18.7.4 Step 4 - Communicate Results and Action Required
Results of the verification tasks are communicated to the operator through three documents:
- the Verification Report (see 18.7.4.1);
- the HACCP System Design Verification Report (see 18.7.4.2); and
- the Inspection Report - Corrective Action Request (CAR) (see 18.7.4.3).
Note: For the purpose of this chapter, the Inspection Report - Corrective Action Request will be referred to as a CAR.
These reports are available through Desktop eForms (See section 18.8 - List of forms). Detailed instructions are included with each form 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.
These documents are presented to the operator in accordance with the following guidance:
18.7.4.1 Verification Report
The Verification Report is used to communicate any items requiring correction by the operator identified during the completion of the verification tasks (other than those deviations recorded on a CAR). All information that appears on the Verification Report is automatically populated from the data entered by the inspector on the Verification Worksheet.
The Verification Report must be issued to operators once per week if there are items identified for correction. At a minimum, the verification report must be issued at least once per month even if no deficiencies have been identified.
The Verification Report is issued at least quarterly at storage establishments.
18.7.4.2 HACCP System Design Verification Report
The HACCP System Design Verification Report is used to communicate any deficiencies which were identified during the completion of the HACCP System Design Verification Tasks.
Note: When a task is rated U all items requiring correction must be entered on the Inspection Report - Corrective Action Request (CAR). The CAR is the only report issued to the operator.
18.7.4.3 Inspection Report - Corrective Action Request (CAR)
A CAR is issued to an operator by CFIA inspectors whenever a verification task is assigned an unacceptable level of compliance. The CAR identifies the non-compliance and requires the operator to implement corrective measures by:
- providing an acceptable action plan by a specified date; and
- effectively implementing the corrective and preventative measures as described in the action plan by a specified date.
The CAR also describes the information gathered during the follow-up inspection conducted after the date for completion of corrective measures specified on the CAR.
When non-compliance is identified, the inspector must prioritize their activities to ensure that immediate inspectional control is initiated and actions are taken as appropriate. It is the responsibility of the operator to implement temporary measures as necessary in order to meet the regulatory requirements prior to continuing the process/activity. The operator then must investigate the cause of the deviation and apply corrective actions to bring the control measure, CCP, prerequisite program or other regulatory requirement under control. These corrective actions must be implemented immediately (prior to action plan submission or request for a CAR review).
The inspector verbally informs the the operator of his/her intention to issue a CAR as soon as the non-compliance is identified. The inspector must endeavour to issue the CAR on the same day the operator is verbally notified or the next day.
The date specified by the inspector for completion of corrective measures must reflect the seriousness of the non-compliance. The maximum timelines for submission of an action plan and completion of corrective measures are only intended as a guide. In cases where food safety is compromised, a shorter timeline must be specified.
Note: In slaughter establishments, the Veterinarian in Charge is responsible to review and sign the CAR.
18.7.4.4 Guidance for the description of the non-compliance
The non-compliance must be described in clear, factual and concise terms. The description of the non-compliance includes two components:
Component 1:
The first shaded box in each task contains a statement. This statement describes what is being assessed when conducting the task. When non-compliance is identified, the statement is not being achieved; therefore the negative form of the statement is used as Component 1.
For example: In sub-section 1 control measure task 1.1.08, "The operator meets the regulatory requirements related to effectively implementing a HACCP Plan" is what is being assessed. If an Inspection Report -CAR must be issued under this task, Component 1 would state: "The operator does not meet the regulatory requirements related to effectively implementing a HACCP Plan".
Component 2:
Describe the deficiency in clear and factual terms that:
- accurately reflect the deficiency identified;
- do not offer solutions or opinions; and
- are related to the task.
The description of deficiencies must:
- Include what was observed, measured or obtained through interviews as they relate to the deficiency.
Include where and when deficiencies were noted as well as the name or title of anyone interviewed.
Such as, "May 10, 2007 10:45 am observed in the cutting room."
- If deficiencies were noted during the record review, include a summary of the review related to the
deficiency. Include the name and date of the records reviewed and the deficiency noted.
Such as, "Reviewed the Cooking Reports for June 2007 and deviations were identified on June 5th, 6th, and 7th but the deviation procedures were not implemented ..."
- If deficiencies were noted during written program review, include the name of the written program
reviewed and the deficiencies noted.
Such as, "HACCP plan X, CCP2B: Monitoring procedures do not meet FSEP Manual requirements. No frequency identified."
- If the operator took control of product(s), include a summary of the control.
