As per bylaw 3.6(9), the designated registrant of a practice or facility must  “promptly inform the registrar, who will convey to the Practice Facility Accreditation Committee (PFAC): 

(a) a substantial change in scope of practice,  

(b) a significant or material renovation,  

(c) a change of mailing address or location,  

(d) a change in the designated registrant, 

(e) a closure, 

(f) a loss of a significant amount of a controlled drug or a loss of records, and  

(g) a change in ownership.   

If the practice facility is fully accredited, once the CVBC office has been informed of the changes related to the practice facility, the new services, equipment and/or space may be offered or used. This is dependent one Designated Registrant ensuring that the relevant accreditation standards are met. You can refer to the Self-assessment Form or the Schedule D – Accreditation Standards for reference. 

If your practice facility is operating with Provisional Approval to Operate or on Limited Accreditation, or if it is a Philanthropic or Consulting Practice, please contact the office at facilities@cvbc.ca with a summary of the changes planned.  

To notify us of changes or if you have any questions relating to the changes to your practice or facility, please contact us at facilities@cvbc.ca and the office will follow up with the next steps. 

Many practices or facilities are considering unique approaches to expansion of their scope of practice and/or space.  The Policy and Guide to Accreditation of Non-Typical Facilities may provide useful information in addition to the processes described below. 

A. Scope of Practice Change (increase or decrease) 

Common increases in Scope of Practice (SoP) that the office processes are the following: 

• Adding an ambulatory (mobile or house call) SoP to a fixed practice facility. 

• Adding a fixed space with surgery, treatment and X-ray to a previously mobile only practice facility. 

• A mobile practice facility adding an X-ray machine. 

• Addition of Complementary therapy such as Acupuncture, Laser Therapy, Chiropractic, etc. 

Given the large variation in what a SoP change may involve, it is best to notify the office with a brief summary of the changes being made.  The office will then summarize what items should be submitted for PFAC consideration as to whether to direct an inspection. 

While awaiting PFAC directions on whether an inspection is required, the facility may start offering their increase in SoP, on the condition the designated registrant is satisfied that the relevant accreditation standards are met. The practice facility does not need office approval before offering the new services. 

If there are further directions by the PFAC, the office will contact you. If you do not hear back from us, then no further action is needed. 

B. Renovation & Expansion

Renovations and expansions can range from the addition of an extra exam room to the addition and renovation of hundreds of square feet of new space with multiple new services added (scope of practice). The office may request various submissions depending on each practice facility’s unique plan. 

The new space can be used on the condition the designated registrant is satisfied that the relevant accreditation standards are met. Performing the applicable sections on the Self-Assessment will help ensure that the standards are met. The practice facility does not require CVBC approval before using the space. 

C. Relocation

1. Fixed Practice Facility

For relocation of public access, fixed (brick and mortar) practice facilities, the CVBC requests two months’ notice prior to the move to allow consideration by the PFAC.  It is expected that in most cases of a full fixed practice facility relocation, the PFAC will direct an inspection, and the related fee, to take place after the relocation has occurred.   

Services from the new location can be offered in the interim. It is the responsibility of the designated registrant that the accreditation standards are met prior to services being offered.  

Considerations for patient and public safety: 

• Only one accredited space should be active at any given time to ensure the public is not confused as to where to seek care. Ensuring that during the relocation, there is safety and security of the controlled drugs and other prescription products and there is a secure location in the new facility for the drugs to be located. 

• Active construction should be complete in the new location before relocation takes place.  Tradespeople should not have unsupervised access to areas where controlled and prescription drugs are located.   

• That the ability to provide oxygen is in place at the new location before any services are offered there.  A source of backup oxygen should be in place before general anesthesia takes place. 

• Clearly communicate to the public that there may be some scopes of practice that cannot be offered as the facility moves equipment and supplies.  For example, relocation of the x-ray machine will require it to be serviced, during which time the machine should not be used. 

Performing the self-assessment at the new location will help ensure the Accreditation Standards are met once the relocation has taken place. 

The Policy on Care during Interruptions in Service may also be helpful. 

Our Senior inspector can review your relocation plans as they near completion, so if you have questions, you may contact the office at facilities@cvbc.ca.  

2. Non-public office for mobile practice or facility

It is expected practices and mobile practice facilities have a “non-public” office where they store records, supplies and/or equipment.  This is most commonly located in the designated registrant’s home but may exist in another location.   

If this practice or facility’s non-public office is relocated, you must notify the CVBC office of the relocation.  

Of paramount importance with relocation of a non-public home office is safety and security of the controlled drugs.  As many of these relocations take place without prior access to set up secure storage in the new location, please consider how to secure the drugs in the new location as soon as they arrive. 

The designated registrant can use their new location as soon as they feel satisfied that the relevant accreditation standards are met. The facility does not require office approval prior to using the new location. 

If there are any further directions from the CVBC after notification and submission of the required materials, the office will follow up.