Audit Team Lead Auditor on site 16.5 Hours off site 8 Other Auditors XXXXX Total hours on site 16.5 Total hours off site 7 Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer Hours 3 Sample Totals audit hours on site 33 Total audit hours off site 18 Total audit hours 51 Number of residents interviewed 10 Number of staff interviewed 21 Number of managers interviewed 4 Number of residents’ records reviewed 9 Number of staff records reviewed 10 Total number of managers (headcount) 4 Number of medication records reviewed 18 Total number of staff (headcount) 96 Number of relatives interviewed 6 Number of residents’ records reviewed using tracer methodology 3 Number of GPs interviewed 1
care plans and supporting documentation is evident (refer evidence 1.3.3) in files the risk is considered low. 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 Low 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 Low During this audit the following was noted: Staff interview confirms there are shifts that have not been able to be covered. In addition it was reported a number of ‘double shifts’ have been worked, this was verified during discussion with the assistant manager. It was estimated six double shifts per month have occurred. Resident and relative interviews inform there are times when there are less staff available in the weekend. This is verified in resident/relative meeting minutes (March - hospital and May - special care unit 2014) where minutes record weekend staff are ‘stressed’ and there is ‘not enough staff’. Relative interview informed a call bell response time of approximately 20 minutes. Weekly management meetings report a ‘number of permanent gaps’ in respect of staffing. Continue to review staffing allocation in relation to resident 30 HDS(C)S.2008 Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. PA Low
Criterion 1.2.9.9 (HDS(C)S.2008:1.2.9.9) All records are legible and the name and designation of the service provider is identifiable. Attainment and Risk: PA Low Evidence: In three (of four) files reviewed – one rest home in the serviced apartment, and two reviewed while tracking incident reporting – the time of entry is inconsistently reported. Finding: Entry in resident files are not consistently recording the time of entry, rather recording ‘am’, ‘pm’ and ‘nocte’. Corrective Action: Record the time of entry in resident files. Timeframe (days): 90 (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.2.9.10 (HDS(C)S.2008:1.2.9.10) All records pertaining to individual consumer service delivery are integrated. 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.) Outcome 1.3: Continuum of Service Delivery Consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation.
Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Standard 1.3.2: Declining Referral/Entry To Services (HDS(C)S.2008:1.3.2) Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate. D4.2 Attainment and Risk: FA Evidence: The right to appeal against assessment outcome policy states the manager at every stage will inform the resident/family of other options. The service records the reason for declining service entry to residents should this occur and communicates this to residents/family/whanau. Anyone declined entry is referred back to the Needs Assessors or referring agency for appropriate placement and advice. Criterion 1.3.2.2 (HDS(C)S.2008:1.3.2.2) When entry to the service has been declined, the consumers and where appropriate their family/whānau of choice are informed of the reason for this and of other options or alternative services. 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 1.3.12.1 (HDS(C)S.2008:1.3.12.1) A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. Attainment and Risk: PA Moderate Evidence: The service uses individualised medication blister for regular, “odd time” medications and PRN medications. Three medication rooms are viewed (rest home, hospital and special care unit) and one medication cupboard (serviced apartments). All medications rooms are secure. Medications trolleys are locked. Contents are all within expiry dates and eye drops are dated on opening. Expiry dates of all medications are checked monthly. There are no gaps identified on the 18 medication sighing sheets reviewed. PRN medications have the time of administration on the signing sheet. Controlled drugs are signed by two persons. Dietary supplements, antibiotics and short course have signing sheets. Alert labels include “look for second pack”, “short course medications” and “controlled drugs”. Finding: (i)There is no documented evidence of medications checked against the medication chart on delivery. (ii) There is transcribing on four non-packaged signing sheets (two special care unit and two rest home). Corrective Action: (i)Ensure medications are checked against the medication chart on delivery. (ii) Ensure there is no transcribing. Timeframe (days): 60 (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Criterion 1.3.12.3 (HDS(C)S.2008:1.3.12.3) Service providers responsible for medicine management are competent to perform the function for each they manage. 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.)