- If the CFIA took action to control a product or thing, include a summary of the action. This action includes the application of a held tag, seizure and detention of a meat product or thing, refusal to certify a product for export or the initiation of a mandatory recall.
- If there is a recently closed CAR related to this task with the same cause of the deviation, link this CAR to the closed CAR by referencing the number of the closed CAR on the new CAR and stating what corrective actions were implemented on the closed CAR, and that these actions were ineffective. The inspector should only link CARs when they were issued for the same task and the non-compliances are from the same cause.
Note: The purpose of linking CARs is to provide notification to the operator that the previous actions were ineffective in, or were not implemented in a way that is preventing the non-compliance from recurring, and that a similar action plan will not be accepted for this CAR.
18.7.4.5 Meeting with the Operator
The inspector will meet with the operator at least once a week to discuss findings and any CARs and/or the Verification Report. This meeting must occur at least quarterly in storage establishments. During meetings with the operator, the inspector must communicate in a clear professional manner. The operator may also want to share information or concerns at this time. In addition, the inspector and operator should discuss pertinent issues such as new policy changes, planned changes at the establishment, etc.
If a CAR was issued to the operator, the inspector:
- Discusses the non-compliance with the operator and clarifies any concerns or questions that the operator may have regarding the description of the non-compliance.
- Informs the operator that the non-compliance described in the CAR requires implementation of corrective measures which includes: submission of a written acceptable action plan and the effective implementation of the corrective and preventative measures described in the acceptable action plan.
- Requests an acceptable action plan from the operator to respond to the non-compliance described in the CAR. Informs the operator that the action plan:
- must include items described in section 18.7.5.1 of this chapter; and
- must be fully implemented by the date specified by the inspector. The date specified by the inspector should reflect the seriousness of the non-compliance. The maximum time for completion of corrective measures is 60 calendar days from the date the CAR is issued.
- Specifies a date the operator is required to submit an acceptable action plan. The date specified by the inspector
should reflect the seriousness of the non-compliance. The maximum time for an action plan to be submitted is 14 calendar days.
Note: Some tasks have prescribed timelines for action plan submissions. e.g. 7.2.02 and 7.2.11
- Informs the operator that the action plan will be reviewed for acceptance and that the CFIA will conduct a follow-up inspection after the date specified for completion of corrective measures.
- Informs the operator that a failure to develop an acceptable action plan may result in a failure to implement effective measures that correct and prevent the non-compliance.
- Informs the operator that a failure to implement corrective measures in relation to the non-compliance noted by the date specified in the CAR may result in the initiation of the process to suspend the operator's licence to operate pursuant to sub-section 29.2(1) of the Meat Inspection Regulations, 1990.
- Obtains the operator representative's signature on the CAR to
indicate they were notified of the non-compliance(s) and they agree to provide an acceptable action plan and correct the deficiencies.
If the operator refuses to sign the CAR, the inspector:
- notes in the Description of Non-Compliance section of the CAR that the operator refused to sign the CAR, and that a copy was left with the operator representative's name and title;
- informs the operator that they must follow Chapter 18, section 18.7.4.7 if they wish to request a review of the CAR; and
- informs the operator that they are required to correct any immediate food safety deficiencies described on the CAR while the CAR is subject to the review process.
If the operator refuses to correct the immediate food safety deficiencies described on the CAR, the inspector must take enforcement action as necessary and document the actions taken on the follow-up section of the CAR.
- Provides the operator representative with a copy of the CAR.
If a Verification Report is issued to the operator (at least once per month in processing and slaughter establishments or at least once per quarter in Storage establishments), the inspector:
- discusses the items requiring correction listed on the Verification Report and the developing trends of non-compliance that those items indicate;
- informs the operator that items requiring correction listed on the Verification Report require correction within 30 calendar days of the date the verification report was issued and that a failure to correct these deviations may result in the issuance of a CAR;
- informs the operator that after 30 calendar days of the date the verification report was issued, the CFIA will follow up to verify the items requiring correction have been corrected;
- obtains the operator representative's signature on the Verification Report to indicate they were notified of the items requiring correction and they agree to correct these items within 30 calendar days of the date the verification report was issued. If the operator fails to sign the report, the inspector notes on the report that the operator refused to sign the report and that a copy was left with operator representative's (name) and (title). The items still require correction and the inspector follows-up after 30 days; and
- provides the operator representative with a copy of the Verification Report.
18.7.4.6 HACCP System Design Closing Meeting
The CFIA team responsible for verifying the design of the operator's HACCP system conducts a closing meeting with the operator's representative.
