The purpose of this process is to help a practice or facility remain compliant with applicable standards as its scope of practice evolves over time. Even with the best intentions, gradual drift from standards can occur because of staffing changes or routine oversights in a busy practice. Practices and facilities should be prepared for inspection at any time and are expected to meet the relevant accreditation standards. Performing the annual Self-Assessment helps the Designated Registrant (DR) review the overall health of the practice each year and identify any gaps that need attention. The Self-Assessment form must be available during an inspection.
The Annual Self Assessment Process involves completing two forms:
1. Practice Facility Annual Declaration Form (link is to abridged version to allow new applicants to view the options for scopes of practice, active version is submitted via designated registrant’s online portal)
- Allows the DR to declare the scope of practice that was offered during the preceding year.
- The Annual Declaration form must be completed and submitted to the College office every year.
2. Practice Self-Assessment Form
- Allows the DR and staff to review the standards relevant to the declared scope of practice to ensure they are still met.
- Must be kept in clinic but only submitted to the College upon request.
3. Additional links that may be helpful:
Important Considerations:
- Submitting the Annual Practice Facility Declaration may be used to notify the College of a minor change or a decrease in the scope of practice, but the DR should notify the College at the time a relocation or significant/substantial changes occur, as required under Bylaw 3.6(9) and explained on this page.
- All practices or facilities, including consulting practices, are required pursuant to Section 3.7 to submit the Annual Declaration and complete the Self-Assessment.
- The Annual Practice Facility Annual Declaration form must be submitted to CVBC no later than January 31 of the following year.
- For a new practice or facility, the Annual Declaration and Self-Assessment help define the intended scope of practice and identify which standards must be met before inspection.
- Once a practice or facility has permission to operate, the DR must complete the Self-Assessment annually to confirm that the practice or facility continues to meet the relevant accreditation standards.
- A Self-Assessment must be completed, and the Annual Declaration form must be submitted, even in years when a physical inspection occurs, because both documents reflect the previous year’s scope of practice.
- Under Bylaw 3.8(1), a DR of a practice facility who does not complete a Self-Assessment form or does not submit an Annual Declaration form by January 31 may be subject to a late filing fee of $250. Bylaw 3.8 also states that failure to submit the required form and/or pay the late fee by February 28 may result in PFAC directing an inspection and initiating a complaint against the DR under section 50 of the Act.
These same actions may also be taken if the DR does not provide the forms when requested by the College office or an inspector.
