Hedgehog Inspection Report Errors

Policy

Category: General – Health Protection
Subject: Hedgehog Inspection Report Errors
Division: Health Protection
Policy Number: CA.86.01.109
Effective Date: April 15, 2015

POLICY STATEMENT

It is the policy of Wellington-Dufferin-Guelph Public Health (WDGPH), Health Protection Division, to ensure all inspection reports are accurate and complete.  Proper documentation is important to ensure the information available in the Hedgehog Inspection database and on the Check Before You Choose disclosure website is correct.  Public Health Inspectors (PHIs) or Public Health Nurses (PHNs) must document findings from an inspection onto an inspection report in Hedgehog in accordance with Agency policy CA.50.01.101 Documentation Practices and the guidelines outlined in the WDGPH Hedgehog Processes and Procedures: Inspectors’ Role manual.  If an error is made by a PHI/PHN when entering or completing an inspection report in Hedgehog, the corresponding procedure shall be followed.

SCOPE

This policy applies to all General Program Public Health Inspectors (GP) and Control of Infectious Diseases (CID) staff members in the Health Protection Division.

DEFINITIONS

Hedgehog Inspection Administrative Error – an error made by a PHI/PHN when completing an inspection report in the Hedgehog Inspection database that does not affect the results of an inspection.  This type of error permits an ‘Administrative Change’.

Hedgehog Inspection Non-administrative Error – an error made by a PHI/PHN when completing an inspection report in the Hedgehog Inspection database that may affect or impact the results of an inspection.  At the discretion of the Manager, this may or may not result in a replacement inspection.

Canned Comment – a statement on a Hedgehog Inspection form that corresponds with a specific question and is used to provide further direction to an owner or operator of a premise on a non-compliance issue or to provide additional information on an item that is in compliance.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure:  CA.86.02.109 Hedgehog Inspection Report Errors
CA.86.01.100  Food Premises Inspection – All Food Premises
CA.50.01.101  Documentation Practices
CA.82.01.102 Personal Services Settings Inspections
WDGPH Hedgehog Processes and Procedures: Inspectors’ Role

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases and Tuberculosis

APPROVED BY

Director, Health Protection


Procedure

Category: General – Health Protection
Subject: Hedgehog Inspection Report Errors
Division: Health Protection
Procedure Number: CA.86.02.109
Effective Date: April 15, 2015

PROCEDURE

  1. General Program Public Health Inspectors (GP) and Control of Infectious Diseases (CID) employees will conduct inspections as per the WDGPH Hedgehog Processes and Procedures: Inspectors” Role manual and relevant Wellington-Dufferin-Guelph Public Health (WDGPH) policies and procedures.
  2. Hedgehog Administrator will complete electronic inspection audit based on inspection auditing checklist once each week. Errors made on an inspection report in Hedgehog will be defined as either an Administrative Error or a Non-administrative Error

Errors Categorized as Hedgehog Inspection Administrative Error:

  • The “Inspection Type” selected was incorrect (e.g. “Required Compliance” type inspection was selected and the inspection was actually a “Follow-up Re-inspection” type inspection.
  • The question “This inspection was conducted as per the Food Safety Protocol under the Ontario Public Health Standards and under the authority of the Health Protection and Promotion Act” did not have a canned comment selected. 
    Note: this question will be worded differently for each program area.
  • There are inconsistencies in the option(s) selected under the “Actions Taken” section (e.g. there are questions answered as “NO” in the inspection report, and “Report Reviewed – No Action Required” was selected; all questions are answered as “YES” or “Corrected During Inspection (CDI)” (no “NO”s were selected) and “Report Reviewed – Action Required” was selected).
  • The time of inspection was not recorded.
  • A water sample was taken at a premises served by a non-municipal water source and it was not indicated under the “Actions Taken” section that a water sample was taken (Food Safety Inspection Reports Only).

