The Licensed Community Care Facilities Risk Assessment Worksheet

Facility Name Data Entry Confirmation

Address

Risk Assessment Licensing Officer Last Risk Assessment Last Routine Hazard Rating at Final Risk
Date Initial Date Insp. Date Last Inspection Rating
Review
DD / MMM / YYYY DD / MMM / YYYY DD / MMM / YYYY _____ /65

Category Wt Weighted Summary Notes

(choose one number in each category A - F) Rating
score x Wt

(A) Reportable Incident, Investigation & Abuse x 3 /15

History Assessment
5. High number of reportable incidents (with
inappropriate response to maintain health
and safety), confirmed abuse allegations,
investigations & hearings OR insufficient
information is currently available.
4. Moderate or high number of reportable
incidents (with inappropriate response to
maintain health and safety) and confirmed
abuse allegations.
3. Moderate or low number of reportable
incidents (with appropriate response to
maintain health and safety) and
unconfirmed abuse allegations.
2. Low number of reportable incidents (with
appropriate response to maintain health &
safety).
1. No history of reportable incidents,
investigations or abuse allegations.
(B) Assessment of Management Effectiveness x3 /15
5. Management lacks an understanding of
facility risks and requires consistent
guidance to develop a systematic health
and safety management plan OR
insufficient information is currently available.
4. There are recurring poor management
practices which prohibit the implementation
of a systematic health and safety
management plan.
3. Management temporarily cannot implement
a systematic health and safety management
plan.
2. Management has an operational systematic
health and safety plan.
1. The management of the facility exceeds
standards for developing a systematic
health and safety plan.

(C) Staff Qualifications & Supervision Practices x 2 /10

Assessment
5. Staff are, overall, unprepared, untrained &
place clients at risk OR insufficient
information is currently available.
4. Staff cannot consistently handle
emergencies because of poor qualifications
or practices.
3. Staff are generally qualified but temporarily
are unable to handle emergency situations.
2. Staff qualifications and supervision
practices do not put clients at risk.
1. Staff are exceptional and protect the health
and safety of clients in care.

Sub-total from A - C: /40

(D) Facility Physical Plant Assessment X2 /10
5. Facility physical plant is extremely
hazardous to client health and safety OR
insufficient information is currently available.
4. Facility physical plant is chronically a health
and safety hazard.
3. Facility physical plant is occasionally a
health and safety hazard to clients.
2 Facility physical plant is safe.
1. Facility physical plant exceeds health and
safety requirements.

(E) Policies & Procedures Assessment x2 /10

5. No policies and procedures are in place OR
insufficient information is currently available.
4. Policies and procedures are typically
ineffective
3. Policies and procedures are generally
effective.
2 Policies and procedures meet minimum
requirements for health and safety.
1. Policies and procedures exceed
requirements for health and safety.

(F) Self-monitoring /Quality Improvement, Staff x1 /5

Training & Prevention
5. No self-monitoring / quality improvement
program is in place OR insufficient
information is currently available.
4. Health and safety are rarely ensured
through self-monitoring /quality
improvement processes.
3. Health and safety are usually ensured
through self-monitoring / quality
improvement.
2. Health and safety are ensured by the
licensee by self-monitoring / quality
improvement processes.
1. Self-monitoring / quality improvement steps
and procedures exceed requirements to
maintain health and safety.

Sub-total from D - F: /25

Transfer Sub-total from A - C: /40

TOTAL: /65

To ensure the risk assessment tool is providing correct information to others who may view it, licensing officers should include
a brief narrative description of the identified risks for every category that scores 3, 4 or 5. These reports are computer
generated and the scoring is done automatically to assign a risk score, thus a risk rating (low, moderate or high). If a facility
borders these risk rating or it is assessed by the licensing officer that a different risk rating should be assigned, the licensing
officer may collaborate with colleagues, review historical and new information and if deemed necessary override the automatic
category of risk rating given. If this is done it is essential that the licensing officer performing the risk assessment provide a
brief overview as to the reasons for the rating change.