Audit Team Lead Auditor XXXXX Hours on site 14 Hours off site 8 Other Auditors XXXXX Total hours on site 14 Total hours off site 7 Technical Experts hours on site Total hours off site Consumer Auditors hours on site Total hours off site Peer Reviewer XXXXX Hours 3 Sample Totals Total audit hours on site 28 Total audit hours off site 18 Total audit hours 46 Number of residents interviewed 3 Number of staff interviewed 27 Number of managers interviewed 3 Number of residents’ records reviewed 7 Number of staff records reviewed 10 Total number of managers (headcount) 3 Number of medication records reviewed 14 Total number of staff (headcount) 190 Number of relatives interviewed 10 Number of residents’ records reviewed using tracer methodology 4 Number of GPs interviewed 2
HDS(C)S.2008 Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. PA Moderate HDS(C)S.2008 Criterion 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Moderate ARHSS D17.3; there is not a rostered registered nurse across 24/7 in the PG unit. D17.4a; As per the ARHSS contract D17.3 ensure a registered nurse is rostered in the PG unit across 24/7. 30 HDS(C)S.2008 Standard 1.3.3: Service Provision Requirements Consumers receive timely, competent, and appropriate services in to meet their assessed needs and desired outcome/goals. PA Moderate HDS(C)S.2008 Criterion 1.3.3.3 Each of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA High A psychogeriatric resident had delayed response to referral to specialist services for management of a deteriorating pressure injury and decreased mobility. The resident did not have care or review of a catheter documented for seven months and fluid intake for the seven days prior to audit did not document an accepted level of intake with no documented or verbal Improvement is required to ensure: a) review of health status changes take place in a timeframe relevant to the a change in status to ensure timely response to changes and issues; b) routine evaluations take place within the timeframes required in policy and monitoring frequency reflects risk level; c) all possible causes of a decline are considered; d) timely referral to specialist services, e) 7
consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. reassessed when they have not previously been identified. (i) Pain assessment tools were not utilised for two residents reviewed (one psychogeriatric and hospital level care) who received pain relief regularly. (ii) The five residents who did not have pain identified previously did not include reassessment during the review process. (iii) Two of six files reviewed that had identified high falls risk on assessment did not include a completed falls prevention strategies form. (iv) Three of seven files reviewed did not include a continence reassessment. (v) Two of four dementia residents did not include behaviour assessment. possible care needs are reassessed routinely. HDS(C)S.2008 Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Low HDS(C)S.2008 Criterion 1.3.6.1 The provision of services and/or interventions are PA Low No care plan or inclusion in long term care plan was Improvement is required to ensure all interventions required 60
consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. sighted for one resident with a current urinary tract infection and two residents with weight loss. are documented on a or long term care plan to ensure staff are aware of all aspects of care to be implemented. HDS(C)S.2008 Standard 1.3.7: Planned Activities Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service. PA Low 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 Activity plans do not include strategies that reflect the resident past activities or are identified as assisting the individual resident. Improvement is required to ensure activity plans identify individual strategies for de-escalating / diverting strategies. 180 HDS(C)S.2008 Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. PA Moderate HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine PA Moderate (i)Two of three residents receiving controlled drugs the time stated in the controlled drug register differed from that stated in the administration signing sheet. (ii)There is no quantitative balance Improvement is required to: (i) the times stated in the controlled drug register reflect the time the controlled drug was administered; (ii) complete six monthly controlled drug 30
reconciliation in to comply with legislation, protocols, and guidelines. completed at least six monthly. (iii) The house G.P. used } to group sign medications on seven of 14 charts reviewed. (iv) Two of 14 charts reviewed did not state allergies or none known. (v) Six of 14 charts the PRN medications did not include indications of use for all PRN medications charted stocktakes; (iii) ensure all medication instructions are individually signed by the prescribing G,P.; (iv) PRN instructions include indication of use; and (v) all medication charts state allergies or none known. HDS(C)S.2008 Standard 1.3.13: Nutrition, Safe Food, And Fluid Management A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery. PA Moderate HDS(C)S.2008 Criterion 1.3.13.2 Consumers who have additional or modified nutritional requirements or special have these needs met. PA Moderate (i)A residents dietitian recommendations were not documented as actioned. (ii) Five residents fluid balance charts for the seven previous days were reviewed; the highest total fluid intake for any resident was 1100 mils in a 24 hour period. (i)Ensure residents with nutritional recommendations are communicated to the kitchen; (ii) a plan for addressing any in fluid intake be documented and implemented. 30 Continuous Improvement (CI) Report Code Name Description Attainment Finding
Criterion 1.2.3.7 (HDS(C)S.2008:1.2.3.7) A process to measure achievement against the quality and risk management plan is implemented. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.2.3.8 (HDS(C)S.2008:1.2.3.8) A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.2.3.9 (HDS(C)S.2008:1.2.3.9) Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of the risk and the probability of change in the status of that risk; (b) A process that addresses/treats the risks associated with service provision is developed and implemented. Attainment and Risk: FA Evidence: