Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.3 The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy. PA Moderate Policies, procedures, work instruction and forms are available in both hard copy versions and electronically. Work is in progress to consolidate and update the around 600 documents on the electronic data base. The current electronic document control system, discussed and reviewed with the quality and development coordinator, shows that many of the policies/documents are overdue for review; however, the number overdue for review was not easily established and was unknown. The coordinator reports this is around 50% of the 600 documents. In the one resident home where policies were discussed and reviewed, the paper version of the clinical policy manual had no policies that were current; some being at least 10 years overdue for review, many of these now being obsolete. There was both an Elizabeth Knox infection control policy manual and an externally supplied infection control manual available, with staff assuming the externally supplied manual was the one to refer to. At the time of audit there are around 50% of the approximate 600 policies and other documents overdue for review in the electronic data base. There are also paper version of policies available for use in the clinical areas that are overdue for review and/or are redundant. The service establishes the exact number of overdue policies and procedures and implements a process to ensure these are reviewed at regular intervals, aligned with current good practice and document controlled. 90 days
state that some of the triggered CAPS do not match other sources of assessment or the teams experience of resident needs. Criterion 1.3.8.3 Where progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Moderate Although short term care plans are being developed when new problems arise, this does not always occur appropriately. There are also examples where changes in the resident’s condition or health status is not captured and transferred to the electronic LTCP for printing for the hard copy file in a timely manner. These plans and evaluations are subsequently printed for use in the hard copy file to guide care, but the most up to date version is not always available to care partners as evidence in several files. Examples include a change in the resident’s infection status, reference to initiation of a last days of life plan and a variety of plans used to manage short term or new problems. Progress notes are used to update care status. The senior team report that the hard copy record is regarded as the one used to direct care delivery. Updating of the care plan is not always evident when the resident’s condition changes, nor the current plan made available to care partners in its most current version to residents’ care. Initiate a process ensures that where resident progress is different from expected, the service makes necessary changes and makes available the most current plan of care. 90 days