Errors Categorized as Hedgehog Inspection Non-administrative Error:

  • An inspection report was created in Hedgehog and there has been a change in owner, facility name, and/or facility address that was not changed or updated in the database prior to the inspection report being completed.
  • An inspection report is completed under the wrong facility number (e.g. an inspection was completed at a Tim Horton’s on Gordon Street but was recorded as an inspection report under the Tim Horton’s on Stone Road).
  • Any answers on an inspection report were left as “No Option Selected (N/S)”

Exceptions: 

  • The answer to the question “Constant supply of potable hot and cold running water under pressure” on a food inspection report shall be left as “N/S” if a water sample is taken;
  • All answers on an “Enforcement Action” inspection type shall be left as “N/S”; and
  • If the answer to the “Inspection Details” question “This inspection was conducted as per the Food Safety Protocol…” is left as N/S, the GP PHI or CID employee who completed the report will be notified of the error and no further action will be taken.
  • A question is answered incorrectly (e.g. the “Compliance Comment” indicates an item was not in compliance although the response answer is “YES”.  

Note:  canned comments may be used with any response answer type except N/S (YES, NO, CDI, Not Observed (N/Ob), or Not Applicable (N/A)) to provide additional information to the owner and/or operator.

  • A question is answered as “NO” with no canned comment selected.

Note: if a GP PHI or CID employee finds a situation where there is not an appropriate canned comment to capture the noncompliance issue, the PHI shall bring this question to the attention of the  Program Manager.

  • The PHI’s signature is not on the inspection report.
  • The owner/operator’s signature is not on the report and there is no explanation indicating why the signature is missing.
  1. The Hedgehog Administrator will notify the GP PHI or CID employee of Administrative Errors.
  2. Upon notification that a Hedgehog Inspection Administrative Error has occurred, the following process will be followed:

  • The Manager will be notified of the error by the Hedgehog Administrator if error needs to be corrected in Hedgehog inspection report.  If an administrative change is approved, the Manager will provide an approval signature.
  • Once approved, the Hedgehog Administrator will reopen the inspection report and make the corrective change.  A note will be added into the “Closing Comment” section of the inspection report indicating:
    • the date of the change;
    • the change that was made;
    • the initials of the person who made the change; and
    • the reason for the change.

Example:  “As the result of an administrative error, under the “Actions Taken” section of this inspection report, “Report Reviewed - Action Required” was unselected and “Report Reviewed - No Action Required” was selected on Jan 1, 2011. [Initials]”.

  • A copy of the corrected report will be sent to the owner/operator of the premises by the GP PHI or the CID employee.
  1. Upon notification that a Hedgehog Inspection Non-administrative Error has occurred, the following process will be followed:
  • The GP PHI or CID employee who conducted the original inspection will be notified of the error. The Manager will determine if a new replacement inspection is required (based on the number of non-administrative errors and whether these pertain to items that are deemed to be critical or non-critical).
  • Non-administrative errors do not need new replacement inspections. The responsible GP PHI or CID employee will add an amendment to the report outlining the error and the correct response (if applicable), the date of the change and the initials of the person who made the change. The responsible GP PHI or CID employee will forward a copy of the amended report to the relevant premises operator.
  1. If the Manager determines a new replacement inspection is required for a non-administrative error, the GP PHI or CID employee who conducted the original inspection will:
  • Return to the premises and conduct a new inspection, complete a new inspection report independent from the original (the same inspection type as the original: e.g. a “Routine Compliance” inspection remains a “Routine Compliance” inspection).
  • The new inspection must be completed within 1 to 2 business days of being notified of the error; notify Hedgehog Administrator after completing inspection.
  • ​The Hedgehog Administrator will reopen the original inspection report containing the error and the inspection type will be changed to “Audited” and the sub-type will remain the same.  A note will be made in the “Closing Comment” section indicating:
    • a new inspection was conducted that replaces the original report (indicate the inspection number);
    • the date of the new inspection;
    • the reason for the new inspection; and
    • the initials of the Hedgehog Administrator

Example: “As the result of a documentation error (Question #5 was left as “No Option Selected”), the inspection report type for this inspection has been changed to “Audited” on January 1, 2011 and this inspection report is replaced by Inspection Report # INS 000-00000 completed on Jan 15, 2011.  [Initials]”.

