 1 0 4
Total Number of Employees Interviewed: 29
Additional Explanation of sampling if required:
Role
Number of Employees Total # of Employees Per
Role Full-Time
Part-Time
Casual
Senior Managers 0 0 0 0
Managers 1 0 0 1
Supervisors 1 0 0 1
Workers 11 9 3 23
Total # of Employees: 211
2012 CCSA Audit Report
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Appendix – Pre-Audit Meeting Minutes
Date: September 10, 2014 Time: 8:30-9:30 Attendees: James Ostoya(Manager, Post Acute Rehab Program), Lian Baceda(Manager, LTC), Debbie Kohutek(Supervisor, Food Services), Lisa Zubach(Manager, Supportive Living, Dementia), Jim Riedhuber(Interim Site Manager), Deb Dodman(Aramark Lead), Tracy Kopp,( Executive Secretary) Agenda:
Introductions of audit team
Purpose of the audit
Sites included in audit and audit schedule
PIR and CCSA Partnerships audit instrument
Describe the audit process and the timing of the process 1. Review of documents 2. Interviews 3. Observation tour
Discuss confidentiality of audit process and auditor code of ethics
Post audit meeting is scheduled for Friday, December 6, 2013
Discuss FAQs and invite other questions or comments
2012 CCSA Audit Report
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Appendix – Post-Audit Meeting Minutes
Date: September 12, 2014 Time: 12:30-13:45
Attendees: James Ostoya(Manager, Post Acute Rehab Program), Lian
Baceda(Manager, LTC), Debbie Kohutek(Supervisor, Food Services), Lisa
Zubach(Manager, Supportive Living, Dementia), Jim Riedhuber(Interim Site Manager),
Deb Dodman(Aramark Lead), Tracy Kopp,( Executive Secretary)
Agenda:
A general overview of the audit
Debriefing of the audit findings:
Key Strengths for each element
Key Recommendations for each element
Scoring summary is not completed by this time so specific scores were not
discussed
Approximate timelines for audit report completion is October 19, 2013
Submission of final report to the CCSA for quality assurance review
Delivery of final report to facility once the quality assurance review has been
received from CCSA
in hard copy and digital format
Invite questions from all participants
Thank you to all participants for their involvement and cooperation in the audit
process
2012 CCSA Audit Report
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Detailed Audit Report
2012 CCSA Audit Report
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Continuing Care Safety Association for Safety Partnerships
Audit Report – November 2011
1. Management Leadership and Organizational Commitment
Questions Score Instructions Notes
1.1 Is there a written Health and Safety
Policy for the organization?
(5 points)
5
Verified by reviewing written policy.
Must be a policy document.
To award the 5 points, the policy must
include:
- declaration of management commitment to
health and safety
- overall goals and objectives
- general responsibilities of managers,
supervisors, workers and contractors
regarding health and safety
- requirement to comply with applicable
government regulations
- requirement to comply with organization’s
own health and safety standards
Strength: Covenant Health has a Health and
Safety Policy (# II-130) contained in the Corporate
Policy and Procedures Manual. The policy states
that Covenant Health is committed to providing a
safe place to work, basic responsibilities and
accountabilities for all employees, physicians,
volunteers, students and contractors, including the
responsibility to perform their work according to
legislative requirements and company standards,
as well as the overall goals of achieving zero harm
through the promotion and encouragement of
occupational health and safety and the mitigation
and elimination of workplace hazards and risks.
Full points were awarded based on the
completeness of the reviewed policy.
1.2 Is the policy signed by the current
senior operating officer?
(2 points)
2
Verified by reviewing documentation.
The signature must be that of the current
senior operating officer.
Strength: The health and safety policy is signed by
current president and CEO of the Covenant Health
Patrick Dumelie.
2 out of 2 points were awarded based on reviewed
of documentation.
2012 CCSA Audit Report
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Questions Score Instructions Notes
1.3 Is the policy readily available to
employees?
(0-3 points)
3
Verified by observation or employee
interviews, as applicable.
Determine the method used by the employer
to make the policy readily available.
The current policy may be posted on bulletin
boards, in lunchrooms and/or reception
areas, and may be in employee handbooks,
safety manuals, and/or on computer.
Points are awarded based on the percentage
of positive observations, or on the
percentage of positive responses from
interviews.
Strength: 96% of interviews and 92% of
observations indicated that the Health and Safety
Policy is readily available to employees at both
sites.
The policy was observed to be posted on OHS
Board and in key areas throughout the facilities.
Interviews stated that the policy was also
discussed during orientation; new employees
received a copy of it.
3 out of 3 points were awarded based on the
percentage of positive indicators from the
interviews and observations.
1.4 Are employees aware of the policy’s
content?
(0-5 points)
5
Verified by employee interviews
Employees should be able to explain, in
general terms, the policy content.
Points are awarded based on the percentage
of positive responses from interviews
Strength: 94% of employees interviewed were
aware of the general content of the Health and
Safety Policy. Interviewees provided examples of
the policy’s key messages, such as Covenant’s
overall commitment to health and safety, their
requirement to provide a safe working environment,
and that established standards and policies must
be followed, as well as the shared responsibility for
health and safety between all persons in the work
place.
5 out of 5 points were awarded based on the percentage of positive interview responses
2012 CCSA Audit Report
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Questions Score Instructions Notes
1.5 Have specific health and safety
responsibilities been written for:
a. Managers? (5 points)
b. Supervisors? (5 points)
c. Workers? (5 points)
d. Contractors? (5 points)
5
5
5
5
Verified by reviewing documentation,
other than the policy (e.g. contracts, job
descriptions, and program manuals).
Depending on size or nature of the
organization, one or more of these
categories may not be applicable (n/a).
Strength: Documentations reviewed indicated that
health and safety responsibility have been writ ten for all of the organizational levels from the Senior Leadership Team to the managers, Supervisors, Workers, contractors, volunteers, and students. The written responsibilities are comprehensive, appropriate and clearly stated for each category. Full points were awarded for each category based on the comprehensive written responsibilities for each level in the organization.
Full points were awarded for each category based
on the comprehensive written responsibilities for
each level in the organization.
1.6 Are the following aware of their specific
health and safety responsibilities
covered by legislation and
departmental policy:
a. Managers? (0-5 points)
b. Supervisors? (0-5 points)
c. Workers? (0-5 points)
d. Contractors? (0-5 points)
5
5
5
5
Verified by employee and contractor
interviews.
Points may be awarded even though specific
written specific responsibilities (in question
1.5) are not in place.
Points are awarded based on the percentage
of positive responses from interviews.
Depending on size or nature of organization,
one or more of these categories may be not
applicable. (N/A)
Strength: 100% of Managers and Supervisors,
Contractors and 96% of employees and
Contractors interviewed were aware of their health
and safety responsibilities, and could provide
examples of that. Common examples of specific
health and safety responsibilities included following
safe work procedures, watching out for each other
safety, participating in hazard assessment process,
the requirement to report incident and hazards,
getting involved in OHS committees, etc.
Full points were awarded for each category of
managers, supervisors, contractors, workers and
based on the percentage of positive interview
response.
2012 CCSA Audit Report
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Questions Score Instructions Notes
1.7 Are employees evaluated on their
individual health and safety
performance?
a. Managers? (0-5 points)
b. Supervisors? (0-5 points)
c. Workers? (0-5 points)
5
5
5
Verified by employee interviews.
Employees at all levels should be able to
explain how their OH&S performance is
evaluated. Some examples are performance
appraisal, discipline process for non-
performance, letters from the employer,
positive reinforcement by supervisors, job
safety observations, management and
supervisor reviews, etc.
Points are awarded based on the percentage
of positive responses from interviews.
Strength: 100% of Managers and Supervisors,
and 96% of Workers interviewed stated that they
were evaluated on their individual health and safety
performance. Employees received feedback and
health and safety performance evaluations verbally
during informal interactions with their supervisor or
manager, as well as during formal annual
performance appraisals. In addition, it was noted
that non-disciplinary interventions and a
progressive discipline process are in place to
correct performance as required.
Full points were awarded for each category based
on the percentages of positive interviews.
1.8 Does the senior operating officer
communicate to employees, at least
annually, the organization’s
commitment to health and safety?
(5 points)
5
Verified by employee interviews to
determine how this is done.
Points awarded for at least 70% positive
response from employees interviewed.
Strength: 95 % of employees interviewed
indicated that the President / CEO of Covenant
Health, as well as the Site Senior Operating
Officers do communicate the organization’s
commitment to health and safety several times per
year. The President / CEO communicate the
commitment to and importance of health and safety
during his appearance in the bELITE training
Video. Senior Operating Officers communicate
regarding health and safety through memos, in
meetings, committees, and informal interactions.
Full points were awarded based on the percentage
of positive interview responses exceeding the
required 70%.
2012 CCSA Audit Report
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Questions Score Instructions Notes
1.9 Do the most senior managers on-site
tour the work site to reinforce health
and safety practices and behaviors:
Every 6 months? (10 points)
OR
Yearly? ( 5 points)
10
Verified by employee interviews.
Senior manager tours can be concurrent with
other business purposes.
Not all sites need to be included in the tours.
Points are awarded for at least 70% positive
response from employees interviewed.
Strength: 98% of employees interviewed stated
that on-site senior management tours the work site
regularly to reinforce health and safety practices
and behaviors. Interviews stated that the frequency
of tours ranges from monthly, to weekly, to bi-
annually, depending on the site.
10 points were awarded based on more than the
required 70% of interviews indicating tours every 6
months or more often
2012 CCSA Audit Report
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Questions Score Instructions Notes
1.10 Is relevant current health and safety
legislation readily available at work
sites?
(5 points)
0
Verified through observation at work
sites.
Copy(s) of current occupational health and
safety legislation (federal, provincial, and
municipal) appropriate to the operation of the
work site(s) should be present on site.
Points are awarded for at least 70% positive
response from observations.
Strength: 65% of observations indicated that the
current Alberta Occupational Health and Safety
Act, Regulation, and Code (2013 revisions) was
readily available to employee by means of the
computers. Several employees that were asked
about their access to the legislation during the
tours weren’t also able to demonstrate how they
can find the legislation on line. There wasn’t any
hard copy of Alberta OH&S Legislations on both
sites.
Recommendations: It is suggested to ensure all
Employees have access to the hard copy of current
Alberta OHS Legislations, and that the location of
the legislation is posted within Unit s/Department if
it is not apparent.
No points were awarded based on percentage of
positive interview response being below the
required 70%.
2012 CCSA Audit Report
25
Questions Score Instructions Notes
1.11 Is there a process in place that
addresses contractor health and safety
while on site?
(5 points)
5
Verified by interviewing contractors on
site and reviewing documentation.
