Inspection of Funeral Homes

Policy

Category: Control of Infectious Diseases
Subject: Inspection of Funeral Homes
Division: N/A
Policy Number: CA.82.01.127
Effective Date: February 24, 2014

POLICY STATEMENT

It is the policy of Wellington-Dufferin-Guelph Public Health (WDGPH), Health Protection Division, to conduct annual inspections of the preparation and/or holding room(s) in funeral homes licensed by the Ontario Board of Funeral Services, upon request by the premise, in order to review those items required to be inspected by a Medical Officer of Health (MOH) or Public Health Inspector (PHI), as per the Ontario Board of Funeral Services (OBFS) request for Public Health inspection as a condition for licensing of funeral homes in Ontario.

PHIs will conduct additional inspections, as necessary, to follow-up on observations from previous inspection(s), investigate complaints and/or follow-up on reports of health hazards, as per the Ontario Public Health Standards – Risk Assessment and Inspection of Facilities Protocol. PHIs will also conduct inspections upon request by the premise or by the Ontario Board of Funeral Services.

Note:

Funeral homes qualifying for religious exemption from licensure by the Ontario Board of Funeral Services will not receive annual inspection from WDGPH unless requested by the premise or by the Ontario Board of Funeral Services (OBFS). Such premises (e.g. mosques) should be registered with the OBFS, may only provide services to their own congregation (with certain restrictions regarding services provided) and do not require licensure or annual public health inspection. Contact the OBFS to find out if a particular premise qualifies for exemption. 

SCOPE

This policy applies to all WDGPH PHIs working in Control of Infectious Diseases (CID) in the Health Protection Division.

RESPONSIBILITIES

CID Public Health Inspectors will:
  • Conduct annual inspections of all licensed funeral homes upon request by the premise, as per the criteria of the BOFS Form 17 – Certificate of Inspection by Local Health Unit, as current;
  • Conduct additional inspections, as necessary, to follow up on observations from previous inspection(s), investigate complaints and/or follow-up on reports of health hazards, as per the Ontario Public Health Standards – Risk Assessment and Inspection of Facilities Protocol; and
  • Conduct inspections upon request by the premise or by the Ontario Board of Funeral Services.  

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Procedure: CA.82.02.127 Inspection of Funeral Homes
Risk Assessment and Inspection of Facilities Protocol
Health Protection and Promotion Act

 

APPROVED BY

Rob Thompson 


Procedure

Category: Control of Infectious Diseases
Subject: Inspection of Funeral Homes
Division: N/A
Procedure Number: CA.82.02.127
Effective Date: February 24, 2014

PROCEDURE

Compliance Inspections and Re-inspections:
Control of Infectious Diseases (CID) Public Health Inspectors (PHI) will:
  • Conduct annual inspections of all licensed funeral homes upon request by the premise, as per the criteria of the BOFS Form 17 – Certificate of Inspection by Local Health Unit, as current;
  • Conduct additional inspections, as necessary, to follow-up on observations from previous inspection(s), investigate complaints and/or follow-up on reports of health hazards, as per the Ontario Public Health Standards – Risk Assessment and Inspection of Facilities Protocol; and
  • Conduct inspections upon request by the premise or by the Ontario Board of Funeral Services.
  1. Upon arrival at the premises, the PHI shall identify him/herself to the owner/operator and state the reason for the visit. The owner/operator shall be provided with the opportunity to accompany the PHI during the inspection.
  2. Depending on the type of premises to be inspected, inspections may be done at any reasonable time during the premises normal hours of operation. However, the Manager must approve inspections done outside of regular business hours.
  3. The PHI will use the Funeral Home Inspection electronic form in Hedgehog to conduct the inspection. Refer to the WDGPH Hedgehog Processes and Procedures Manual: Inspector Role for instructions on how to complete the form. If there is a new owner of the premises, a change in the premise name, or a change in address, the PHI may complete the inspection using a paper inspection report and transfer the inspection information to Hedgehog once the necessary changes to premise information have been made.
  4. If necessary, the PHI may utilize the assigned evidence notebook to capture inspection details observed during the inspection, which will then be transcribed into the Hedgehog inspection report prior to leaving the premises and prior to obtaining an operator signature. Refer to procedure CA.86.01.103 – Notebook Documentation.
  5. The PHI shall document whether the inspection was scheduled or unannounced, and if the inspection was scheduled, the reason for the scheduled visit and how far ahead of the inspection the visit was scheduled.  When answering this question in Hedgehog, the PHI must select the appropriate canned comment, indicating the WDGPH policy and procedure which was followed during the inspection.
  6. The PHI shall document the time at which the inspection was conducted (start time), and whether the inspection was a joint inspection with another PHI or other individual (e.g. Ministry employee, student PHI, etc.).
  7. The PHI will record any observed infractions on the Hedgehog inspection form. Where potential infection prevention and control or environmental issues are identified, the PHI will select ‘NO’ in response to the relevant compliance question, and will select the appropriate canned comment. The PHI will also record any observations relevant to the observed infraction, the required actions to be taken by the premises, and the expected date for compliance for each non-compliant item. Deadlines for compliance will be determined in discussion with the operator and will be based on the severity of the observed infraction and realistic time frames for corrective action.  Operator comments regarding anticipated completion dates and corrective actions to be taken will be documented under the operator response comment section for each relevant item.
  8. The time frame for follow-up re-inspections will depend on the items to be corrected and the importance of these non-compliant items with regards to their potential to result in an infectious disease outbreak or to present a health hazard or infection control risk.
  9. The PHI will record any observed infractions that are corrected during the inspection by selecting ‘CDI’ in response to the relevant compliance question, and will select the appropriate canned comment. The PHI will also record any observations relevant to the observed infraction and the remedial actions taken by the operator to address identified non-compliance.
  10. Where the PHI has selected ‘NO’ to one or more questions, the PHI will select ‘Report Reviewed - Action Required’ at the end of the report.
  11. The PHI will attempt to observe all applicable aspects of infection prevention and control practices that are carried out by a premise during inspection. Where a specific process is unable to be observed at the time of inspection the PHI will record the item as ‘Not Observed’ on the Hedgehog inspection form and will attempt to verify that appropriate infection prevention and control practices are followed, via discussion with the operator and/or staff. Operators may be asked questions regarding infection prevention and control practices and may be asked to describe steps that are followed during unobserved infection control practices, i.e. sharps disposal etc. Any items that are not relevant to the premises (e.g. if the premises does not perform embalming) will be selected as ‘N/A’.  
  12. The PHI will review the completed inspection report and other applicable forms (see here for Form 17: http://www.funeralboard.com/PublicUploads/223402BOFS-Frm17-2013.pdf ) with the operator/staff member present at the time of inspection. The PHI will discuss and explain the public health significance of the inspection, findings, violations and requirements to comply with the Health Protection and Promotion Act and associated Public Health Standards and Protocols.
  13. The PHI will advise the owner/operator of the expected dates of compliance for items observed during the inspection to be potential infection prevention and control risks.  The owner/operator will be given an opportunity to ask questions or clarify concerns. The operator will be informed of the enforcement consequences of not resolving identified non-compliant items by the deadlines indicated on the inspection report.  
  14. The PHI will ask the owner/operator to sign the completed inspection report. The PHI will sign the report after obtaining the signature of the owner/operator. The PHI will indicate on the report the method by which the inspection report will be delivered to the owner/operator (i.e. via fax/email/mail/hand delivery).

