Standards for Canadian organizations

2020 Edition

Administrative and Service Environment (CA-ASE) 4: Facility Safety and Maintenance

The organization's facilities and grounds are safely maintained and are routinely monitored.
2020 Edition

Currently viewing: ADMINISTRATIVE AND SERVICE ENVIRONMENT (CA-ASE)

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Purpose

The organization’s administrative and service environments are respectful, safe, and accessible and contribute to organizational effectiveness.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-ASE 4 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 4 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 4 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-ASE 4 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Procedures for vehicle use including license validation, insurance coverage expectations, etc. 
  • Monthly maintenance inspection reports for the prior six months
  • Documentation of corrective action where indicated
  • Documentation of license, driving records, and insurance validation
  • Contracts, including safety expectations, with any outside transportation providers, if applicable
  • Contracts/agreements with any host sites  
  • Interviews may include:
    1. Relevant personnel
  • Observe facilities
  • Observe vehicles

 
Fundamental Practice

CA-ASE 4.01

All facilities in which the organization operates are properly maintained through:
  1. monthly inspections to ensure the organization’s facilities are safe and heating, lighting, and other systems are functioning properly;
  2. preventive maintenance by a qualified professional; and
  3. quick responses to emergency maintenance issues and potentially hazardous conditions.

Interpretation

If the organization is a tenant in its facilities, some or all of the above activities may be conducted by the landlord. In such instances, the organization must be able to demonstrate that it monitors and documents the completion of elements (a) through (c) to provide a safe environment for people to work and receive services.
Examples: “Emergency maintenance issues” can include: overflowing toilets, flooded basements, defective heating systems, and other situations that can damage property, pose a threat to clients, or interfere with service delivery.
 
Examples of “hazardous conditions” include: uncovered electrical outlets, improper storage of cleaning supplies and other hazardous materials, unsecured floor coverings or equipment, stairs without handrails, harmful water temperatures, inadequate lighting, improper ventilation, uncomfortable room temperatures, unscreened areas or unmarked glass doors, broken or malfunctioning tools or equipment, including electrical appliances.
Note: Please see the Facility Observation Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard. All administrative and service-delivery facilities are safe and well-maintained in accordance with comprehensive maintenance procedures as per the requirements of the standard.
2
Practices are basically sound and facilities are generally safe and well-maintained, but there is room for improvement; e.g.,
  • Inspections are conducted regularly on a timeframe established in procedures at all administrative and program sites, but non-emergency or non-hazardous issues identified as needing maintenance are not always resolved in a timely manner; or
  • The organization rarely reviews the need for, or conducts, preventive maintenance, instead making repairs on an "as needed" basis; or
  • Review of the physical plant at some programs or sites is conducted less than monthly but at least quarterly; or
  • Maintenance records are not always up-to-date at rented facilities.
3
Practice requires significant improvement and potentially unsafe conditions exist at at least one administrative or service-delivery site; e.g.,
  • One of the standard's elements is not addressed at all; or
  • Poorly written or incomplete maintenance procedures, or use of unqualified staff have resulted in the failure to recognize critical problems needing attention; or
  • Maintenance procedures are implemented in a cursory or haphazard manner; or
  • Needed repairs are typically not made in a timely manner; or
  • There are ongoing problems with critical systems, like the hot water supply or heat, that the organization is attempting to remediate, thus far unsuccessfully; or
  • There are deficiencies in regard to health, sanitation, and safety codes and regulations, and remedial action is being taken under direction from authorities; or
  • Maintenance at rented facilities is not routinely monitored and/or documented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • At least two of the standard's elements have not been addressed at all; or
  • Staff and/or clients are at risk due to the organization's failure to conduct routine inspections or maintenance, make critical repairs of emergency issues or hazardous conditions, or otherwise properly maintain at least one of its owned or rented facilities; or
  • Licensure or certification has been denied or revoked due to failure to meet applicable health and safety codes and regulations.

 
Fundamental Practice

CA-ASE 4.02

An organization that permits or requires the use of agency- or privately-owned vehicles to transport clients requires:
  1. the use of age-appropriate passenger restraint systems;
  2. adequate passenger supervision, as mandated by statute or regulation;
  3. proper maintenance of agency-owned vehicles;
  4. current registration and vehicle safety review;
  5. annual validation of licenses and driving records for staff who are permitted to transport clients; and
  6. motor vehicle insurance.

Interpretation

This standard does not apply to vehicles owned by resource families, which are covered by CA-FKC 18.05 and CA-AS 10.06.

Interpretation

When the organization has a contract with an outside transportation provider, it must include relevant safety expectations in the contract.
NA The organization does not permit or require transporting clients in agency- or privately-owned vehicles.
Note: Please see the Facility Observation Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • In rare instances routine vehicle maintenance or driver’s license checks are delayed.
3
Practice requires significant improvement; e.g.,
  • The process for validating drivers licenses or driving records of staff currently using organization-owned vehicles to transport clients in their own vehicles is backlogged; or
  • Vehicle maintenance, insurance, or other records are poorly maintained resulting in confusion about how well the standard is being implemented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.

 

CA-ASE 4.03

When services are offered on a consistent and on-going basis, in a location that is not owned or leased by the organization, prior to using the facility, the organization develops a memorandum of understanding (MOU) or a contractual agreement with the host that includes:
  1. space and equipment needs;
  2. health and safety expectations; and
  3. each group’s responsibility for cleaning, maintenance, liability risk, and other costs (e.g., utilities, insurance, and repairs).
NA The organization does not offer services on a consistent and on-going basis at locations it does not own or lease.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures need strengthening; or
  • One element has not been fully addressed.
3
Practice requires significant improvement; e.g.,
  • Agreements/contracts are often poorly executed and maintained, e.g., terms and conditions are general, nonspecific, or unclear; or
  • At least two of the elements have not been fully addressed; or
  • One element has not been addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.