18.7.2 Step 2 - Gather Information to Determine Compliance

18.7.2.1 Gathering Information to Determine Compliance

The "Verification Task Procedures" detail how to gather information to determine compliance for each task.

The tasks permit a thorough, in-depth evaluation of the operator's compliance to regulations including implementation of their HACCP system within a limited time frame.

Inspectors are to seek guidance and program clarifications as required.

Using the task procedure, inspectors will collect information by:

• observing procedures being implemented using the written program as a reference (e.g. watching employees at work, watching employees taking measurements);
• inspecting (e.g. evaluating equipment cleaning or building maintenance);
• interviewing/questioning designated employees using the written program as a reference; and
• reviewing documentation (e.g. HACCP system written programs and records).

When using the operator's written program as a reference, the inspector should be concerned with the following:

Note: The operator's written program can be any document that the operator uses to record an instruction, process or procedure. For example, it could be Standard Operating Procedures (SOPs), Facility Manuals, Training Material, Prerequisite Programs, HACCP Plans etc.

1. written program(s) that do not meet regulatory requirements;
2. incomplete finding(s) that affect the integrity and effectiveness of the operator's written program; and
3. incomplete finding(s) which results in situations in which potential hazards are not controlled.

The situations listed above are considered deviations that affect the integrity of the HACCP System; therefore the inspector must rate the associated task "U" and issue a CAR. The inspector can always ask for support from the FSEP Specialist before rating the task "U" or prior to the follow-up of the action plan. The inspector must not wait for the Section 4 Verification Tasks to identify these types of deviations.

If the integrity of the entire HACCP system is compromised, the inspector must contact the Area CVS coordinator who will evaluate the situation and provide the necessary support to the inspector.

Inspectors are to review the operator's written program and records at the establishment. Inspectors may obtain photocopies of these documents when the inspector believes, on reasonable grounds, that the documents are directly related to non-compliance with the MIA, MIR or other applicable legislation.

Records will be examined for completeness and accuracy. It is not necessary to examine all the documentation that is available; a sample of the records produced since the last verification shall be taken for review. If any significant deviations or problems are encountered, the inspector must expand the record review to determine the extent of the problem.

If the inspector encounters a situation where the operator is unwilling or unable to take action to protect public health, protect consumers from fraud or protect animal welfare or health, the inspector must initiate actions to control the situation (See MOP Chapter 14).

18.7.2.2 Unscheduled Verification Findings (Stumble On)

When conducting a task or other inspection activity, if the inspector identifies a deficiency that is not related to the current verification activity (a stumble on), the following actions must be initiated:

• The inspector verbally notifies the operator of the deficiency.
• The inspector is responsible for taking enforcement action(s) when necessary to protect public health, to protect consumers from fraud and to protect animal welfare or health.
• If the deficiency requires immediate enforcement action(s) to be taken by the CFIA, the inspector adds the verification task related to the deficiency to the scope of the current verification activity and completes only the applicable sections of the task related to the deficiency including record review.

Note: The entire task must be conducted at the required frequency at a subsequent visit to the establishment.

• If the deficiency does not require immediate enforcement action(s) to be taken by the CFIA, the inspector considers selecting the task related to the deficiency at a subsequent visit to the establishment.

When a stumble on finding is identified during the HACCP System Design tasks, the following actions should be initiated:

• The FSEP specialist inspector verbally notifies the operator of the deficiency.
• If the deficiency does not require immediate enforcement action(s) to be taken by the CFIA, the FSEP specialist inspector considers whether the task related to the deficiency should be conducted by the responsible inspector at a subsequent visit to the establishment. If so, the responsible inspector or the FSEP Specialist inspector must note on the verification worksheet CFIA/ACIA 5470 in the "Activities conducted to assess compliance" that this task must be completed at a subsequent visit.
• If the deficiency requires immediate enforcement action(s) to be taken by the CFIA, the team adds the operator's written program related to the deficiency to the scope of the verification. The team must assess if the written program is designed to effectively control the hazard.
  • If the written program is not designed to control the hazard, a Corrective Action Request is issued under the HACCP System Design task.
  • If the written program is designed to control the hazard but was not implemented correctly, a CAR must be issued by the inspector under the verification task related to the deficiency.

18.7.2.3 Identifying Non-Compliance that is Related to an Open CAR

Important: The guidance below is to be applied when the observed non-compliance directly relates to a non-compliance identified in an open CAR. If the observed non-compliance only relates to the same task associated with the CAR, but is not the same situation/type of non-compliance, the inspector must issue a separate CAR.

When a non-compliance is observed during completion of a regularly scheduled task or as a stumble-on and it is directly related to a non-compliance already identified in an open CAR, the inspector must consider:

• Is there an immediate food safety risk?
• Has the operator attempted to correct the problem and is in control of the situation?

Ultimately, the inspector must judge whether this situation demonstrates a loss of control by the operator.

