Employers interested in participating in the Certificate of Recognition Program need to follow the outlined process and complete all required forms.
COR POLICY AND PROCEDURES: Audit Certification Process 150623
When an organization wishes to attain and retain COR certification they must go through the following process:
- Confirm Eligibility
- COR Application
- Notice of Audit
- Auditor Selection
- Audit Submission
- Audit Review & Decision
- COR Decision
- Maintenance Audits
- Recertification Process
- Complaint Procedure (where applicable)
1. Confirm Eligibility
Any Local Government registered in the Classification Unit 753004 in BC is automatically considered a member of the BC Municipal Safety Association and is qualified to participate in Local Government COR.
Naturally Aligned Organizations (NAO) are Organizations without a Certifying Partner; they may apply to participate in Local Government COR, however approval must be attained from WorkSafeBC prior to application.
WorkSafeBC Contact Information:
NOTE: At least one Management member of the organization is required to complete the Safety Management System Course (in a face-to-face course or online on the BCMSA website) as a prerequisite to this process.
2. COR Application
A COR Application Form must be completed and sent to the BCMSA.
Once a completed COR Application form is received, a Certificate of Recognition Program Documentation Tracking Form is started by the BCMSA to track progress and ensure all required information is received.
3. Notice of Audit
Any organization that conducts an Audit must complete a Notice of Audit Form at least 2 weeks prior to the audit start date. Once the form is received the potential auditor will be confirmed as ‘qualified’ or ‘unqualified’ by the BCMSA.
- If qualified, the form will be filed in the appropriate folder and the BCMSA management will monitor the audit progress informally.
- If unqualified, a Letter of Non-Acceptance will be sent to the applying organization with an explanation and further instructions.
4. Auditor Selection
Organizations with 20 or more employees are required to hire a BCMSA Certified External Auditor. The BCMSA has no role to play in the selection of External Auditors, other than to provide a list on the website for organizations to choose from.
Organizations with 19 or less employees may utilize the services of an External Auditor or an Internal Auditor for the COR cycle. Internal Auditor qualifications are detailed in Step 9.
Auditors have 45 days to complete the audit including onsite interviews, document reviews and observations. Auditors may refer to Documentation for Auditors to Review Form as reference while conducting the audit. Auditors must use the e-Compliance COR Audit Tool.
- Small Employer Audit Tool
6. Audit Submission
Completed audits will be submitted electronically to the Manager of Audit & Training Services. The audit submission date must be within 30 days after completion (i.e. last on-site date) of the audit.
Note: If an Auditor requires additional time to complete the report a Local Government COR Audits Request for Audit Extension Form must be completed and approved by the BCMSA.
7. Audit Review & Decision
Completed audits will be reviewed by the Manager of Audit & Training Services or Executive Director. Certificate of Recognition Program Documentation Tracking Form is reviewed to ensure all items/documents are received. If a required item is missing from the submission, it may be a bar to certification until provided.
Required documentation includes:
- Organizational Chart
- Fully completed electronic audit in both .eca and .pdf formats
- Interview Selection Sheet
- Observation Selection Sheet
- Pre and post-audit meeting records
- Signed Auditor Code of Ethics (required once)
Each element in the audit will be reviewed to ensure that all:
- Questions are scored properly and have comments supplied,
- Comments provide clear justification and do not conflict with other comments.
BCMSA Management will identify any specific questions in the audit requiring improvement. A summary provided to the Auditor on the Audit Review Checklist will indicate whether the submission is acceptable or needs to be revised.
The e-Compliance Audit Tool will facilitate the compilation of the entire audit, including an element-by-element description of audit findings, key strengths, and recommendations for improvement.
8. COR Decision
If the applying organization passes the COR Audit they are to submit a customized Action Plan to the BCMSA within 30 days of notification of Audit “pass”, then the BCMSA will update the iCOR database to reflect the successful audit completion. If the organization does not submit an Action Plan within the required timeframe then a notice of ‘Non Completion’ will be sent to the applying organization. NOTE: If an organization cannot complete the Action Plan due to extenuating circumstances, they must contact the BCMSA Manager of Audit and Training Services by email to request an extension.
Only after the BCMSA has reviewed the Audit, may the External Auditor hold the final meeting with the organization to communicate the results.
