Report To: HealthCERT, Ministry of Health Provider Name Bupa Care Services NZ Limited Premise Name Street Address Suburb City Liston Heights Rest Home & Hospital 19 Liston Avenue Hilltop Taupo Proposed changes of current services (e.g. reconfiguration): Type of Audit Certification audit and (if applicable) Date(s) of Date: 22-Aug-13 End Date: 23-Aug-13 Designated Auditing Agency Health and Disability Auditing New Zealand Limited Audit Team Audit Team Name Qualification Auditor on site Auditor Hours off site Auditor Dates on site Lead Auditor XXXXXXX RCompN, Health cert 15.00 6.00 22-Aug-13 to 23-Aug-13 Auditor 1 XXXXXXX Medical technologist, 15.00 5.00 22-Aug-13 to 23-Aug-13
MBA lead auditor Auditor 2 Auditor 3 Auditor 4 Auditor 5 Auditor 6 Clinical Expert Technical Expert Consumer Auditor Peer Review Auditor XXXXXXX 1.00 Total Audit Hours on site 30.00 Total Audit Hours off site (system generated) 12.00 Audit Hours 42.00 Staff Records Reviewed 9 of 65 Client Records Reviewed (numeric) 8 of 67 Number of Client Records Reviewed Tracer Methodology 3 of 8 Staff Interviewed 15 of 65 Management Interviewed (numeric) 2 of 2 Relatives Interviewed (numeric) 8 Consumers Interviewed 8 of 67 Number of Medication Records Reviewed 24 of 67 GP’s Interviewed (aged residential care and residential disability) (numeric) 1
Finding Statement Six of eight files reviewed included a flu vaccine (Medical practice flu vaccine consent form) form and a Bupa specific consent in place (two of eight were palliative care/end of life had did not have flu vaccine's given). The Bupa specific consent form had been signed by EPOA or resident at the end of 2012. Of the six medical practice consent/administration forms signed, all six had the signature of the practice nurse administering the flu vaccine, EPOA/resident signature, the batch sticker, but no date to identify what day the flu vaccine was given Corrective Action Required: Ensure consent forms are clearly dated to include date of consent and administration date. Timeframe: 3 months Criterion 1.1.10.7 Advance directives that are made available to service providers are acted on where valid. Audit Evidence Attainment: FA Risk level for PA/UA: Finding Statement Corrective Action Required: Timeframe: STANDARD 1.1.11 Advocacy And Support Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. ARC D4.1d; D4.1e ARHSS D4.1e; D4.1f Evaluation methods used: D SI STI MI CI MaI V CQ SQ STQ Ma L How is achievement of this standard met or not met? Attainment: FA Advocacy policy (026) states 'All residents will be informed of right to an advocate' – information on the availability of advocacy services is held within the Admission Agreement. The Health and Disability Advocacy services brochure will be provided by the facility as part of the Admission Information Pack and will be displayed in the facility'. Residents are provided with a copy of the Code of Health and Disability Services Consumer Rights and Advocacy pamphlets on entry. Interviews with staff described how residents are informed about advocacy and support. Interviews with eight residents confirmed that they are aware of their right to access advocacy. D4.1d; discussion with family identified that the service provides opportunities for the family/EPOA to be involved in decisions