If the operator is not in control, the inspector:

• Takes immediate enforcement action as necessary, i.e. holds product or stops the process until control is restored by the operator.
• Documents these actions/activities on the follow up section of the CAR. This will serve as information gathered to support the decision as to whether or not to close the CAR when the date for completion of corrective measures arrives.
• Informs the operator immediately that this information will be documented on the CAR and will be considered to determine whether the CAR can be closed or not.
• Enters a "U" on the worksheet and notes the original CAR number in Box 15 (items requiring correction) A new CAR is not generated, however, it may be necessary for the operator to amend their action plan. This will be discussed during the meeting with the operator. This information gathered will support the decision as to whether or not to close the CAR when the date for completion of corrective measures arrives.

If the operator is in control, the inspector:

• May note the information on the follow up section of the open CAR. This will serve as information gathered to support the decision as to whether or not to close the CAR when the date for completion of corrective measures arrives.
• Enters an "A" on the worksheet, where the task was being conducted as per the prescribed frequency.

Note: In slaughter establishments, the Veterinarian in Charge is responsible to review and sign the CAR.

18.7.2.4 Recording Information Gathered to Determine Compliance

The information gathered is recorded by the inspector/FSEP specialist inspector on two worksheets:

• The Verification Worksheet (see 18.7.2.5); and
• The HACCP System Design Verification Worksheet (see 18.7.2.6).

Notes made on the worksheets must be clear, concise and accurately reflect the conditions observed or an answer to a question. As the completed worksheets are part of the CVS file, subjective comments, personal opinions, etc. are inappropriate.

The worksheets are available through Desktop eForms (See section 18.8 - List of forms). Detailed instructions are included with each worksheet and are available in two formats: as pop-up help (where help appears when you place the cursor over a field) and as a printable instruction page.

18.7.2.5 Verification Worksheet

The Verification Worksheet is completed by the inspector and is used to record:

• establishment information and proof of daily presence;
• verification task performed or applicable code for activities performed in lieu of a verification task;
• activities conducted to assess compliance;
• level of compliance (rating) or code assigned to each task; and
• items requiring correction.

The Worksheet is completed each time the inspector or the CFIA team visits the establishment to do a verification task or a verification activity.

Note: For Section 4 tasks, the inspector will not be required to describe the activities conducted to assess compliance on the verification worksheet as this information will be recorded on the HACCP System Design Verification Worksheet. If a section 4 task is assigned an Unacceptable level of compliance, the appropriate field of the Verification Worksheet will be completed to make reference to the CAR number.

If the inspector visits a stand alone processing establishment for reasons other than doing a verification task, the reason for the visit must be recorded on the Verification Worksheet. In situations where the inspector's home office is at an establishment, each visit must be documented on the Worksheet. Specific instructions and codes for other activities are included on the Verification Worksheet. The Worksheet is for use by the inspector only and not for presentation to the operator. Information related to items requiring correction will automatically populate the Verification Report which is then presented to the operator.

The following is a list of codes that are used when completing the Verification Worksheet.

Verification Task Codes

Code	Verification Task
E	The inspector is unable to complete a task according to the prescribed frequency because the establishment/process was not operating. The inspector only assigns this code to the task when the frequency for the task has expired.
I	The inspector is unable to complete a task according to the prescribed frequency for a reason other than the establishment/process was not operating. The inspector only assigns this code to the task when the frequency for the task has expired.
P	Task started but not completed (rating is pending).This code is used when an Inspector begins a task and is unable to complete it during that visit. It is also used when a sample is submitted to a Lab and results are pending. When the results of the sample are received the inspector would make a new entry and apply the appropriate rating.
C	Task was completed and rating is not required. This code is used when a task does not require a rating and applies to some current issue tasks that are in the form of a survey and certain sampling tasks such as import samples where a rating does not apply.

Activity Codes

Activity code	Activity
9000	Other inspection duties: sampling, consultation with operator, returned/rejected loads, consumer complaint follow up, recall
9001	Import or export activities: export certification, import reinspection, returned/rejected import loads
9002	Administration: emails, filing, expenses, month end report
9003	Follow-up on CARs and items requiring corrections
9006	Establishment closed for the week
9008	Establishment operating for the day but not visited
9010	Forecasting activity
9011	Establishment not operating for the day

18.7.2.6 HACCP System Design Verification Worksheet

The HACCP System Design Verification Worksheet is used by the FSEP specialist inspector to record:

• the activities conducted to assess compliance;
• the HACCP system design verification scope;
• the items requiring correction identified during the completion of the HACCP System Design Verification Tasks (see 18.7.4.2);
• the level of compliance (rating) of the HACCP System Design Verification Tasks conducted; and
• in-depth Review findings.

Note: When the HACCP System Design Verification Tasks are completed at an establishment, both the HACCP System Design Verification Worksheet and the Verification Worksheet must be completed.

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