  • A copy of the original inspection report with the added “Closing Comments” notes and a copy of the new inspection report will be sent to the owner/operator of the premises by the GP PHI or the CID employee.
  1. If an Administrative Error and a Non-administrative Error is made on an inspection report, the process for handling non-administrative errors will be followed and the original administrative error will also be corrected on the new inspection report if determined by the Manager.
  2. If a GP PHI or CID employee has a concern about the results of an electronic audit, they may consult with their Manager.

Types of Inspection:

Type

Inspection Sub-type Details Related Procedure

Required

Compliance inspection

Regular required inspection

CA.80.02.101

Follow-up

Re-inspection

Re-inspection due to critical infractions observed

CA.80.02.101

Complaint

Food adulteration/outdated product

Complaint received regarding adulterated food/outdated product

CA.82.02.113
CA.80.02.107

 

Food handling concerns

Complaint received regarding food handling concerns

CA.80.02.107
CA.82.02.113

 

Food quality concerns

Complaint received regarding food quality

CA.80.02.107
CA.82.02.113

 

Pest control

Complaint received regarding pest control (e.g. flies, rodents)

CA.80.02.107
CA.82.02.113

 

Sanitation

Complaint received regarding premise cleanliness and sanitation

CA.80.02.107
CA.82.02.113

 

Suspect food-borne illness

Illness reported in association with food item at/from premise

CA.82.02.115

Demand

Emergency response

Flood, fire, power outage, etc.

 
 

Food recall

Food items recalled by CFIA or MOHLTC etc.

CA.80.02.111

 

Lawyer’s request

   
 

License inspection

Demand by county, City of Guelph, MOHLTC, etc.

 
 

LLBO inspection

   
 

Outbreak follow-up

Inspection required - several cases of illness associated with premises

CA.82.02.115

Pre-opening

Initial assessment

Inspection of new premises prior to opening

CA.80.02.101

Enforcement

Enforcement

Issuance of Section 13 order (HPPA), ticket or summons (Part I or Part III, POA)

 

Infection Control Complaint (Personal Service Settings)

 

Infection Control Complaint

An unannounced inspection resulting from an infection control complaint from a member of the public.

 

RESPONSIBILITIES

Manager will:
  • Ensure GP and CID employees  review and are trained on the guidelines in the WDGPH Hedgehog Processes and Procedures: Inspectors’ Role manual;
  • Ensure Hedgehog Administrator complete electronic inspection audits once a week and notify GP PHI and CID employees of the errors; and
  • Ensure GP and CID employees conduct inspections and complete inspection reports as per relevant WDGPH polices and the WDGPH Hedgehog Processes and Procedures: Inspectors’ Role manual.
GP and CID Employees will:
  • Review the WDGPH Hedgehog Processes and Procedures: Inspectors’ Role manual and complete  inspections as per the guidelines outlined in the manual;
  • Ensure  inspections are conducted as per relevant WDGPH policies and procedures; and
  • Notify the Hedgehog Administrator if an error is found on a completed inspection report in Hedgehog.

DEFINITIONS

Hedgehog Inspection Administrative Error – an error made by a PHI/PHN when completing an inspection report in the Hedgehog Inspection database that does not affect the results of an inspection.  This type of error permits an ‘Administrative Change’.

Hedgehog Inspection Non-administrative Error – an error made by a PHI/PHN when completing an inspection report in the Hedgehog Inspection database that may affect or impact the results of an inspection.  At the discretion of the Manager, this may or may not result in a replacement inspection.

Canned Comment – a statement on a Hedgehog Inspection form that corresponds with a specific question and is used to provide further direction to an owner or operator of a premise on a non-compliance issue or to provide additional information on an item that is in compliance.

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy:  CA.86.01.109 Hedgehog Inspection Report Errors
CA.50.02.101 Documentation Practices
CA.82.01.102 Personal Services Settings Inspections
CA.82.02.113 Complaints
CA.86.02.100 Food Premises Inspection – All Food Premises
WDGPH Hedgehog Processes and Procedures: Inspectors’ Role
Inspection Report Auditing Checklist

CONTACT FOR INQUIRIES

Manager, Control of Infectious Diseases and Tuberculosis

APPROVED BY

Director, Health Protection