How to Submit Corrective Action Plans, Review and Close NCs

The purpose of this guide is to identify what composes an NC (non-compliance) Review and Closure form and how to address the NCs identified during a Fair Trade USA (FTUSA) audit in ChainPoint.

Training Audience

This guide is intended to be a resource for Certificate Holders (CH), FTUSA Certification Team, FTUSA Producer and Commercial Teams, and Conformity Assessment Bodies (CAB).

NC Review and Closure Form:  Overview

The NC Review and Closure Form contains the following sections:

NC Review and Closure:  Who Can Access 

The following users can access the NC Review and Closure Form:

How NC Review and Closure Rounds Work

A CH can use review rounds on the Corrective Action Plan (CAP) and NC Review, to close all NCs identified during an audit. A round has two parts:

1. The applicant/CH responds to each NC with a CAP and evidence of implementation of corrections and preventative actions.
2. The CAB reviews the CH’s CAP and any evidence of CAP implementation of corrections and preventative actions. The CAB determines if the CAP is acceptable and if the NC can be closed based on the evidence submitted. For an NC to be closed, the CAB must confirm that corrections and preventative actions have been implemented.

If the deadline to submit a response passes without the CH, the CH forfeits their review and the CAB starts a new round of CAP and NC review.

Additional rounds can be added to the review process, for more information on CAP and NC closure review rounds consult section 11.3 of the PAM. 

NC Review and Closure as a Certificate Holder

If non-compliances are identified during the FTUSA audit, the CH provide a root causes analysis, corrections and preventative actions and evidence of implementation of corrections and preventative actions.  All NC Critical criteria and only NC Progress criteria selected by the client to reach sufficient Progress Points required in the applicable certification year.  For more information on progress criteria and progress points, please review the Score System Guide and the Score System Guide for the Capture Fisheries Standard.

 All supporting evidence must be submitted by the CH by the round due date specified under the current review round. Once the CH has submitted the NC Review and Closure form, CAB review is the next step.

Below is a summary of how the CH  submits evidence of correction and preventative action implementation:

1. CH will receive email notification when CABs start the NC review process. Use the link provided in the email notification to access NCs in the NC Review and Closure form.
2. Alternatively, you can log in to ChainPoint and from the left menu, select “NC Review and Closure,” then you can search for the NC Review and Closure form associated with your most recent audit by using the Status, Audit End Date or audit ID filters.
3. 
4. Review the general information and Review Round sections for information on the CAB, CAP Reviewer, and due dates.
   
   
   
5. To address specific NCs, scroll down to the section named “NC.”  This section lists each NC found during the audit. 
   
6. Click on any NC to view additional details. Each NC has the following components:
   a. Criteria – from the relevant standard
   b. Intent and Clarification – from the relevant standard
   c. Type of NC – NC grade resulting from the audit
   d. Farm Size – APS only – size of the operation that received the NC during the associated audit
   e. Auditor Evidence – explanation of the NC from the audit
   f. NC Status+ – indicates if an NC is open or closed
   g. Root Cause Analysis* – a systemic evaluation of why the NC occurred
   h. Preventative Action* – steps taken to correct/reverse negative impacts to workers and/or the environment and steps taken to prevent reoccurrence of the NC
   i. Correction* – any immediate actions taken to address the NC
   j. Evidence of NC Closure* – information based on facts that can be proved and are clearly identifiable; and must correspond to the specific action plan measure; and either verify that implementation is complete or present a detailed plan for implementation in the near future
   k. CAP Status+ – indicates if NC evidence and CAP has been accepted by the CAB
   l. Attached Documents* - added by the Certificate Holder
   m. Comments+ – feedback about the CAP and evidence the Certificate Holder has submitted
   *completed by the CH
   +completed by the CAB
7. To edit an  NC and submit supporting evidence, select edit at the top of the page and scroll down to the NC section. Click on the NC to be addressed and add information as required. 
8. Once you have added the information required for the NC, scroll to the end of the NC window and select “Close.”
9. Repeat, as needed, for each NC.
   
10. Select ‘Save’ at the top of the NC Review and Closure form to save changes. NC Review and Closure form can be revisited by the CH to add additional details or revise before the round due date for CH CAP & NC Evidence Submission as many times as needed by using the ‘Save’ function.
11. If the CH completes submission of evidence for all NCs before the due date and wants to expedite review by their CAB, they can advance the NC Review and Closure form to the CAB for review by selecting “Submit to CAB for review.”
    
12. If the CH does not advance the NC Review and Closure form to the CAB before the round due date for CH CAP & NC Evidence Submission, the form will automatically advance to the CAB for review on the due date. When the form is in status “Review CAB,” the Certificate Holder will not be able to make any edits.
13. If the submitted CAP and evidence are not sufficient to close an NC, another CAP and NC Review Round will start once the CAB submits their review by advancing the NC Review and Closure Form to “Review CH.” The CH must submit additional information in the NC Review and Closure Form in the next round for NCs with an NC Status of Open and a CAP Status of Not Accepted or Not reviewed. For additional information on NC closure timeframes please review the Program Assurance Manual. 
    
14. Repeat the steps above to respond to any open NCs and send the NC Review and Closure Form back to the CAB for review.
15. Once all NCs have been closed by the CAB, the NC Review and Closure process is complete.