Points are awarded for at least 70% positive
response from persons interviewed and
documentation to conform the process.
If no contractors are on site, then the score is
based on documentation. For example, look
for a documented contractor orientation
program that ensures all contractors are
oriented to the hazards at their site.
Strength: 81% of interviews and 80% of reviewed
documentation reviewed indicated that a process in
place to address contractor safety while they are
on site. The health and safety policy states that
contractors will comply with the all applicable
legislations. Also formal contractor’s information
package provided to all contractors covering
comprehensive information including
responsibilities, work permits, start-up meetings,
and emergency response procedures, fire safety,
locations of emergency response equipment and
first aid, and infection controls. Interview confirmed
that items are discussed and followed.
Recommendation: It is further suggested to
review the process to address contractor health
and safety for some of the other types of
contractors being used on sites, such as persons
dealing with biomedical equipment, physicians, etc.
These types of contractors are not covered under
the standard contractor information package, and
generally not monitored by facility maintenance.
Establishing standardized processes and
responsibilities for the management of these
contractors will ensure greater consistency across
the various departments/units and sites.
5 out of 5 points were awarded based on the percentage of positive indicators exceeding 70%
2012 CCSA Audit Report
26
Questions Score Instructions Notes
1.12 Is there a process in place that
addresses visitor health and safety
while on site?
(5 points)
5
Verified by review of documentation or
employee interviews.
An external auditor is considered a visitor on
site.
Points are awarded based on at least 80%
positive indicators from documentation or
interviews.
Strength: 93% of the interviews and 100% of
reviewed documentation indicate that a process is
in place to address visitor health and safety while
on site. This procedure include posted information
and signage in facilities and, keeping restricted
access areas locked, staff monitoring visitors and
responding to any issues , hand washing and
infection, prevention procedures, on site protective
services and, check in and outs of units visitors,
interaction with staff . Also, Interviews indicated
that visitor health and safety is protected by
ensuring that the building and overall environment
are kept clear and free of hazards, Practicing good
housekeeping.
Full points were awarded based on the percentage
of positive indicators from the reviewed
documentation and interviews exceeding the
required 80%.
2012 CCSA Audit Report
27
Questions Score Instructions Notes
1.13 Does the employer provide the health
and safety resources needed (workers,
equipment methods, materials, and
money) to implement and improve
health and safety?
a. Managers? (0-5 points)
b. Supervisors? (0-5 points)
c. Workers? (0-5 points)
4
5
4
Verified by employee interviews.
Points are awarded based on the percentage
of positive interview responses
Strength: 80% of managers interviews,
100%supervisors interviews, and 72% of worker
interviewed stated that the sufficient resources are
provided to implement and improve health and
safety .Examples of resources include JWHS
committees, education and ongoing training,
personal protective equipments, extra funding to
address issues /emergency, code of the month
reviews, etc.
Recommendation: 20% of Managers, and 28% of
Workers interviewed felt that the resources
available to implement and maintain health and
safety at the work site were Insufficient. The
biggest concern voiced was a lack of time to keep
up with the required health and safety activities and
ensure worker participation. Other areas of concern
focused on a need for more hands-on training for
some critical skills, issues with aging equipment
and short staffing levels. It is suggested that
regular communications and dialogue with staff
from all work areas and shifts is promoted and
enhanced, so that issues can be discussed and
addressed in an ongoing basis. This will ensure
that resources are allocated to maintain the health
and safety of the work environment, and to support
the front line staff in their service delivery.
4 out of 5 points were awarded for the Manager
and Worker interviews based on the interview
responses and 5 out of 5 points awarded for
Supervisors.
2012 CCSA Audit Report
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Questions Score Instructions Notes
Total Points Possible: 115
Audit Score
Total points possible: 108 - Points not applicable (N/A) 0 = Total points 108 Total Points scored = 108
(divided by)
X 100 = FINAL SCORE 94%
Total points = 115
2012 CCSA Audit Report
29
2. Hazard Identification and Assessment
Questions Score Instructions Notes
2.1 a. Does the employer have a list of all
jobs carried out at the work site?
(0-15 points)
b. Has the employer compiled a list of
all tasks associated with each job?
(0-15 points)
30
Verified by reviewing documentation.
A list of employee occupations/jobs should
be in place, and the various tasks within
those occupations/jobs should be identified.
Points are awarded based on the percentage
of jobs and tasks inventoried.
Strength: A very concise inventory of the
jobs/positions has been developed and updated through over two years (2011 and 2012). Each job has the breakdown of tasks associated with the performance of the specific job. The inventory includes a hazard assessment for each position. Hazards assessment binder maintained in administration office. Also an electronic copies are readily available online which maintained in the Database (K drive). Full points were awarded based on of percentage of job and tasks being inventoried
2012 CCSA Audit Report
30
Questions Score Instructions Notes
2.2 Are health and safety hazards identified
for the jobs and tasks?
(0-30 points)
29
Verified by reviewing documentation to
determine if there is a system in place to
identify hazards associated with the jobs and
tasks (Refer to 2.1).
Both health and safety hazards should be
identified to ensure that ergonomic risks,
exposure to chemicals, noise, heat stress,
etc. are addressed. Consider road safety if
driving is a component of the job inventory.
Points are awarded based on the percentage
of jobs and tasks for which hazards have
been identified compared to the total number
of jobs and tasks identified. In other words,
the maximum score allowed for this
question will be determined by the total
score awarded in question 2.1.
For example, if only 50% of the points were
awarded in question 2.1, question 2.2 will be
scored out of 15 (50% of the original 30
points available for the question).
Key Strength: The review of the hazard
assessment documents indicated that all of the required position specific Typical Task Hazard Assessments were available at the units / departments sampled during the audit. Hazards assessments are address almost the entire hazards associate with the positions. Identified health and safety hazards includes chemical, physical, biological, and psychosocial Hazards. Recommendation: Documentation sampling in
care units indicated that hazard associated with cytotoxic drugs had not been identified within the care units. It is suggested that all care units, periodically review their hazard assessments to ensure that task hazard assessments are available for each position / job conducted in their area. This will ensure that health and safety hazards are identified for each job task. 29 out of 30 points were awarded based on the percentage of positive indicators from the reviewed documentation
2012 CCSA Audit Report
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Questions Score Instructions Notes
2.3 Have the health and safety hazards
been evaluated according to risk?
(0-30 points)
29
Verified by reviewing documentation.
There must be a system/process for
evaluating risk.
System should include an assessment of
the:
- Potential consequences of exposure to
the hazard (severity)
- Likelihood of an incident occurring
(probability)
- Degree of exposure to the hazard
(frequency)
This evaluation could be qualitative (High,
Medium, Low, A, B, C,) or quantitative (3, 2,
1).
Points are awarded based on the percentage
of hazards that have been evaluated
compared to the health and safety hazards
identified in 2.2. In other words, the
maximum score allowed for this question
will be determined by the percentage score
awarded in question 2.2. (See question 2.2
for example.)
Strength: All health and safety hazards identified
in job Hazards Analysis forma are ranked according to the risk. The ratings are determined by combining of probability, frequency of exposure, and severity. Also, ranking hazards uses a 1 to 4 scale to rate each component. The maximum score is therefore 12.
Recommendation: It is suggested that the hazard
evaluation process is continued to be applied consistently when the existing hazard assessments are further refined.
29 out of 30 points were awarded based on the score achieved in question 2.2.
2012 CCSA Audit Report
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Questions Score Instructions Notes
2.4 Are identified health and safety hazards
prioritized according to risk?
(0-30 points)
29
Verified by reviewing documentation to
determine if a system to assess the
evaluated hazards and rank them from the
highest to lowest. In other words, the
maximum score allowed for this question
will be determined by the percentage score
awarded in question 2.3.
Strength: All health and safety hazards in job
Hazards Analysis form are prioritized into low medium or high risk categories, based on the outcome of their risk evaluation and overall rating total. These total values represent three different risk / priority classifications. 3-6 points equates to low risk /priority, 7-9 to medium risk / priority, and 10-12 to high risk / priority. Recommendation: It is suggested that the hazard
evaluation process is continued to be applied consistently when the existing hazard assessments are further refined. 29 out of 30 points were awarded based on the score achieved in question 2.3.
2012 CCSA Audit Report
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Questions Score Instructions Notes
2.5 Are workers involved in health and
safety hazard identification and
assessment?
(10 points)
0
Verified by review of hazard assessment
documentation and interviewing workers
to confirm whether the involvement in the
formal hazard assessment process is
meaningful.
At least 70% of those interviewed must be
aware of worker involvement to award
points. Not all workers need to be involved.
Worker involvement could be through health
and safety committees, teams, safety
representatives, projects, pre-job planning,
etc.
Strength: hazard assessment document review
indicated that the worker involvement in the hazard assessment process is clearly marked by naming the workers that are involved in the process. Element 2 of the Covenant Health Occupational Health and Safety Program states that employees performing the work being assessed must be involved in the hazard assessment through either direct participation or by reviewing the report completed by others. Recommendation: Only 67% of interviews
were aware of worker involvement in the health and safety hazard identification and assessment processes. It is suggested that the results of hazard assessment development, updates, or reviews be communicated to all affected workers, to ensure each employee is aware of the hazard assessment pertaining to their job and of the worker involvement and input opportunities in the hazard assessment process. No points were awarded based on less than the required 70% of interviews being aware of worker involvement in the identification and assessment of hazards.
2012 CCSA Audit Report
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Questions Score Instructions Notes
2.6 Are key employees trained in the
process of hazard identification and
assessment?
(0-10 points)
6
Verified by review of documentation and
interviewing key employees.
Key employees lead the hazard assessment
process (team leaders, etc.).
Score: 0 - 5 points for documentation
0 - 5 points for interviews
Points are awarded based on the percentage
of positive indicators.
Strength: 80 % of reviewed documentation and
39% of interviews indicating that key employees
have received training in the process of hazard
identification and assessment. Hazard identification
and assessment training is included in both the
Covenant Health Leaders and workers Guide to
Occupational Health and Safety courses, which are
available online. Training records indicated that
none of key employees have completed one of
these courses; however, Interviews indicated that a
number of them had attended CCSA and others
hazard assessment training.
Recommendation: It is suggested that all
Managers, Supervisors, and the Workers assigned
to participate in the hazard assessment process
complete this course as required by element 2
(hazard management) of the OHS program. This
will ensure that key persons are knowledgeable,
and better able to participate in and facilitate the
hazard assessment activities. It is further
suggested to provide in-house training sessions for
those employees who can’t use computers
4 out of 5 points were awarded based on the interview responses, and 2 out of 5 based on the available documentation.
2012 CCSA Audit Report
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Questions Score Instructions Notes
2.7 Are the health and safety hazard
assessments reviewed when changes
to the operation are implemented?
