Inspection Priority Level Worksheet

Facility Name Data Entry Confirmation

Address

Date of Assessment Licensing Officer Previous Assessment Date Last Routine Inspection Date Hazard Rating at Last Insp Final Priority Rating
Initial
/ / Review / / / / _____ /65
DD MMM YYYY DD MMM YYYY DD MMM YYYY

Category Wt Weighted Summary Notes

(circle one number in each category) Rating
(score x wt )
(A) Reportable Incident, Investigation & Abuse History Assessment x3 /15
5. High hazard facility with reportable incidents
(with inappropriate response), confirmed abuse, investigations
& hearings OR insufficient information is currently available
4. Moderate or high hazard facility with reportable incidents
(with inappropriate response) and confirmed abuse allegations.
3. Moderate or low hazard facility with reportable incidents
(with appropriate response) and unconfirmed abuse allegations
2. Low hazard facility with reportable incidents
(with appropriate facility response to maintain health & safety)
1. Low hazard facility with no history of reportable incidents,
investigations or abuse allegations
(B) Assessment of Management Effectiveness x3 /15
5. Management lacks qualifications/skills to adequately operate
facility and consistently require guidance
OR insufficient information is currently available
4. There are recurring poor management practices which inhibit
adequate operation of the facility
3. There are occasional poor management practices which may
impact the adequate operation of the facility
2. Management generally effective in the successful
operation of the facility
1. Management very effective in the successful operation of facility
(C) Staff Qualifications & Supervision Practices Assessment x2 /10
5. Staff are, overall, unprepared, untrained & place clients at risk
OR insufficient information is currently available
4. Staff cannot consistently handle job responsibilities because of
poor qualifications or practices
3. Staff are generally qualified but are occasionally unable to
handle required job functions
2. Staff qualifications and supervision practices are appropriate
1. Staff are exceptional and protect the health and safety of clients
in care
Sub-total for page 1: /40

CCFL GEN 200a (rev Aug 1, 2008) Fraser Health Authority – Community Care Facilities Licensing Program Page 1 of 2
 Category Wt Weighted Summary Notes
(circle one number in each category) Rating
(score x wt )
(D) Facility Physical Plant Assessment x2 /10
5. Facility physical plant is extremely hazardous to client health
and safety
OR insufficient information is currently available
4. Facility physical plant is chronically a health and safety hazard

3. Facility physical plant is occasionally a health and safety hazard

to clients
2 Facility physical plant is safe
1. Facility physical plant exceeds health and safety requirements
(E) Policies & Procedures Assessment x2 /10
5. No policies and procedures are in place
OR insufficient information is currently available
4. Policies and procedures are typically ineffective
3. Policies and procedures meet minimum requirements for health
and safety
2 Policies and procedures are generally effective
1. Policies and procedures exceed requirements for health and
safety
(F) Self-monitoring /Quality Improvement, Staff Training & Prevention x1 /5
5. No self-monitoring / quality improvement processes in place
OR insufficient information is currently available
4. Health and safety are rarely ensured through self-monitoring /
quality improvement processes
3. Health and safety are usually ensured through self-monitoring /
quality improvement processes
2. Health and safety are ensured through self-monitoring / quality
improvement processes
1. Self-monitoring / quality improvement processes exceed
requirements to maintain health and safety

Sub-total for page 2: /25

Transfer Sub-total from page 1: /40

TOTAL: /65

Inspection Priority Inspection Frequency Target

High (approximately 40 to 65) • Routine annual inspection and two follow up inspections. May be necessary to contact the facility monthly.
Medium (approximately 30 to 39) • Routine annual inspection and one follow up inspection.
Low (approximately 13 to 29) • Routine annual inspection.

CCFL GEN 200a (rev Aug 1, 2008) Fraser Health Authority – Community Care Facilities Licensing Program Page 2 of 2