If the applying organization fails the COR Audit with a score of between 70%-80%, and no more than one element with less than 50%, they have the opportunity to complete a Request for Limited Scope Audit Form to achieve a pass score. The organization must request a Limited Scope Audit within fourteen days of notification of failing the audit. The organization has 3 months to complete and submit the Limited Scope Audit, from the date of application, and in no case may the Limited Scope Audit be submitted and approved later than March 31. Organizations scoring less than 70% will have to engage the entire process again to achieve a pass mark.
If the applying organization fails the COR Audit with a score of less than 70%, or with more than one element scoring less than 50%, the Auditor shall provide an Executive Summary with element-by-element details of the shortcomings. BCMSA will enter the information into iCOR as a “fail”. No additional audit information is provided to WorkSafeBC.
9. Maintenance Audits
Maintenance audits in years 2 and 3 of the audit cycle follow the same process as Certification audits and are a full and comprehensive audit of the entire organization (steps 3-7). Organizations have the option to utilize a BCMSA-certified External Auditor, or a Certified Internal Auditor. If using an External Auditor, the organization may choose the audit to be a Recertification, or a Maintenance audit. Only those with the BCMSA training are able to conduct audits. The BCMSA Manager of Audit and Training Services will remind organizations 3 months prior to their maintenance audit date to ensure planning and organization takes place. All maintenance audits must be completed and submitted to the BCMSA by original audit pass date.
10. Recertification Process
Recertification audits are conducted after the three-year audit cycle has been completed, and follow the full process (steps 3 to 7). If successful, the organization will enter into another audit cycle requiring maintenance audits in years 2 and 3.
Internal Auditors must be employees of the organization and are required to take and pass the BCMSA 16 hour Internal Auditor training. Each successful auditor must complete their student audit within 3 months of training and submit that report to the BCMSA Manager of Audit and Training Services to finalize course requirements and achieve a pass mark. All processes and paperwork outlined in this document are also required to fulfill the requirement of a successful Student Audit.
If there is more than one internal auditor candidate from an organization, then student audits must be undertaken so that the BCMSA Manager of Audit and Training Services can identify that the candidate has successfully utilized all aspects of the Audit, including Documentation review, Observations, Interviews, and completion of the COR Audit Tool. This may be accomplished through individual department audits (provided the department has 20 or more employees), or by verification by the candidates of the percentage of each aspect completed by each candidate.
An organization wishing to have more than one internal auditor, must limit the number of auditors to one per department plus one extra.
The organization may choose to use the same auditor used in the original audit or another certified BCMSA external auditor for maintenance audits or recertification audits (or internal auditor in the case of small employers with 19 or less employees).
11. Complaint Procedure (where applicable)
LOCAL GOVERNMENT ORGANIZATION
All COR-participating organizations have the right to make a complaint or appeal regarding the handling of an audit, including that of the following:
- Conduct of the auditor
- Individual audit findings
- Final audit results
- Organization – complete Complaints and Appeals Form and forward to the BCMSA office within 14 days of the audit report being submitted.
- BCMSA Manager of Audit and Training Services initiates immediate investigation of the concerns raised.
- BCMSA will contact organization’s representative by phone and/or email for discussion of findings.
- BCMSA will rectify, as appropriate, with the involvement of the Executive Director.
Should BCMSA’s findings not satisfy the organization, the organization’s representative will be notified that he/she is invited to appeal in writing to the BCMSA Board of Directors for one final review of the organization’s concerns; directions by the Board of Directors will be then forwarded to the Executive Director who will contact the organization with the findings. The decision of the Board of Directors is final.
All auditors will have the right to appeal any finding against them or discipline imposed. Any appeal made by the auditor will be conducted by the Executive Director.
- Auditor – complete Audit Complaints and Appeals Form and forward to the BCMSA office. Under reason for complaint/appeal, check “other”.
- BCMSA Executive Director – affect immediate investigation into the concerns.
- BCMSA Executive Director – contact auditor by phone, if possible, to discuss results and actions.
Should an infraction still have been deemed to have occurred, the auditor shall have the right to appeal any disciplinary action taken to the BCMSA Board of Directors. Such appeal must be provided in writing and must be submitted within thirty (30) days of any action being applied against the auditor. The findings of the Board of Directors shall be final.
Auditor Satisfaction Survey
After a large organization has received the final audit results and Executive Summary, a survey will be sent to the organization contact for feedback on the auditor and audit process. These surveys will be used to ensure External Auditors maintain the highest standard of competency and customer service.