(0-30 points)
25
Verified by records review and employee
interviews.
Documentation may include meeting
minutes, supervisor’s logbook, assessment
documents, etc.
Changes to the operation could include
introduction of new equipment, processes,
products, materials, etc.
Score: 0 – 10 points for documentation
0 – 20 points for interviews
Interview points are awarded based on the
percentage of positive indicators.
Strength: 90% of reviewed documentation and
81% of interviews indicated that health and safety
hazard assessments are reviewed when changes
to the operation are implemented. 95% of sampled
hazard assessments were current, last reviewed /
updated in 2014. In addition, seven specific
samples were noted of hazard assessments having
been completed or revised as a result of
implemented changes. 81% of employees
interviewed indicated that the Typical Task Hazard
Assessments are reviewed annually or that
changes are discussed when new equipment or
new procedures are implemented.
Recommendation: 19% of Interviews indicated
that some employees are unaware of the updated
hazard assessment when changes to the operation
are implemented. It is suggested to communicate
hazard assessment changes to the all employees.
To ensure that everyone has been included in this
communication, consider keeping a hard copy
sign-off sheet behind each hazard assessment in
the binders within the units.
9 out of 10 points were awarded based on the
positive indicators from reviewed documentation,
and 16 out of 20 based on the interview responses.
Total Points Possible: 170 148
2012 CCSA Audit Report
36
Audit Score
Total points possible: 170 - Points not applicable (N/A) 0 = Total points 148 Total Points scored = 148
(divided by)
X 100 = FINAL SCORE 87%
Total points = 170
2012 CCSA Audit Report
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3. Hazard Control
Questions Score Instructions Notes
2012 CCSA Audit Report
38
Questions Score Instructions Notes
3.1 Have hazard controls been identified
and implemented?
a. Engineering? (0-25 points)
b. Administrative? (0-25 points)
c. Personal Protective Equipment
(PPE)? (0-15 points)
20
20
12
Verified by review of documentation and
observation as appropriate. Verification
process involves looking at the
recommended hazard control measure in the
hazard assessment document and verifying,
through either observation or documentation,
that controls have been put into place.
Points are awarded based on the percentage
of controls implemented compared to the
number of hazards identified in question 2.4.
The maximum score allowed for this
question will be determined by the
percentage score allowed in question 2.4.
Strength: 80% of the reviewed documentation and
observations indicated that appropriate hazard
controls have been identified and implemented in
the various work areas. Engineering hazard controls
included mobile lifts and overhead lift systems,
trolleys, pallet jacks, carts, locked doors for
restricted access, noise enclosure, ergonomically
adjustable computer work stations, lock
housekeeping cart, ant-fatigue/ anti-slip mats,
machine guards, fume hoods and ventilation, etc.
Administrative controls included safe work policies
and procedures, infection control and prevention
emergency response quick reference charts, MSI
prevention, chemical safety information, office
ergonomic breaks poster, use of good lifting
techniques, proper hand hygiene practices,
warning signs, etc. PPE controls included a variety
of gloves, gowns, steel toe boots, hair nets, ear plug
and ear muff, oven mitts, face shields, goggles, etc.
Recommendation: 20% of the reviewed
documentation and observations indicated that
some required hazard controls were not identified
or not consistently implemented. It is suggested
that special attention is paid to controls required for
potential health hazards, including airborne
pathogen, violence and patient abuse, chemical
hazards (cytotoxic and hazardous drugs), etc. To
ensure that appropriate controls are in place such
as engineering control (dress alarm, radio, cell
phone, camera, curved mirrors), PPE (N95 mask),
and administrative control (safe work procedures, ).
20 out of 25 points were awarded for the
engineering and administrative controls, and12 out
of 15 for the PPE controls
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.2 Are workers involved in establishing the
control of health and safety hazards?
(10 points)
10
Verified by employee interviews.
At least 70% of workers interviewed must be
aware of worker involvement in the
development, review or implementation of
controls. Worker involvement could be
through health and safety committees,
teams, safety representative, etc.
Not all workers need to be involved, but the
auditor must confirm that workers were
involved in the formal hazard control
process.
Strength: 70% of interviews indicated that workers
are involved in establishing controls for identified
health and safety hazards. Interviews stated that
workers are involved by being part of the hazard
assessment teams, reviewing their position specific
Hazard Assessments and commenting on them,
discussing controls during staff meetings or as part
of the JWHS committees, reporting requirements
through E-Facility or to the supervisor / manager,
being part of teams to develop safe work practices
and procedures, etc.
Key Recommendation: 30% of interviews were
unaware of worker involvement in the
establishment of hazard controls. It is suggested to
ensure you include all employee levels and
positions in the hazard assessment and control
processes in all work areas. In addition, it is
suggested to communicate the results of such
process and the worker involvement and input
opportunities to all affected staff to ensure their
awareness of the hazard controls and worker
involvement in their development.
10 points were awarded based on the percentage
of positive interview responses exceeding the
required 70%.
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.3 Are employees using controls
developed for identified health and
safety hazards?
(15 points)
0
Verified by employee interviews and
observation.
Compare/observe employee performance
against hazard controls developed in
question 3.1.
Points are awarded based on any
combination of interviews and observations
to achieve 90% positive response.
Strength: 90% of observations and 85% of
interviews indicated that employees are using the
developed hazard controls. Interviews stated that
employees are consistent in their use of the
required hazard controls, and observations noted
that employees were using most of required PPE,
use appropriate body mechanics, have equipment
guards in place, etc. in all work areas that were
toured.
Recommendation: Employee interviews indicated
that although employees are using most of the
control in their work place, many of the employees
are not using proper PPE (such as N95 mask,
gloves) within the work areas in the sites. It is
suggested to ensure all employees knowledgeable
about control hazards affecting them. Ensure all
employees are using proper PPE (included N95
mask) in their work are as outline in Alberta OHS
codes (Part 18 Section 228) and Covenant Health
policy and procedures regarding.
No points awarded based on positive interview
response and observations being below the
required 90%
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.4 Is there a process for maintaining
equipment and preventing the use of
defective equipment?
(10 points)
10
Verified by review of documentation and
employee interviews.
Review maintenance and work order
records. Interview workers to confirm
defective equipment is removed for repair.
Points are awarded based on any
combination of interviews and documentation
to achieve 70% positive response.
Key Strength: 100 % Documentation review and
95 % of employee’s interview indicated that a
process is in place for maintaining equipment and
preventing the use of defective equipment. These
are maintenance procedures on the site as follow:
Preventive maintenance which check quarterly all equipments on the site.
Computer based system E-Facility maintenance which records are coordinate on-demand maintenance activities. Employees use E-Facility to maintain and report defective equipments within units/departments.
Full points were awarded based on the percentage
of positive interview responses and reviewed
documentation exceeding the required 70%.
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.5 Does management enforce the use of
engineering controls?
(0-10 points)
5
5
Verified by worker interviews and
observation.
Interview workers (0-5 points)
Interview points are awarded based on the
percentage of positive responses.
Observation (0-5 points)
On the observation tour, observe whether
management is enforcing the use of
engineering controls. Observations points
are awarded based on the percentage of
positive observations.
Strength: 96% of observations and 93% of
interviews and indicated that management
enforces the use of engineering controls.
Interviews stated that management monitors the
consistent use of engineering controls by staff
during their daily rounds and informal observations.
Noncompliance is initially addressed through non
disciplinary interventions, such as reminders,
instructions and coaching. Observations indicated
that employees are generally using the required
controls.
Recommendation: It is suggested to reinforce the
importance of consistent enforcement of all
required engineering controls to staff from all work
areas and shifts. Actively monitoring and enforcing
standards will help in overall injury reduction
efforts.
5 out of 5 points were awarded for the observations
and 5 out of 5 points for the interviews, based on
the percentage of positive indicators from each.
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.6 Does management enforce the use of
safe work procedures, rules and work
practices?
(0-10 points)
5
5
Verified by worker interviews and
observation.
Interview workers (0-5 points)
Interview points are awarded based on the
percentage of positive responses.
Observations (0-5 points)
On the observation tour, observe whether
management is enforcing the use of safe
work procedures, rules and work practices
when there is a violation. Observation points
are awarded based on the percentage of
positive observations.
Strength: 96% of observations and 93 % of
interviews indicated that management enforces the
use of safe work practices and procedures.
Interviews stated that management monitors the
consistent use of administrative controls by staff
during their daily rounds and informal observations.
Non-compliance is initially addressed through non-
disciplinary interventions, such as reminders,
instructions, and coaching. During observation
tours employees were observed using the required
controls.
Recommendation: It is suggested to reinforce the
importance of consistent enforcement of all
required administrative controls to staff from all
work areas and shifts. Actively monitoring and
enforcing standards will help in overall injury
education efforts.
5 out of 5 points were awarded for the observations
and 5 out of 5 points for the interviews, based on
the percentage of positive indicators from each
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.7 Is the required PPE available?
(10 points)
0
Verified by observation and worker
interviews.
Auditor must observe that the PPE identified
in the hazard control document (refer to
question 3.1) is readily available for
employee use.
Points are awarded based on at least 90%
positive indicators using any combination of
observation and interviews.
Strength: 60% of observations and % 66 of
interviews indicated that most of required PPE is
readily available to employees at both sites and
work areas.
Recommendation: Employee interviews indicated
that although employees are using most of the
require PPE in their work area, many of the
employees have been not N95 mask fit tested
mask at both sites. Also, employees are using
surgical mask during their work activities.
Observations indicated that PPE were kept in
locking room and was not readily available to
employees in the care Units.
The decision whether or not to require workers to
use either surgical masks or respirators must be
based upon a hazard analysis of the workers'
specific work environments and the different
protective properties of each type of personal
protective equipment. Alberta OHS codes stated
that If respiratory protective equipment is used,
employers are required to provide the appropriate
equipment, maintain and store it properly, and
ensure that it is properly fitted to the individual
worker.
It is suggested to ensure all employees are N95
mask fit tested and used N95 mask (if necessary).
In addition, All personal PPEs are readily available
within the Units/departments.
No points awarded based on positive interview
response and observations being below the
required 90%
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.8 Where Personal Protective Equipment
(PPE) is used as a method of control,
are employees trained in the use, care
and maintenance of the protective
equipment?
(0-15 points)
3
7
Verified by observation and employee
interviews.
Interview (0-5 points)
Interview points are awarded based on the
percentage of positive responses indicating
that training was provided.
Observation (0-10 points)
Observation points are awarded based on
the percentage of positive observations
confirming that PPE is used, cared for and
maintained properly and as instructed.
Strength: 70% of observations and % 66 of
interviews indicated that employees are trained in
the use, care, and maintenance of the PPE they
are required to use. Interviews indicated that
training for the required PPE is provided during
orientation, job specific training, annual essential
education, etc. Observation verified that the PPE
was in good conditions, as well as the correct use
and storage of PPE in the various work areas.
Recommendations: 25% 0f observation and 34%
of the interviewed indicated that employees are not
wear mask correctly and consistently. Employees
are using surgical mask instead of the N95 mask. It
is important that all manager, supervisor and
employees understand the significant differences
between these two types of personal protective
equipments. The decision whether or not to require
workers to use either surgical masks or respirators
must be based upon a hazard analysis of the
employees' specific work environments and the
different protective properties of each type of
personal protective equipment. Surgical masks are
used as a physical barrier to protect the user from
hazards, such as splashes of large droplets of
blood or body fluids.N95 masks are designed to
reduce a worker's exposure to airborne
contaminants .it is suggested to ensure all
employees are using proper PPE as outline in their
hazard assessment.
4out of 5 points were awarded based on the
percentage positive indicator from interview, and 5
out of 5 from observation, and 5 out of 5 from
documentation.
2012 CCSA Audit Report
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Questions Score Instructions Notes
3.9 Is the use of PPE enforced?
(0-15 points)
4
4
4
Verified by review of documentation,
observation and worker interviews.
The key here is enforcement.
Documentation review (0-5 points)
Determine if there is a management system
in place (e.g. written document, discipline
process) and if it is followed.
Interview workers (0-5 points)
Interview points are awarded based on the
percentage of positive responses. Use
interviews to verify that the management
system is followed.
Observation (0-5 points)
On the observation tour, observe whether
management is enforcing the use of PPE.
Observation points are awarded based on
the percentage of positive observations.
Strength: 73% of interview and 76% of
observation and 85% of reviewed documentation
indicated management enforces the use of all
required PPE.
A covenant Health Discipline and Termination
policy (policy no11-20 in the Corporate Policy and
Procedures Manual) outlines the progressive
discipline process and refers to the potential for
disciplinary action in cases of non-compliance to
expected policies and procedures. When non-
disciplinary interventions have not resulted in
acceptable work performance progressive
discipline is applied. This includes verbal warnings,
written warnings, and suspension without pay and
termination Interviews indicated that use of require
PPE controls is monitored in all areas. 80 % of
observation verified consistent proper PPE use by
staff, and storage of PPE in the units and
departments. Also 73% of Interviews verified that
management monitors the consistent use of
required PPE by staff during their daily rounds and
informal observations confirm the process to
address non-compliance. 76% of Observations
indicated that employees are generally using the
required control.
Recommendations: Ensure all employees are
aware of Covenant Health policy and procedures
regarding PPE enforcement. In addition, it is
suggested to ensure all employees are using
proper PPE as outline in their hazard assessment
4out of 5 points were awarded based on the
percentage positive indicator from interview, and 4
out of 5 from observation, and 4 out of 5 from
documentation
2012 CCSA Audit Report
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Questions Score Instructions Notes
Total Points Possible: 160
Audit Score
Total points possible: 160 - Points not applicable (N/A) 0 = Total points 114 Total Points scored = 114
(divided by)
X 100 = FINAL SCORE 71%
Total points = 160
2012 CCSA Audit Report
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4. Ongoing Inspections
Questions Score Instructions Notes
4.1 Is there a formal written process that
includes frequency of formal
inspections by:
a. Managers? (5 points)
b. Supervisors? (5 points)
c. Worker participation? (5 points)
5
5
5
Verified by review of documentation.
Process could be in the form of a policy,
plan, procedures, etc.
Frequency is established by the employer
based on the health and safety hazards.
Inspections should be done on a regular
basis to cover all work areas at least
annually.
Strength: Documentation reviewed indicating that
there is formal written inspection policy and
process in place. Element 3 (work place safety
inspection process) outlines the standard
requirements for workplace inspections. Formal
inspections are to be completed by inspection
teams consisting of a manager and/or supervisor
responsible for the department/area, a
representative of the local health and safety
committee if applicable, or another employee
appointed to the inspection team. Formal
inspections are to be conducted on a minimum
quarterly basis in each work area.
Full points were awarded for each category based
on the reviewed documentation.
2012 CCSA Audit Report
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Questions Score Instructions Notes
4.2 Are formal health and safety
inspections carried out in accordance
with the process by:
a. Managers? (5 points)
b. Supervisors? (5 points)
5
5
Verified by review of documentation (e.g.
inspection records), and by management
and supervisor interviews. Must also
verify the frequency of inspection is being
followed (reference question 4.1).
Formal documentation must exist to award
points.
Verify through interviews that inspections are
carried out by the individuals, and at the
frequency indicated in the documentation. At
least 70% of those interviewed must confirm
that the process is followed.
Depending on size or nature of the
organization, there may not be managers or
supervisors. In either case, one of these
categories may not be applicable (n/a).
Strength: 100% of reviewed documentation, 100%
Of manager and supervisor interviews indicating
that formal health and safety inspections are
conducted and completed as required by Covenant
health Standard requirements for workplace
inspections (Element 3).
.
5 out of 5 points were awarded for each category
based on the percentage of positive indicators from
reviewed documentation and interviews exceeding
the required 70%.
2012 CCSA Audit Report
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Questions Score Instructions Notes
4.3 Are workers involved in the
inspections?
(15 points)
15
Verified by worker and supervisor
interviews.
There must be evidence of worker
involvement in inspections to award points
(e.g. doing inspections).
At least 70% of those interviewed at each
site must be aware of worker involvement.
Not all workers need to be involved.
Strength: review Interviews indicting that 72% of
persons interviewed were aware of worker
involvement in the formal workplace inspections.
Recommendation: 28% of interviews indicated
that Some employees had been involved in the
formal inspection in some units/departments;
however this was not done consistently at all sites
and units /departments. It is suggested that all sites
promote regular worker involvement in the formal
inspection processes, and that this is
communicated to all staff. Involving workers from
all shifts on a rotating basis is very beneficial to
ensure greater participation and awareness of the
activity, as well as ensuring better monitoring of the
different work processes and hazard controls that
may be specific to certain shifts.
2012 CCSA Audit Report
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Questions Score Instructions Notes
4.4 Are the individuals designated to
conduct formal inspections given
appropriate training?
(0-10 points)
5
4
Verified by documentation and employee
interviews.
Documentation review (0-5 points)
Review training records to verify training is
appropriate. Points are awarded based on
the percentage of individuals who have
received the appropriate training.
Interview workers (0-5 points)
Interview designated individuals to confirm
they have received the appropriate training.
Interview points are awarded based on the
percentage of positive responses.
Strength: % 95 of documentation reviewed and
75% of interviews documentation indicated that
individuals designated to conduct formal inspection
have received training on how to conduct formal
workplace inspections.
Recommendation: Although majority of
documentation indicating employees received
training on formal inspection, 75% of employee’s
interviewed show they were unaware of who has
received the training for formal inspections.
Workplace inspection training is included in the
Covenant Health OHS Awareness Workers online
course. It is suggested that all employees complete
this course. This will ensure that all employees are
knowledgeable, and they are able to conduct and
document thorough safety inspections
4 out of 5 points were awarded based on the
interview responses, and 5 out of 5 based on the
available documentation.
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Questions Score Instructions Notes
4.5 Is a site/operation specific checklist
used for the inspection?
(0-10 points)
5
Verified by review of documentation (e.g.
inspection reports).
A site specific inspection checklist must be in
place at all operational sites/areas (could be
work sites, departments, operations, etc.)
Points are awarded based on the percentage
of operational sites/areas using the checklist.
Strength: Documentation review indicated that a
generic Workplace Inspection Checklist is in place
which includes observations on the work
environment, task, hazardous / bio-hazardous
materials, equipment, and emergency response.
Other area specific inspection checklists were
noted to be used for kitchen areas, labs, pharmacy,
etc.
Recommendation: The generic Workplace
Inspection Checklist mainly represents patient care
areas, and although it can be modified, little
customization was observed in the sampled
documentation in the units / departments. It is
suggested to develop area / operation specific
inspection checklist templates for each of the main
departments / types of work areas (i.e. dietary,
housekeeping, maintenance, etc.), and to make
those available to all locations.
5 out of 10 points were awarded to represent the
percentage of areas that were adequately
represented in the observed inspection checklists
4.6 Are inspections reports reviewed and
signed off by management?
(5 points)
5
Verified by review of inspection reports.
The report must be signed off by the
manager, at least one level above the
supervisor responsible for the area.
Points are awarded if at least 90% of
inspection reports reviewed and signed off
by management.
Strength: 100% of sampled inspection reports
were signed-off by management. It is suggested
that managers review and signed-off the completed
inspection, and ensure that follow up has occurred
on the identified items.
Full points were awarded based on the percentage
of positive indicators from reviewed documentation
being below the required 90%.
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Questions Score Instructions Notes
4.7 Are deficiencies identified in the
inspection report corrected in a timely
manner?
(0-15 points)
5
4
5
Verified by review of documentation,
employee interviews, and observation.
Points are awarded based on the percentage
of deficiencies corrected.
Documentation review (0-5 points)
Documentation should include a timeframe
for correction (that is as soon as practical)
and who is responsible. Verification that work
was completed (e.g. work orders, purchase
orders, memos, etc.) should also be
available.
Interview workers (0-5 points)
Interview management, supervisors and
workers to verify corrective action is done for
those actions that cannot be observed, and
determine whether corrective action is
completed in a timely manner.
Observations (0-5 points)
On the observation tour, observe whether
deficiencies identified in the documentation
have been corrected.
Strength: 98% of reviewed documentation ,76% of
interviews, and 96% of observations, indicated
that:
Deficiencies were observed to be identified
and documented in the inspection reports
Noted deficiencies had been followed up,
corrected and completed in a timely manner
The inspection forms had been reviewed and
signed off by management
Recommendation: Only 24 % of interviewed
indicated that they were unsure of the inspection
results or any follow up. It is suggested that each
work area communicate the inspection results and
corrective actions taken to all affected staff to
ensure their awareness of the activity and positive
outcomes.
5out of 5 points were awarded for the reviewed
documentation, and observations and 4out of 5
points were awarded for the reviewed interviews
based on the percentage of positive indicators.
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Questions Score Instructions Notes
4.8 Is there a system in place whereby
employees can report unsafe or
unhealthy conditions and practices?
(5 points)
5
Verified by a review of documentation and
employee interviews.
The evidence of a reporting system is
verified by first reviewing documentation
(policy, procedure) to confirm there is a
process, and then through interviews to
confirm awareness.
Points are awarded based on at least 80%
positive indicators using any combination of
documentation and interview results.
