Audit Team Lead Auditor XXXXX Hours on site 12 Hours off site 4 Auditors XXXXX Total hours on site 12 Total hours off site 4 Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXX Hours 2 Sample Totals Total audit hours on site 24 Total audit hours off site 10 Total audit hours 34 Number of residents interviewed 8 Number of staff interviewed 9 Number of managers interviewed 2 Number of residents’ records reviewed 5 Number of staff records reviewed 7 Total number of managers (headcount) 2 Number of medication records reviewed 10 Total number of staff (headcount) 40 Number of relatives interviewed 5 Number of residents’ records reviewed using tracer methodology 1 Number of GPs interviewed 2
age, culture, and the setting of the service. HDS(C)S.2008 Criterion 1.3.7.1 Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer. PA Low Three of the five resident files reviewed show evidence of the activity plans not being reviewed in a timely manner. Activity plans to be reviewed six monthly. 180 Continuous Improvement (CI) Report Code Name Description Attainment Finding NZS 8134.1:2008: Health and Disability Services (Core) Standards Outcome 1.1: Consumer Rights Consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs. Standard 1.1.9: Communication (HDS(C)S.2008:1.1.9) Service providers communicate effectively with consumers and provide an environment conducive to effective communication. ARC A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1b.ii; D16.4b; D16.5e.iii; D20.3 A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1bii; D16.4b; D16.53i.i.3.iii; D20.3 Attainment and Risk: FA
at appointment have completed apropriate training within six months of appointmentStaff interviews confirm orientation / induction is provided for new staff. Care staff also confirm their attendance at on-going in-service education. There are two areas requiring improvement around staff in-service education and staff performance reviews. ARC requirements are not fully met. Criterion 1.2.7.2 (HDS(C)S.2008:1.2.7.2) Professional qualifications are validated, including evidence of registration and scope of practice for service providers. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Criterion 1.2.7.3 (HDS(C)S.2008:1.2.7.3) The appointment of appropriate service providers to safely meet the needs of consumers. Attainment and Risk: PA Low Evidence: Seven staff files reviewed evidence all processes are followed as per human resources policies and procedures except currency of performance reviews. Finding: staff files reviewed. One of seven staff files evidences performance review has not been conducted for that staff member (clinical leader). Corrective Action: Provide evidence of current performance reviews of all staff. Timeframe (days): 180 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)