If a CAR was issued to the operator, the FSEP Specialist inspector:
- discusses the non-compliance(s) with the operator and clarifies concerns or questions that the operator may have regarding the description of non-compliance;
- informs the operator that the non-compliance described in the CAR requires implementation of corrective measures which includes: submission of a written acceptable action plan and the effective implementation of the corrective actions and preventative measures described in the acceptable action plan;
- requests an acceptable action plan from the operator to respond to the non-compliance described in the CAR. Informs the operator that the action plan:
- must include items described in section 18.7.5.1 of this chapter; and
- must be fully implemented by the date specified by the inspector. The timelines specified by the inspector should reflect the seriousness of the non-compliance and the time required to correct the non compliant section of the HACCP system. Due to the nature of HACCP System Design Tasks, CARs generated as a result may require a specified timeline for completion of corrective measures that is over 60 days;
- specifies a date the operator is required to submit an acceptable action plan. The timelines specified by the inspector should reflect the seriousness of the non-compliance. The maximum time for an action plan to be submitted is 14 calendar days;
- Informs the operator that the action plan will be reviewed for acceptance and that the CFIA will conduct a follow-up inspection after the date specified for completion of corrective measures.
- Informs the operator that a failure to develop an acceptable action plan may result in a failure to implement effective measures that correct and prevent the non-compliance.
- Informs the operator that a failure to implement corrective measures in relation to the non-compliance noted by the date
specified in the CAR may result in the initiation of the process to suspend the operator's
licence to operate pursuant to sub-section 29.2(1) of the Meat Inspection Regulations, 1990; and
If the operator refuses to sign the CAR, the inspector:
- notes in the Description of Non-Compliance section of the CAR that the operator refused to sign the CAR, and that a copy was left with the operator representative's name and title;
- informs the operator that they must follow Chapter 18, section 18.7.4.7 if they wish to request a review of the CAR; and
- informs the operator that they are required to correct any immediate food safety deficiencies described on the CAR while the CAR is subject to the review process.
Note: If the operator refuses to correct the immediate food safety deficiencies described on the CAR, the inspector must take enforcement action as necessary and document the actions taken on the follow-up section of the CAR.
- provides the operator's representative with a copy of the CAR.
If a HACCP System Design Verification Report is issued to the operator, the FSEP specialist inspector:
- discusses the items requiring correction listed on the report and the developing trends of non-compliance that those items indicate;
- informs the operator that items requiring correction listed on the report require correction within 60 calendar days of the date the report was issued and that a failure to correct these items may result in the issuance of a CAR;
- informs the operator that after 60 calendar days of the date the report was issued, the CFIA will follow-up to verify if the items requiring correction have been corrected;
- obtains the operator representative's signature on the HACCP System Design Verification Report to indicate they were notified of the items requiring correction and they agree to correct these items within 60 calendar days of the date the report was issued. If the operator fails to sign the report, the inspector notes on the report that the operator refused to sign the report and that a copy was left with operator representative's name and title. The items still require correction and the inspector follows-up after 60 days; and
- provides the operator's representative with a copy of the HACCP System Design Verification Report.
18.7.4.7 Request for Review of a CAR
An operator may request a review of a CAR before the date specified for the submission of an action plan. The operator must submit its reason for the request in writing, to the Area CVS Coordinator. The operator is required to correct any immediate food safety deficiencies described on the CAR while a CAR is subjected to the review process. If the operator refuses to correct the immediate food safety issues described on the CAR, the inspector must take enforcement actions.
When a request for review is submitted prior to the date for submission of an acceptable action plan, the operator will not be required to submit an action plan until the review results have been communicated to the operator and CFIA staff.
The Area CVS coordinator is responsible to:
- review the request submitted by the operator;
- advise the responsible inspector and supervisor of the request;
- seek expertise from programs or the National CVS Coordinator where necessary;
- seek clarification or information from the operator; and
- make a final decision regarding the request.
A written decision is returned to the operator with a copy sent to the responsible inspector, supervisor and the Area Meat Programs Manager.
The inspector will describe in the follow-up section of the CAR any decision taken by the CFIA with regard to the review process. The CFIA written decision must be attached to the CAR.
If the CAR is upheld, the Area CVS Coordinator will assign a new due date for the submission of an acceptable action plan and/or completion of corrective measures if deemed appropriate. The operator must submit the action plan by the date specified.
If the CAR is overturned, the CAR will be cancelled (closed). The inspector must note in the follow up section of the CAR that the CAR was overturned as a result of a review by the CVS Area Coordinator.
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