Strength: 100% of reviewed documentation and
95% of employees interviewed indicated that a
system is in place whereby employees can report
unsafe or unhealthy conditions and practices.
These process and system are includes:
A Health and Safety Issue Resolution Process
is outlined in Element 1 of the Covenant
Health OHS Program.
Systems to report unsafe or unhealthy
conditions and practices include near miss and
incident reporting, and
E-Facility reports for facility maintenance.
Verbal reports to supervisors or managers
Use of communication and discussions of
issues during staff / team meetings or local
JWHS committee meetings.
Full points were awarded based on the percentage
of positive indicators from interviews and reviewed
documentation exceeding the required 80%.
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Questions Score Instructions Notes
4.9 Does the system for reporting unsafe or
unhealthy conditions and practices
ensure action is taken by management
in a timely manner?
(0-10 points)
9
Verified by interviewing employees.
Interview points for action taken are awarded
based on the percentage of positive
responses indicating that timely action was
taken, and could include informing
employees of the corrective action taken.
Strength: 90% of employees interviewed indicated
that timely action is taken by management when
unsafe of unhealthy conditions and practices are
reported.
Recommendation: It is suggested to ensure that
follow up actions taken in response to any reported
health and safety issues / concern are
communicated to all potentially affected staff. This
will ensure that all employees are made aware of
positive actions taken.
9 out of 10 points were awarded based on the
percentage of positive interview responses
Total Points Possible: 95
Audit Score
Total points possible: 95 - Points not applicable (N/A) 0 = Total points 87 Total Points scored = 87
(divided by)
X 100 = FINAL SCORE 92%
Total points = 95
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5. Qualifications, Orientation and Training
Questions Score Instructions Notes
5.1 Is there a process in place to ensure
employees have the qualifications and
training to perform their jobs in a
healthy and safe manner?
(15 points)
15
Verified by review of documentation (e.g.
training records, application forms, hiring
records and employee records) and
employee interviews.
Documentation must exist to verify a process
is in place (can include things like degrees,
diplomas, certificates, trade certificates,
apprenticeship program diplomas, etc.).
Interviews should confirm that qualifications
and training are reviewed as part of the hiring
process, and are felt by workers to be
appropriate for the job.
Points are awarded based on at least 70%
positive indicators using any combination of
documentation and interview results.
Strength: 100% of interviews and 100% 0f
reviewed documentation indicated that a process is
in place to ensure employees have the
qualifications and training to perform their jobs in a
healthy and safe manner. These policy and
procedures is followed in recruitment process to
ensure that employees have the qualifications and
training to perform their jobs in a healthy and safe
manner.
The process includes developing job description,
advertizing Job, screening Job applications
(according qualification and experience outlined in
job posting), interviewing the candid ( by using a
formal interview guide and suitability rating
process), checking documents (certificate
,diplomas proof of current professional
registration), criminal record check and reference
check, and a pre placement assessment conducted
through the OHS department to verify vaccinations
and suitability for position.
Full points were awarded based on percentage of
positive indicator from reviewed documentation
exceeding the required 70%.
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Questions Score Instructions Notes
5.2 Are critical health and safety issues
addressed before the employee starts
his/her normal job responsibilities?
(0-15 points)
14
Verified by reviewing orientation
documentation and by employee
interviews.
Critical issues must include:
Organization Rules/Enforcement
Right to Refuse Unsafe Work
Emergency Response
Incident Notification
Critical Hazards
Score: 0-5 points for documentation
0-10 points for interviews
Points are awarded based on the percentage
of positive indicators.
Strength: 91% of interviews and 95 %
documentation reviewed indicated that critical
health and safety issues are addressed with new
employees prior to starting their normal job
responsibilities. Critical health and safety issues
are discussed in the site orientation, department /
unit orientations, or position specific orientations
and buddy shifts.
Recommendation: It is suggested to ensure that
all unit / department, site corporate orientations be
standardized to contain the required critical health
and safety issues, and be consistently
documented. With completion dates entered into
spreadsheets or a database which will enable more
effective monitoring and management of this type
of training. This will ensure that documentation can
be monitored and verify that all new employees
5 out of 5 based on the positive indicators from the
reviewed documentation, and 9 out of 10 points
were awarded based on the interview responses
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Questions Score Instructions Notes
5.3 Is the new employee orientation
completed within the first week of
employment?
(0-15 points)
14
Verified by reviewing records and
interviewing employees.
Look for orientation documentation.
Score: 0-5 points for documentation
0-10 points for interviews
Points are awarded based on the percentage
of positive indicators.
Strength: 84% of employees interviewed indicated
that they had completed a unit / department,
general site orientation within their first day of
employment. Documentation review indicated that
95% of new employees have completed the
corporate or general site orientation.
Recommendation: 15% of interviewed indicated
that employees had not completed site orientation
within the week. Negative comments indicated
since the new program (2013) was introduced; the
employees are being oriented on their first day of
employment. It is suggested to continue with the
current process of orientation prior to the start of
the first day.
5 out of 5 based on the positive indicators from the
reviewed documentation, and 9 out of 10 points
were awarded based on the interview responses.
5.4 Does the new employee orientation
cover employer heath and safety
policies and procedures?
(10 points)
10
Verified by reviewing documentation and
employee interviews.
Documentation includes orientation records
and orientation contents. Interviews should
support that the material is covered. Points
are awarded for at least 70% of positive
indicators using any combination of
documentation and interview results.
Strength: 100% of reviewed documentation and
90% of interviews indicated that the new employee
orientation covers key Covenant Health OHS
policies and procedures.
The site orientation, as well as various department
/ unit, and position specific orientation packages
included the Covenant Health Safety and Health
Policy, OHS responsibilities, infection prevention
policies and practices, ethics, information privacy
and IT security, PPIC, HR policies, etc.
Full points were awarded based on the percentage
of positive indicators from reviewed documentation
and interviews exceeding the required 70%.
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Questions Score Instructions Notes
5.5 Do employees receive the job specific
training required to perform their
jobs/assignments in a healthy and safe
manner?
(0-15 points)
5
9
Verified by reviewing training program /
training records and employee interviews.
Job specific training could include working
with a competent person until competency
can be demonstrated (e.g. buddy system).
Points are awarded based on percentage
positive indicators. Both health and safety
issues must be dealt with to obtain full points.
Documentation review (0-5 points)
Examples of job specific training include
training on safe work procedures, PPE,
ergonomics, use of equipment, WHMIS, first
aid, defensive driving, TDG, etc. One way of
doing this is to look for a match between job
descriptions and training received.
Interviews (0-10 points)
Interviews should confirm whether the
training received is appropriate for workers to
perform their jobs/assignments in a healthy
and safe manner.
Strength:89% of interviews and approximately
97% of reviewed documentation indicated that job
specific training is provided during the site
orientation, unit / department orientation, job
specific orientations, buddy shifts, and in services
Recommendation: it is suggested to ensure all
workers receive job-specific training to workers
who may be exposed to a hazard. It is further
suggested to enter learning records into
a spreadsheet program in order to enable
Educators and Managers to more efficiently and
effectively monitor the completion of all training
requirements.
9 out of 10 points were awarded based on the
interview responses, and 5 out of 5 points for the
positive indicators from reviewed documentation.
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Questions Score Instructions Notes
5.6 Is on-going training provided as
required?
(0-15 points)
4
8
Verified by reviewing documentation and
employee interviews.
An organization may choose to set timelines
for ongoing training on some of these
subjects, or as legislated.
Points are awarded based on the percentage
of positive indicators.
Documentation review (0-5 points)
Documentation must show on-going training,
refreshers and recertification in job-specific
training (e.g. skills upgrading, WHMIS, first
aid, defensive driving, TDG, maintenance
procedures, respiratory protection, etc.)
Interviews (0-10 points)
Interviews should verify that on-going training
is provided.
Strength: 83% of interviews and 87%
documentation reviewed indicated that ongoing
training is provided to employees as required. This
includes the mandatory annual essential education,
which covers infection prevention and control, fire
safety, legislation, bELITE training, etc. and is
required for all staff.
Recommendation: 17% of Interviews and 13%
documentation reviewed indicated that essential
training had not been provided for some of
employees.
It is suggested to actively monitor the completion of
mandatory annual and refresher training, and to
provide feedback to managers regarding who has
not completed. In order to accomplish this in an
effective and time efficient manner, It is further
suggested to enter learning records into a training
record spreadsheet. This will provide timely records
and overviews of the percentage of training
completion, as well as lists of employee names
which still require the training.
8 out of 10 points were awarded based on the
interview responses, and 4 out of 5 for the positive
indicators from reviewed documentation.
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Questions Score Instructions Notes
5.7 When employees are transferred or
assigned new tasks, do they receive job
specific training?
(0-15 points)
13
Verified by reviewing training records and
interviewing employees.
Job specific training could include working
with a competent person until competency
can be demonstrated.
Score: 5 points for documentation
0-10 points for interviews
Points are awarded based on the percentage
of positive indicators.
Strength: 83% of the interviews and 98% of
documentation reviewed indicated that employees
receive job specific training when they are
transferred or assigned new tasks. Usually, each
transferred employee receives the Unit/department
specific orientation. Training for new equipment or
procedures is provided through inservices or
courses for the affected staff
Recommendation: It is suggested to continue the
current procedures of training employees who are
transferred or receive new tasks. It is further
suggested to monitor completion of required job
specific training to ensure greater consistency in
the training completion and documentation when
employees who are assigned new tasks or
assignments.
8 out of 10 points were awarded based on the
interview responses, and 5 out of 5 for the positive
indicators from reviewed documentation.
Total Points Possible: 100
Audit Score
Total points possible: 100 - Points not applicable (N/A) 92 = Total points Total Points scored = 92
(divided by)
X 100 = FINAL SCORE 92%
Total points = 100
2012 CCSA Audit Report
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2012 CCSA Audit Report
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6. Emergency Response
Questions Score Instructions Notes
6.1 a. Is there a written emergency
response plan for each work site
appropriate to the hazards at the
site?
(0-15 points)
b. Does the plan include:
- Communication procedures?
(0-5 points)
- Emergency phone numbers?
(0-5 points)
- List of responsible emergency
response personnel?
(0-5 points)
- Evacuation procedures?
(0-5 points)
5
5
5
5
Verified by review of emergency response
plans for each work site. On mobile sites,
plans may be kept in vehicles.
Emergency response is taking immediate
action to deal with injuries, fires, motor
vehicle accidents, bomb scares, chemical
spills, explosions, etc.
a. Review the plan and award points by
percentage of plan completion.
b. Each piece of supporting information
needs to be evaluated for completeness.
Award points based on the positive
indicators.