NC Review and Closure as a CAB CAP Reviewer

CABs are responsible for reviewing and providing feedback on CAPs and NC evidence submitted by the Certificate Holder through the NC Review and Closure Form.  All NCs must be closed in accordance to Program Assurance Manual guidelines within the allotted timeframe.

To begin CAB review, the CAB Program Administrator assigns the CAP Reviewer on the NC Review and Closure form once the Final Audit report has been completed. 

1. The CAB Program Admin can find the associated NC Review and Closure form by clicking the NC Review and Closure form ID from the audit ‘Coversheet’ links section of the most recent audit for a CH.  
   
2. A CAB may also click on the NC Review and Closure menu item and use the filters on the overview page of the NC Review and Closure section to find the correct form.
   
3. Once the NC Review and Closure form has been filtered, click on the form to open it and select ‘Edit’ on the NC Review and Closure Form to update the CAP Reviewer field from the NC Review and Closure section.
   
4. Once the CAP Reviewer is selected from the list, save the form. Note that only CAB staff with the role of CAP Reviewer will appear in the list. If you don’t see a member of your team who should be listed, reach out to the FTUSA team for updating the list.
   

Below is a summary of how a CAB CAP Reviewer reviews the CAPs and NC evidence submitted through the NC Review and Closure form.

1. Use the link provided in the email notification or log in to ChainPoint
2.  From the left menu, select ‘NC Review and Closure’
3. Find the NC Review form using the NC Review ID provided in the notification email or the NC Review in status ‘Review CAB’
   
4. After reviewing the general information and round details, scroll down to the section called ‘NC.’ This section lists each NC that was found during the audit.
5. Click on any NC to view additional details. Each NC has the following components:
   a. Criteria – from the relevant standard
   b. Intent and Clarification – from the relevant standard
   c. Type of NC – NC grade resulting from the audit
   d. Farm Size – APS Only – size of the operation that received the NC during the associated audit
   e. Auditor Evidence – explanation of the NC from the audit
   f. NC Status+ –  indicates if an NC is still open or has been closed
   g. Root Cause Analysis* – a systemic evaluation of why the NC occurred
   h. Preventative Action* – steps taken to correct/reverse negative impacts to workers and/or the environment that have been taken to prevent reoccurrence of the NC
   i. Correction* – any immediate actions taken to address the NC
   j. Evidence of NC Closure* – information based on facts that can be proved and are clearly identifiable; and must correspond to the specific action plan measure; and either verify that implementation is complete or present a detailed plan for implementation in the near future
   k. CAP Status+ –  indicates if NC evidence and CAP has been accepted by the CAB
   l. Attached Documents* - added by the Certificate Holder
   m. Comments+ – feedback about the CAP and evidence the Certificate Holder has submitted
   *completed by the CH
   +completed by the CAB
6. To review NCs evidence submitted by the CH , select edit at the top of the page and scroll down to the NC section. Click on the NC to be reviewed and update the CAP status and NC status if applicable. Refer to the Program Assurance Manual for requirements on reviewing CAPs and closing NCs. Any explanation on why the CAP is not accepted or a NC is not closed must be provided in the comments field. If additional evidence is required from the CH, this must be entered in the comments field.
7. Once you have updated the CAP and NC status and entered any comments select “Close.”
8. Repeat for each NC that the CH has submitted information.
9. By selecting ‘Save’ at the top of the page, the CAP reviewers work is saved and the NC Review and Closure form can be revisited by the CAP Reviewer to add additional details or revise before the Round End Date.
10. When the CAP Reviewer completes their review of all NCs with the evidence provided by the CH, they must  advance the NC Review and Closure form to the Certificate Holder by selecting “Submit to CH for review.”
    
11. If the submitted CAP and evidence are not sufficient to close an NC, the CAP Reviewer will automatically generate a new round by sending the NC Review and Closure form back to the Certificate Holder for review; the certificate holder must submit additional evidence in the new round for any open NCs.
12. Repeat the steps above to review any open NCs and send the NC Review and Closure Form back to the Certificate Holder for review.
13. Once there are no longer any open or closed with contingency NCs, the NC Review and Closure process is complete and the CAB CAP Reviewer or CAB Program Admin can advance the NC Review and Closure Form to ‘Complete.’
    

NC Review and Closure:  Summary of Progress Points*

*APS and CFS Only

For APS and CFS audits, a Summary of Progress Points table is included  at the bottom of the NC Review and Closure form. The table, organized by module, includes

• APS only - Farm size
• the number of progress points achieved including any points from NCs closed during the NC Review and Closure process
• the number of progress points required to be compliant with the standard
• the number of progress points possible
• the percentage of progress points achieved including any points from NCs closed during the NC Review and Closure process
• the percentage of points required to be compliant with the standard
• an indication of if the program requirements were met

Only the audited farm sizes have results included in the Summary of Progress Points table. In the example below, the CH sites are categorized as medium, and therefore no information is included for small or large farms.

This table will update automatically as the NC Review and Closure process advances and progress point NCs from Module 3 or 4 are closed.  Once the CH has achieved the required number of progress points, the CAB CAP Reviewer can update the remaining progress point NCs to status ‘Removed.’ This status indicates that the NC does not need to be addressed in subsequent rounds.

For more information about how progress points are scored, please refer to the Score System Guides in the resource section below.

Resources 

Agriculture & Seafood Program Assurance Manual

Factory Program Assurance Manual

Score System Guide

Score System Guide for the Capture Fisheries Standard