NOTE: the signature of the owner/operator is not required for completion of the inspection form(s). If the operator refuses to sign the report or is unavailable to sign the report once the inspection is completed, this does not invalidate the inspection report. If the report is unable to be signed due to operator refusal or unavailability this must be documented under the closing comments section of the report.

  1. Where a re-inspection of a premise is required in order to address non-compliant items from a previous inspection, all items that were in compliance at the time of the original inspection will be selected as ‘Not Observed’ at the time of re-inspection. Any items that are not relevant to the premises (i.e. if the premises does not perform diaper changing) will be selected as ‘N/A’. 
Enforcement actions under the HPPA:
  1. Non-compliance where a health hazard (as defined by Section 1 of the HPPA) is deemed to exist will result in the issuance of a Section 13 order by a PHI under the HPPA.
  2. The Section 13 order may require the closure of a premise, or require the ceasing and desisting or taking of any action necessary to minimize or prevent the health hazard from occurring, as deemed necessary by the PHI. The PHI will issue a verbal order for the item(s) in question at the time of inspection and will document any enforcement actions via a separate inspection report. The PHI will follow-up the verbal order with a written order as soon as is practicable, and will set out the time frame for compliance with the order. Where the PHI recommends the closure of a premise, this will be determined via consultation with the Program Manager/Supervisor.
  3. The PHI, MOH or designate will review the details of the order with the owner/operator present at the premises. The PHI, MOH or designate will ensure that the owner/operator understands that failure to comply with the order can result in a legal charge under the HPPA. The PHI, MOH or designate will ensure that the owner/operator is aware of the right to appeal the order and the procedure to be followed in the event of an appeal.
  4. Additional enforcement or legal actions (such as the issuance of a summons under Part III of the POA) or referral to the relevant County or Ministry representative will be considered via discussion with the Program Manager/Supervisor.
Complaints and other investigations:
  1. All complaints received with respect to a potential health hazard or other concerns will be entered into Hedgehog as a CSR and investigated within 24 hours as per procedure CA.82.02.113 Complaints.
  2. Where photographs are taken as part of a complaint investigation, these will be taken as per Procedure CA.86.02.104 Collecting Photographic Evidence, and documented as per Procedure CA.86.02.103 Notebook Documentation.
  3. Following the investigation of a food-related complaint, findings will be relayed back to the complainant as per Procedure CA.82.02.113 Complaints

REFERENCES AND RELATED FORMS, POLICIES AND PROCEDURES

Corresponding Policy: CA.80.82.127 Inspection of Funeral Homes
CA.82.02.113 Complaints
CA.86.01.103 Notebook Documentation
CA.86.01.104 Collecting Photographic Evidence
Risk Assessment and Inspection of Facilities Protocol
Health Protection and Promotion Act

APPROVED BY

Rob Thompson