Key Strength: Written emergency response plans
were in place for all sites, including response
protocols for appropriate hazards. These included
emergency response procedures for code red –fire,
code green – evacuation, code white –violence /
aggression, code blue – cardiac arrest or medical
emergency, code purple – hostage situations, code
yellow – missing person, code black – bomb threat
/ suspicious package, code grey –air exclusion,
code brown – hazardous spill, code orange – mass
casualty incident, emergency lockdown, and
severe weather. The emergency response plans
were available online, as well as in hard copies in
all areas visited.
Site specific communication procedures,
emergency phone numbers, responsible personnel,
emergency equipment and its locations, and
evacuation procedures are included in the site
specific emergency response manuals. Quick
reference charts were available in many work
areas for easy reference of the various protocols
and procedures.
Full points were awarded for each category based
on the positive indicators from reviewed
documentation.
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Questions Score Instructions Notes
6.2 Do employees at the site understand
their responsibilities under the plan?
(20 points)
20
Verified by interviewing employees at the
site.
Requires at least a general understanding of
emergency response.
Points are awarded based on at least 90% of
positive responses from interviews.
Strength: 91% of employees interviewed were
aware of and knowledgeable about their roles and
responsibilities in the event of an emergency.
Recommendation: is suggested to ensure that all
staff receives the training they require for their
responsibilities under the emergency response
plan and protocols. Special attention should be
paid to weekend, night shift, and casual staff to
ensure that they are knowledgeable and competent
to respond to the various potential emergencies.
Full points were awarded based on the percentage
of positive interview responses exceeding the
required 90%.
6.3 Are employees given emergency
response training appropriate to their
individual responsibility?
(0-10 points)
8
Verified by employee interviews.
Deals with specific training required to
implement the emergency response plan on
site.
Points are awarded based on the percentage
of positive responses from interviews.
Strength: 78% of employees interviewed indicated
that they have received emergency response
training appropriate to their responsibilities. This
included instructions and reviews of the emergency
response procedures in site orientation, annual
essential education, and code of the month
reviews, as well as first aid and CPR training.
Recommendation: 22% of employees interviewed
felt they had not received appropriate emergency response training. It is suggested to ensure that all staff receives the training they require for their responsibilities under the emergency response plan and protocols. Special attention should be paid to weekend, night shift, and casual staff to ensure that they are knowledgeable and competent to respond to the various potential emergencies. 8 out of 10 points were awarded based on the interview responses.
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Questions Score Instructions Notes
6.4 Are emergency response drills
conducted annually or more often, as
required?
(10 points)
10
Verified by review of documentation. If
no documentation exists, interview
employees.
Deals with planned drills, not an actual
response. For example, an emergency
response drill could include a full blown
implementation of the emergency response
plan, review of the emergency response plan
at meetings, part of an operation, table-top
review, practice drills, etc.
Points are awarded if documentation
indicates that at least 70% of sites are
conducting drills, or (if no documentation
exists) by at least 70% of positive responses
from interviews.
Strength: 78% documentation reviewed and 77%
of interviews indicated that emergency drill conducted on monthly basis. The drills focus on the different colours as determined by Covenant Health. Fire drills occur monthly and are supplemented with the other Codes. Recommendation: 23% of interviews indicated
that some employees have not been able to
participate in emergency drill. Also, employees
stated that some of the emergency response drills
had not been conducted after OHS representative
left the site. It is suggested to consider conducting
table top drills with all units and all shifts to ensure
that everyone is kept up-to-date on emergency
procedures for the site. It is further suggested to
continue with the practice of reviewing the code of
the month with all staff members.
Full points were awarded based on the percentage
of positive indicator from reviewed documentation
exceeding the required 70%
6.5 Are emergency response records kept?
(5 points)
5
Verified by review of emergency response
records (e.g. First Aid Record Book).
This question cannot be marked as “n/a”. In
the absence of an actual emergency
response, employers should at least have
records of emergency response drills.
Strength: Documentation review indicated that
emergency response records are kept at all sites.
These records included first aid records, incident
reports, records of actual emergency responses, as
well as fire drills and other emergency response
exercises.
Full points were awarded based on the reviewed
documentation.
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Questions Score Instructions Notes
6.6 Are all records of emergency
responses, including drills, reviewed to
correct deficiencies?
(10 points)
10
Verified by review of documentation
This question cannot be marked as “n/a”. In
the absence of an actual emergency
response, employers should at least have
records of emergency response drills.
Strength: Documentation Reviewed indicated that
emergency response and drill records are
reviewed, and noted deficiencies are addressed.
Full points were awarded based on the reviewed
documentation
6.7 IS the appropriate number of
employees trained in first aid, as
required by legislation?
(10 points)
0
Verified by review of documentation
Check legislation and review first aid
certificates. To award points, the auditor
must verify that legislated first aid
requirements have been met across all
shifts.
Recommendation: OHS code (part 11- section
182(2)) state that an employer must ensure that the
first aiders at a work site have successfully
completed a first aid training course approved by a
Director of Medical Services and hold a valid
certificate in first aid. RNS and LPNs must
complete either Supplementary First Aid or Valid
First Aid Certification Courses to be recognizing as
designated Standard and Emergency Level First
Aider.100% of documentation reviewed indicated
that none of the RNS and LPNs employees took
Covenant Health supplementary first on line course
aid or Standard Valid First Aid Certification training
course (as outlined in Part 11 First Aid of the
Alberta OHS Code). Therefore, none of them
recognize as first aider on the sites. It is suggest
encouraging all Linsang RNs employees to take
online supplementary first aid course.
No points were awarded based on the reviewed
documentation.
2012 CCSA Audit Report
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Questions Score Instructions Notes
6.8 Do first aid supplies and facilities meet
legislated requirements?
(10 points)
0
Verified by observation.
Check supplies and facilities against first aid
regulation. To award points, the auditor must
verify that legislated first aid requirements
have been met at all visited sites and
facilities.
Strength: Observation tour indicated that both
sites had first aid kids #2, eyewash station, spill
kits, Automated External Defibrillators, etc.
Recommendation: Although There are some
supplies and equipments available in the both
sites, facilities are not meeting all legislature
requirements. This includes lack of the designated
first aid area, first aid kids #3, first aid signage, first
aid provider, etc.
No points were awarded based on the observation
reviews.
Total Points Possible: 110
Audit Score
Total points possible: 110 - Points not applicable (N/A) 0 = Total points 73 Total Points scored = 73
(divided by)
X 100 = FINAL SCORE 66 %
Total points = 110
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7. Incident Investigation
Questions Score Instructions Notes
7.1 Is there a written procedure that
requires the reporting of occupational
incidents and illness?
(10 points)
10
Verified by review of documentation.
Documentation should require the reporting
of all types (i.e. incidents, illness) to award
full points.
Strength: Documentation review indicated that the
reporting of work-related Incidents, Injury, and
Illness policy and procedure is in Place outlining
reporting requirements and the investigation
process.
Element 6: Incident Management of the Covenant
OHS Program outlines the procedure to be used to
report occupational incidents and illnesses. The
document states that employees must report
incidents and near misses to their supervisor /
manager. This includes all serious incidents as
defined in the Alberta OHS legislation, as well as
all lost time, medical aid, property damage, first aid,
and near miss incidents. The procedure continues
to state the forms to be used, responsibilities, and
internal and external reporting / communication
requirements for each type of incident.
Full points were awarded based on the positive
indicators from the reviewed documentation
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Questions Score Instructions Notes
7.2 Are employees aware of their
responsibilities to report work-related
incidents and illness?
(0-10 points)
10
Verified by employee interviews.
Interview points are awarded based on the
percentage of positive responses.
Strength: 91% of employees interviewed were
aware of their responsibilities to report work related
incidents, illnesses, and near misses, and
knowledgeable about the reporting processes to be
used.
Recommendation: Although employees
demonstrated a good awareness of their
responsibilities to report work-related incidents and
illness, some of them are un aware of incident
investigation process. It is suggested, to educate
all workers in the process of what happens after
they report an injury. Workers don’t need high level
information. They just need to know, that their
responsibility to report related incident and near
miss, and able to explain the report process
Full points were awarded based on the percentage
of positive interview responses.
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Questions Score Instructions Notes
7.3 Is there a written procedure for
investigating occupational incidents and
illnesses?
(15 points)
15
Verified by review of documentation.
Documentation must require the investigation
of all types (i.e. incidents, illnesses) to award
full points.
Strength: Documentation review indicated that a
written procedure is in place for the investigation of
occupational incidents and illnesses.
Element 6: Incident Management of the Covenant
OHS Program outlines the incident investigation
procedure. This includes determining the facts of
what happened, identification of immediate,
underlying and root causes, recommendation of
control measures, implementation of controls
measures and effective documentation and records
keeping. The document continues to outline a
detailed seven step process for investigation of
incidents. This includes the initial response,
investigating the incident using 6 key questions,
identifying immediate, underlying and root causes,
developing and implementing corrective actions,
reporting the findings, communicating findings to
affected staff, and evaluating the effectiveness of
the implemented preventative measures.
Full points were awarded based on the reviewed
documentation.
7.4 Is there an investigation report form?
(5 points)
5
Verified by review of documentation.
The form must systematically record incident
or occupational illness occurrence
information, including the circumstances,
causes, corrective actions and follow-up.
Strength: Documentation reviewed indicating that
standardized investigation report form is in place.
The Employee Incident / Injury Reporting and
Investigation form systematically records all details
information according for incident investigation
process. The form is comprehensive, health care
oriented, user friendly, and includes a good level of
detail.
Full points were awarded based on the reviewed
documentation
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Questions Score Instructions Notes
7.5 Have the persons conducting
investigations been trained in
investigation techniques?
(0-15 points)
12
Verified by review of documentation and
employee interviews.
Check training records of those persons
required to conduct investigations, and
interview them to confirm training received is
appropriate to conduct investigations.
If trained investigators are brought in, full
points may be awarded. Proof must exist.
Points are awarded based on the percentage
of positive indicators using any combination
of documentation and interview results.
Strength: 59% of interviews and 90% of reviewed
documentation indicated that key employees have
received incident investigation training. Training
records indicated that two training sessions for
incident investigation had been held on site in
2010. Interviews verified that key employees have
received incident investigation training.
Recommendation: 41% of interviews indicating
that many of employees unaware of who has
received the training on investigation techniques. It
is suggested to ensure that incident investigation
training is completed by all persons in leadership
positions. This will ensure that all persons who may
conduct incident investigations and have to
complete the report forms are knowledgeable
about investigation techniques and root cause
analysis. It is further suggested to communicate the
training to the staff.
12 0out of 15 points were awarded based on an
average of 59% positive indicators from the
interview responses and reviewed documentation.
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Questions Score Instructions Notes
7.6 Are workers involved in the
investigation process?
