This policy will be reviewed to ensure efficacy following the completion of the first series of compliance audits or no later than by September 1, 2015, whichever is earlier.
Scope of Onsite Activities
1. The auditor shall identify and review onsite physical evidence directly relevant to compliance with applicable standards.
2. The auditor shall identify and review onsite materials relating to the accuracy of onsite recordkeeping needed to determine compliance with applicable standards.
3. The auditor’s review may encompass all points relevant to the full suite of CSSD standards.
4. The frequencies and auditor guidance outlined below shall not be construed to limit the auditor from verifying compliance to all CSSD standards.
Schedule and Scope of Review
1. Initial certification audit
Desk – 90 day operational window:
- Each company shall work with the auditor to develop a schedule for submitting, or making available to the auditor on an ongoing basis, all materials deemed by the auditor necessary to evaluate compliance during the first 90 days from the company’s date of application for certification. Each company agrees to respond to reasonable additional requests for information from the auditor in a timely manner.
- All documents necessary to determine compliance with applicable standards shall be produced, or made available to the auditor within 120 days of the date of the company’s application.
- The auditor shall identify and review all plans, reports and records submitted by the company relating to compliance with CSSD standards during the first 90 days following application for certification and any identified issues relating to the drafting or interpretation of those standards.
Field – 90 day operational window:
- At the request of the auditor, the company will provide a schedule of relevant activities and relevant inventory of sites.
- The auditor will select a representative suite of sites to be audited in conformance with the nominal frequencies listed below for each operator with discretion to visit as many sites as necessary to verify compliance.
- Notice:
The company representative to the CSSD will receive 48 hours of advance notice of a scheduled visit to the site. While it is anticipated that the auditor will have full access to the site, the site operator is responsible for safe operations at the site and may restrict auditor access to portions of the site where and for so long as s/he deems that safety concerns warrant.
Any modifications, relevant to any of the performance standards, which are initiated following the notice of a scheduled site visit shall be documented. - The auditor will develop an audit schedule to maximize efficiency.
Auditor’s Initial Certification Report:
- Within 60 days of the completion of the “90 day” field audits and receipt of all information deemed necessary, the auditor shall produce a report that documents the company’s degree of compliance with the CSSD standards. If all information needed to determine compliance has not been received within 120 days of the initial application, or 90 days of the annual review date, as appropriate, the auditor shall make a request for additional information and such information will be made available to the auditor within 30 days of such request. Following this period, the auditor shall prepare its report with respect to all other items and note the missing information that precludes a determination of compliance.
- The auditor’s report shall identify any specific areas where action or additional informationis needed to provide for continuous compliance with the CSSD standards and any perceived barriers to sustained compliance.
2. Compliance Assurance
Annual Desk Audits:
- Each company shall work with the auditor to develop an “annual review date” for submitting or making available to the auditor all materials deemed by the auditor necessary to evaluate compliance during the prior year. Each company agrees to respond to reasonable additional requests for information from the auditor in a timely manner.
- For the first year the annual review date shall be between 9 months and 15 months of the Date of Certification of the participating company and annually thereafter.
- All documents necessary to determine compliance with applicable standards shall be produced, or made available to the auditor within 60 days of the annual review date.
- The auditor shall identify and review all plans, reports and records submitted by the company relating to the prior year’s compliance with CSSD standards and any identified issues relating to the drafting or interpretation of those standards.
Ongoing (annual cycle) Field Audits:
- At the request of the auditor, the company will provide a schedule of relevant activities and relevant inventory of sites.
- The auditor will select a representative suite of sites to be audited in conformance with the nominal frequencies listed below for each operator with the discretion to visit as many sites as is necessary to verify compliance.
- Notice:
The company representative to the CSSD will receive 48 hours of advance notice of a scheduled visit to the site. While it is anticipated that the auditor will have full access to the site, the site operator is responsible for safe operations at the site and may restrict auditor access to portions of the site where and for so long as s/he deems that safety concerns warrant.
Any modifications, relevant to any of the performance standards, which are initiated following the notice of a scheduled site visit shall be documented. - The auditor will develop an audit schedule to maximize efficiency.
Auditor’s Annual Compliance Assurance Report:
- Within 60 days of the completion of the “annual cycle” of field audits and receipt of all information deemed necessary, the auditor shall produce a report that documents the company’s degree of compliance with the CSSD standards. If all information needed to determine compliance has not been received within 120 days of the initial application or 90 days of the annual review date, as appropriate, the auditor shall make a request for additional information and such information will be made available to the auditor within 30 days of such request. Following this period, the auditor shall prepare its report with respect to all other items and note the missing information that precludes a determination of compliance.
- The auditor’s report shall identify any specific areas where action or additional documentation is needed to provide for continuous compliance with the CSSD standards and any perceived barriers to sustained compliance.
Onsite Verification – Relevant Standards and Audit Frequencies:
It is anticipated that the auditor’s onsite inspection activities will provide information that will assist the auditor in determining compliance with the following standards at a minimum, and that such activities may yield information relevant to all CSSD standards.
Whenever possible during an onsite audit, compliance to multiple standards should be verified and accrue to each standard’s frequency.