(0-10 points)
2
3
Verified by review of investigation
documentation and employee interviews.
There must be evidence of worker
involvement in investigation to score points.
Involvement should include more than the
injured worker or witnesses.
Score: 0-5 points for documentation
0-5 points for interviews
Points are awarded based on the percentage
of positive indicators.
Strength: 61%employees interviewed indicated
that workers are involved in the investigation
process through, during staff/ team meetings, as
witnesses or through other informal interactions
with their Supervisors or Managers.
Recommendation: Only 35% of reviewed
documentation indicated that workers, other than
an injured employees or witness, are involved in
the investigation process. This is mainly
documented in some of the sampled staff / team
meeting minutes, which indicated that incidents
were discussed. It is unclear from these
documents, however, if the workers were just made
aware of the investigation results, or if they have
actual participation and input into the investigation
process.
It is suggested to involve some key employees in
the investigation process, and to document this on
the report forms, as well as on any applicable
meeting minutes. Workers could be involved during
staff / team meetings or as part of a regular
incident review and discussion during local JWHS
committee meetings. This will ensure that a
balanced perspective has been taken into
consideration during the investigation, resulting in a
more thorough investigation being conducted
2 out of 5 points were awarded based on the
reviewed documentation, and 3 out of 5 based on
the interview responses.
2012 CCSA Audit Report
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Questions Score Instructions Notes
7.7 Do investigations focus on:
a) Identifying root causes?
(0-10 points)
b) Recommending corrective action?
(0-10 points)
4
4
Verified by reviewing completed
investigation report forms.
Points are awarded based on the percentage
of reviewed investigation reports that focus
on identifying root causes and
recommending corrective action.
Recommendation: Only 40% of sampled incident
investigation reports properly identified direct,
indirect and root causes, and had appropriate
recommended corrective actions documented. It is
suggested that thorough root cause analysis is
applied to all investigations to determine the most
effective preventative measures, and that this be
properly and fully documented in the investigation
reports or other attached information. It is further
suggested to ensure that all recommended
corrective action be also properly and fully
documented on the investigation report forms. This
ensures that investigations result in the most
effective recommendations to prevent recurrence,
and that these recommendations can be tracked
more effectively.
4 out of 10 points were awarded for the
identification of root causes, and 4 out of10 for the
recommended corrective actions.
7.8 Are supervisors held responsible and
accountable for the investigation
process?
(0-10 points)
10
Verified by review of investigation
documentation and by employee
interviews.
Score: 0-5 points for documentation
0-5 points for interviews
Points are awarded based on the percentage
of positive indicators.
Strength: 100% of reviewed documentation and
97% of employees interviewed indicated that
supervisors and managers are held responsible
and accountable for the investigation process.
Full points were awarded based on the percentage
of positive indicators from interviews and reviewed
documentation
2012 CCSA Audit Report
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Questions Score Instructions Notes
7.9 Are investigation reports reviewed and
signed off by management?
(5 points)
5
Verified by reviewing completed
investigation reports.
The report must be signed off by the
manager at least one level above the person
responsible for the area.
Points are awarded if at least 90% of
investigation reports being reviewed and
signed off by management.
Strength: 98% documentation reviewed indicating
that all sampled investigations reports were
reviewed and signed off by management.
Full points were awarded based on the reviewed
documentation
7.10 Are completed investigation reports /
results shared with employees?
(0-10 points)
5
Verified by reviewing documentation and
employee interviews.
Documentation could be health and safety
meeting minutes, investigation reports
posted on bulletin boards, notes on
investigation reports. Results shared should
not contain personal information pertaining to
the affected parties.
Score: 0-5 points for documentation
0-5 points for interviews
Points are awarded based on the percentage
of positive indicators.
Recommendation : Only 24% of documentation
reviewed and 39% of interviews indicated that the
results of incident investigations are shared with
employees through staff/team meetings, notes in,
emails communication books, , or verbal
interactions. Most of the interviews and
documentation reviewed indicated that most of the
time investigation results were not shared at all or
only in uncertain terms with very little detail. It is
suggested that investigation results are routinely
shared with potentially affected staff, to ensure
their awareness of the situation and opportunity for
feedback regarding the recommended corrective
actions. Such communications should include an
incident description, identified causes, and
corrective actions taken This is not considered to
be confidential information since it includes no
names or personal details, and will only ensure that
meaningful information is conveyed to summarize
the investigation and inform affected employees.
2 out of 5 points were awarded based on the reviewed documentation, and 3 out of 5 based on the percentage of positive interviews
2012 CCSA Audit Report
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Questions Score Instructions Notes
7.11 Are corrective actions taken to prevent
recurrence?
(0-15 points)
12
Verified by interviewing employee and
observing corrective action where
applicable.
Points are awarded based on the percentage
of corrective actions implemented.
Strength: 61% of employees interviewed and 92%
of observations indicated that corrective actions are
taken after an incident to prevent recurrence.
Recommendation: 10% of sampled corrective
actions were observed to not be implemented. In
addition, 39% of employees interviewed were
unsure if corrective actions were taken after an
investigation to prevent recurrence. It is suggested
to conduct proper follow up after each investigation
to ensure that all required corrective actions have
been fully implemented to prevent recurrence. It is
further suggested to communicate the investigation
outcome, including the recommended corrective
actions, and the implementation status of these
actions to all affected employees. This will ensure
that staff in each work area is aware of positive
actions being taken, and any changes that may
impact them.
12 out of 15 points were awarded based on an
average 79% of positive indicators from
observations and interviews
Total Points Possible: 125
2012 CCSA Audit Report
76
Audit Score
Total points possible: 125 - Points not applicable (N/A) = Total points 97 Total Points scored = 97
(divided by)
X 100 = FINAL SCORE 78 %
Total points = 125
2012 CCSA Audit Report
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8. Program Administration
Questions Score Instructions Notes
2012 CCSA Audit Report
78
Questions Score Instructions Notes
8.1 Is there a system to ensure:
a. Health and safety issues are
communicated with employees?
(15 points)
b. Feedback on health and safety
issues from employees?
(15 points)
c. Follow-up on health and safety
issues?
(15 points)
15
15
15
Verified through review of documentation
and employee interviews (e.g. newsletter,
records of safety meetings, records of
toolbox meetings, bulletins, hazard
identification and assessment records,
suggestion boxes, etc.).
a. Identify how employees are advised of
health and safety issues, and confirm this
is being done.
b. Identify how employees are enabled to
offer feedback on health and safety
issues, and confirm employee awareness
of the system.
c. Identify how follow-up is done, and
confirm that employees are aware of it.
Points are awarded based on at least 70%
positive indicators using any combination of
documentation and interview results.
Strength: 100% of reviewed documentation
indicated that a system is in place to communicate
health and safety issues with employees, provide
feedback opportunities, and ensure follow up on
health and safety issues. 98% of employees
interviewed confirmed that health and safety issues
are regularly and effectively communicated. 100%
of employees felt that they were enabled to offer
feedback and input on any issues raised, and 92%
stated that health and safety issues are
consistently followed up on. Health and safety
issues are communicated and addressed during
JWHS committee meetings, staff / team meetings,
education sessions, as well as via memos, memo,
emails, hazard assessment reviews, OHS boards
and through interactions with educators and
members of the OHS department.
Recommendation: It is suggested to ensure that
that all health and safety concerns and issues are
adequately followed up on, including
communication of any actions taken to the affected
staff. This will increase the overall awareness of
the health and safety management processes,
worker participation and input, and reinforce that
such participation leads to improved health and
safety of the work place.
Full points were awarded for each category based
on the percentage of positive indicators exceeding
the required 70%.
2012 CCSA Audit Report
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Questions Score Instructions Notes
8.2 Does the employer have a system to
control contractor health and safety?
(0-5 points)
5
Verified by reviewing documentation and
interviewing contractors.
Documents could be minutes of toolbox,
health and safety committee meetings, unit
or team meetings, where applicable.
If contractors are not utilized this question is
not applicable.
Points are awarded based on the percentage
of positive indicators, using any combination
of documentation and interview results.
Strength: 100% of interviews and 90% of reviewed
documentation indicated that a process is in place
to control contractor health and safety while on site.
Contractors must complete the contractor
orientation prior to starting work, which outlines
health and safety requirements, emergency
response procedures, locations of emergency
response equipment and first aid. Interview
indicated that Contractors receive a tour of the
facility or area they are to work in. In addition,
contractors are required to sign in, adhere to the
required standards and procedures and use all
required PPE. Also, interviews verified that
Contractors are required to follow all permit
requirements, and are monitored by facility
maintenance or other Covenant Health staff.
Full points were awarded based on the average
95% of positive indicators from interviews and
reviewed documentation
8.3 Does management participate in the
planned health and safety meetings?
(5 points)
5
Verified by review of documentation.
To award points there must be documented
evidence of management participation.
Strength: Meeting minutes indicated that
management participated regularly in all unit /
department meetings, general staff meetings /
forums, as well as in site and local JWHS
committee meetings.
Full points were awarded based on the reviewed
documentation
8.4 Are records of health and safety
meetings kept?
(10 points)
10
Verified by review of documentation.
Records to review include attendance
records, agendas, minutes, etc.
Strength: All meetings minutes include OHS
members and staff meetings minutes are kept
consistently at sites.
Full points were awarded based on the reviewed
documentation
2012 CCSA Audit Report
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Questions Score Instructions Notes
8.5 Are records pertaining to the
organization’s health and safety system
kept for a minimum three-year period?
(10 points)
10
Verified by review of documentation
records (e.g. hazard assessment records,
inspection reports, training records,
investigation reports, etc.)
If the employer’s system has not been in
place for 3 years, records should be
available since the start up of the health and
safety system. (If less than 1 year’s worth of
documentation is available for review, the
auditor must make note of this.)
Strength: Documentation review indicated that all
records pertaining to the organization’s health and
safety management system are retained for a
minimum of three years. This includes policies and
procedures, hazard assessments, inspection
reports, investigation reports, statistics, training
records, etc.
Full points were awarded based on the reviewed
documentation.
8.6 Are health and safety statistics
maintained?
(10 points)
10
Verified by review of documentation.
Identify the type of statistics maintained by
the employer (e.g. frequency rate, severity
rate, cost per claim, audiometric stats,
pulmonary stats, air quality, blood levels, first
aid, etc.).
If the employer’s system has not been in
place for 3 years, records should be
available since start up of the health and
safety system.
Strength: documentation reviewed indicated that
Health and safety statistics are maintained for each
site which include:
Statistics and Accident Prevention Report
spreadsheets included the total number
incidents reported, hazardous situations, first
aid requirements, health care, lost time
injuries, and days lost for the current month
and year to date, as well as the same
information for the previous year.
WCB summaries include number of claims,
claim costs, etc.
Full points awarded based on the documentation
reviewed
2012 CCSA Audit Report
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Questions Score Instructions Notes
8.7 Are records or statistics analyzed to
identify trends and needs?
(10 points)
10
Verified by review of documentation.
Identify examples of the statistics being
analyzed, and any trends/needs identified by
the employer.
Strength: Documentation review indicated that
records and statistics analyzed to identify trends
needs.
Examples of identified trends include the following:
The Statistics and Accident Prevention Report
spreadsheets compare the numbers of
incidents and injuries of the current month and
year to date to the same time period of the
previous year for each site.
The WCB Account / Industry Synopsis report
evaluates the number of injuries reported,
frequency rates, severity rates, average claims
cost, total number of claims, duration bands for
lost time claims, types of accidents, age
groups involved, nature of the injury, body
parts injured, etc.
Full points were awarded based on the reviewed
documentation
8.8 Is the health and safety system
evaluated at least annually through the
use of an audit process?
(5 points)
5
Verified by review of previous audits.
This could include internal or external audits.
If this is the employer’s first health and safety
audit, this question is not applicable (n/a).
Strength: The Both sites Health and safety
management system is evaluated annually through
the participation in the COR audit process. An
internal COR audit was conducted towards the end
of 2013.
Full points were awarded based on the reviewed
documentation
2012 CCSA Audit Report
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Questions Score Instructions Notes
8.9 Has an action plan been developed as
a result of the previous audit?
(10 points)
10
Verified by review of previous audits.
If this is the employer’s first health and safety
audit, this question is not applicable (n/a).
Strength: Documentation review indicated that
an action plan had been developed as a result of
the previous audit. There are 3 areas (employee’s
education, work place inspection and hazard
assessment) and several items for each area on
the action plan and all items of 3 areas have been
addressed. Several of item action plan had been
not completed.
Full points were awarded based on the reviewed
documentation
2012 CCSA Audit Report
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Questions Score Instructions Notes
8.10 Has the action plan been implemented?
(0-15 points)
12
Based on items in the action plan, verify
implementation by observation, review of
documentation, or employee interviews.
Points are awarded based on the percentage
of items in the action plan (refer to question
8.9) implemented to date.
If this is the employer’s first health and safety
audit, this question is not applicable (n/a).
Strength: 100% documentation review and
observations indicated that the key action item
areas from the previous audit have been
addressed to date.
Recommendation: 80% of reviewed
documentation and observations indicated that the
action plan specific OHS initiatives have been
implemented. Although 70% of employees
interviewed were aware of previous audits and
stated that audit results were shared. It is
suggested to ensure that an action plan is
developed and systematically implemented over
the next year. It is further suggested to ensure all
employees are aware of audit process and action
plan results. This can be done by discussing the
audit with the employees through the OH&S
meetings and Staff meeting, and also posting
action plan on OHS board.
12 out of 15 points were awarded based on the interview responses, and positive indicators from reviewed documentation and observation .
Total Points Possible: 125
Audit Score
Total points possible: 125 - Points not applicable (N/A) 0 = Total points 112 Total Points scored = 112
(divided by)
X 100 = FINAL SCORE 90%
Total points = 125
2012 CCSA Audit Report
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2012 CCSA Audit Report
85
Observation Report Audit Question What To Look For Location(s) Notes
1.3 Is the policy readily available to
employees?
Health and safety policy may be
posted on bulletin boards, in
lunchrooms, reception areas, or may
be accessible on computers or inside
safety manuals that are readily
available to employees.
90% of observations indicated that the
Health and Safety Policy is readily available
to employees at all sites. The policy was
observed to be posted in key areas
throughout the facilities, as well as in OHS
binders available in specific units
/departments
1.10 Is the relevant health and safety
legislation readily available at work
sites?
Copies of Occupational Health and
Safety legislation (federal, provincial,
municipal) appropriate to the operation
of the work sites should be present on
site. Some examples could be:
- Occupational Health and Safety
Act
- General Safety Regulations
- Chemical Hazards Regulations
- First Aid Regulations
- WHMIS
- TDG
65% of observations indicated that the
Alberta Occupational Health and Safety Act,
Regulation, and Code were readily available
to employee by means of the computers.
Several employees that were asked about
their access to the legislation during the
tours weren’t also able to demonstrate how
they can find the legislation on line. There
wasn’t any current hard copy of Alberta
OH&S Legislations on both sites.
2012 CCSA Audit Report
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Audit Question What To Look For Location(s) Notes
3.1 Have hazard controls been
identified and implemented:
Engineering?
Personal Protective Equipment
(PPE)?
Engineering and personal protective
equipment controls outlined in the
hazard assessment documents must
be observed. The engineering
controls could be ventilation, guarding,
substitution, isolation, noise control,
etc.
The personal protective equipment
controls could be hard hats, steel-toed
boots, gloves, respiratory masks, etc.
90% of observations indicated that
appropriate hazard controls have been
identified and implemented in the various
work areas.10% of observations indicated
that some required hazard controls were not
identified or not consistently implemented.
These included
Hazards of Cytotoxic drugs have been missed in the Care units and hazard assessment.
Some of the controls for Violence Hazards
Have been missed in the dementia care
units.
Employees are not using Proper mask
N95within the care units.
Personal Protective Equipment (PPE) are
not readily available to employees within the
care units.
Employees are not using proper PPE when
they are using O2 cylinders.
Some of control been missed food services
and hazard assessment , These included :
Non Slip Mat ( food services) are not used
within slippery areas,
2012 CCSA Audit Report
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Audit Question What To Look For Location(s) Notes
3.3 Are employees using controls
developed for identified health and
safety hazards?
Auditor to physically observe
employees using the engineering,
administrative, and personal protective
equipment controls identified and
approved in the hazard assessment
documents.
96% of observations indicated that
employees are using the developed hazard
controls. These included:
Engineering controls:
Trolleys, Pallet jacks, Carts, Dolly, Keyboard
trays ,Mobile lifts for safe patient handling (
care unit), Ergonomic Chair/stools ( all
unit/department ), Emergency eye wash
stations, appropriate carts for transport of
clean and dirty dishes ( food services
),appropriate carts for moving food and
supplies (food services), machines have all
required safeguards (food services ), hood
and ventilation ( Food services), Storage
Cabinets and Shelves (facilities), etc.
Administrative controls:
Office ergonomic breaks poster, Good
lifting technique, Proper bending/ lifting
technique, proper respiratory and hand
hygiene practices, Isolate area for infection
control within unit areas, appropriate
procedures for garbage and waste control,
the proper instructions and any training or
demonstrations, Warning signs, etc.
PPE controls:
Gloves, Gowns, , Steel toe boots, N95
masks, Hair nets, Variety of protective
Gloves ( facility), Nitrile Gloves, Ear plug
and Ear muff (Boiler room), Oven mitts, Cut-
Resistant Glove (kitchen), Face shields,
Goggles , safety glasses, etc.
2012 CCSA Audit Report
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Audit Question What To Look For Location(s) Notes
3.5 Does management enforce the use
of engineering controls?
Look for compliance with engineering
control requirements (i.e. have safety
guards been removed). Non-
compliance may indicate non-
enforcement. When there is non-
compliance, note if management in the
area responds and enforces the use of
control.
St Michael's Health Centre
St. Therese Villa
96% of observations indicated that
management enforces the use of
engineering controls. Observations
indicated that employees are generally
using the required controls.
3.6 Does management enforce the use
of safe work procedures, rules and
work practices?
Look for compliance with safe work
procedures, rules and work practices.
Non-compliance may indicate non-
enforcement. When there is non-
compliance, note if management in the
area responds and enforces use of
control.
St Michael's Health Centre
St. Therese Villa
96% of observations indicated that
management enforces the use of safe work
practices and procedures. Observations
indicated that employees are generally
using the required controls.
3.7 Is the required PPE equipment
available?
Auditor must observe that the PPE
identified and approved in the hazard
assessment document (refer to 3.1) is
readily available for employee use.
St Michael's Health Centre
St. Therese Villa
Strength: 60% of observations indicated that
most of the required PPE is readily
available to employees at both sites and
work areas. PPE were kept in locking room
in the care units and weren’t readily
available to employees in the care Units.
2012 CCSA Audit Report
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Audit Question What To Look For Location(s) Notes
3.8 Where PPE is used as a method of
control, are employees trained in
the use, care and maintenance of
the PPE?
PPE observed at the workplace should
be clean, properly stored, in good
condition, etc. Employees should be
able to explain how each article of
personal protective equipment is used
and how it is maintained.
St Michael's Health Centre
St. Therese Villa
70% of observations indicated that employees are trained in the use, care, and maintenance of the PPE they are required to use. Observations noted that PPE was in good conditions, as well as the correct use and storage of PPE in the various work areas.
3.9
Is the use of PPE enforced? Look for compliance with PPE
requirements. Non-compliance may
indicate non-enforcement.
St Michael's Health Centre
St. Therese Villa
76 % of observations indicated that
management enforces the use of required
PPE. Observations indicated that
employees are generally using the most of
the required controls.
4.7 Are deficiencies identified in the
inspection reports corrected in a
timely manner?
Auditor selects items from past
inspection checklists and physically
observes the workplace to confirm the
identified deficiencies have been
corrected.
St Michael's Health Centre
St. Therese Villa
96% of sampled deficiencies identified in the
inspection reports have been corrected in a
timely manner
2012 CCSA Audit Report
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Audit Question What To Look For Location(s) Notes
6.8 Do first aid supplies and facilities
meet legislation requirements?
Check to see whether the first aid kit is
clean, the right size and stocked
appropriately, and that the log book is
being used. Check to see whether the
first aid room is clean and maintained.
St Michael's Health Centre
St. Therese Villa
Both sites visited had a good supply of #2
first aid kits, eyewash stations, spill kits, etc.
readily available. Although There are some
supplies and equipments available in the
both sites, facilities not meet all legislature
requirements. This includes, lack of the
designated first aid area, first aid kids #3 ,
first aid signage, first aid provider, etc.
7.11 Are corrective actions taken to
prevent recurrence?
Auditor selects some approved
corrective measures from the incident
investigation reports and visually
confirms they have been implemented.
St Michael's Health Centre
St. Therese Villa
92% of sampled corrective actions were
completed and fully implemented.
8.10 Has the action plan been
implemented?
Auditor must get the action plan from
the previous audit and confirm
implementation of the action items.
St Michael's Health Centre
St. Therese Villa
80% of observations indicated that the
action plan specific OHS initiatives have
been implemented. There are 3 areas
(employees education, work place
inspection and hazard assessment) on the
action plan and all 3 have been addressed
with 1 of the 3 areas competed (work place
inspection).
Recommended