Standard 1.2.8: Service Provider Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. PA Low Criterion 1.2.8.1 is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low Contractual requirements are not met in regards to the hospital unit at Leslie Groves hospital. is a registered nurse on duty from 7am – 3pm and 3pm – 11pm. There is no rostered RN on duty overnight in the hospital unit (as per ARC D17.4a.i.). Advised the RN is shared from the PG unit. Ensure that staffing levels meet contractual requirements within the hospital unit. 30 Standard 1.3.4: Consumers' support requirements, and preferences are gathered and recorded in a timely manner. PA Moderate Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Moderate Assessment documentation has not been completed for the following residents: a) falls risk, continence, pain or pressure area assessment for a resident in the hospital that was recently admitted b) continence assessment for four residents -two resident in the PG unit and two resident in the rest home with change in continence needs; c) nutrition/dietary assessment for a resident with swallowing problems in the dementia unit; d) behaviour assessment for a resident in the rest home with wandering behaviour. Ensure assessments are conducted for all identified needs to support the development of care plans and service delivery. 60 Standard 1.3.6: Service Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Moderate
Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Moderate of the rest home files sighted; interventions are recorded in the evaluations and progress notes and not transferred to the body of long term care plan. Four (one of the hospital, one of the dementia and two of the PG unit) do not have detailed interventions recorded to guide the staff: a) the initial care plan for the hospital resident’s wound management needs do not have the frequency of wound dressing changes or renew dates of the dressing changes recorded; b) the resident in the dementia unit presents with challenging behaviour; however no individualised management strategies are recorded on the long term care plan; c) one resident in the PG unit has interventions recorded on the falls risk assessment and not transferred to the body of the long term mobility care plan; d) another resident in the PG unit has a wound assessment /care plan with no review date ,frequency of dressing changes or outcome recorded. Ensure that interventions are (a) entered into the care plans, and (b) are detailed, to guide staff 60 Standard 1.3.8: Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Moderate Criterion 1.3.8.3 Where progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Moderate (i)Three of three rest home residents` files evidence that progress different from the expected goal are documented in the evaluation section and not transferred to the body of the long term care plan: a) one resident is evaluated to need supervision when toileting however the long term care plan stated that she needs no supervision; b) one resident is (i)Ensure that the long term care plan reflect any changes to interventions and goals if the progress be different from the outcome. (ii) Ensure that short term care plans are utilised for all acute or short term issues. 60
rest home CD register; e) controlled drug medications in the rest home are checked out by the RN on a Friday - prior to administration by the caregivers over the weekend; f) the CD register in the hospital shows three places where a second signature omits; g) the medication packs are not checked against the medication charts in either the hospital or rest home upon arrival to the facility as per accepted best practice. ensure that the CD register evidence two staff signatures; g) ensure that there is evidence that medication are checked against the medication charts upon arrival to the facility. Criterion 1.3.12.3 Service providers responsible for medicine management are competent to perform the function for each stage they manage. PA Moderate On review of the medication competency register, and on discussion with the quality manager, it is that medication competencies for some staff have expired. On review of two registered nurse staff files it is noted that medication competencies have not been conducted and syringe driver training and competency has expired. One rest home caregiver file evidenced medication competency last conducted in 2011. Ensure that medication competencies are conducted annually for all staff that have responsibilities for administering medications. 30 Standard 1.4.7: Essential, And Security Systems Consumers receive an appropriate and timely response during emergency and security situations. PA Moderate Criterion 1.4.7.1 Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures. PA Moderate First aid training is not provided by a certified trainer. CPR training is not provided for staff. Provide evidence that complete a certified first aid course and CPR course to ensure that there is at least one staff member on each shift on each site with a current first aid certificate. 90
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.2.1.3 (HDS(C)S.2008:1.2.1.3) The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of 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.) Standard 1.2.3: Quality And Risk Management Systems (HDS(C)S.2008:1.2.3) The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. ARC A4.1; D1.1; D1.2; D5.4; D10.1; D17.7a; D17.7b; D17.7e; D19.1b; D19.2; D19.3a.i-v; D19.4; D19.5 ARHSS A4.1; D1.1; D1.2; D5.4; D10.1; D16.6; D17.10a; D17.10b; D17.10e; D19.1b; D19.2; D19.3a-iv; D19.4; D19.5 Attainment and Risk: FA Evidence: Leslie Groves Home and Hospital has a current operation quality programme for 2014, which includes the mission and philosophy of service, a quality policy statement and objectives. The quality programme objectives consists of, care services, human resources, health and safety, risk management, building and maintenance, marketing, quality and financial. Hazard management for the facility and include health and safety, staff safety, resident safety, external environment, chemical storage, kitchen, laundry and cleaning. Progress with the operations quality plan (OpQual plan) is monitored through the twice monthly management meetings, monthly unit staff meetings, and various monthly staff meetings. A three monthly progress report is conducted by the quality manager (March 2014) and an annual comprehensive review is conducted (last conducted Jan 2014). The annual review involves review of objectives and updates on the actions taken.
Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.2.7.4 (HDS(C)S.2008:1.2.7.4) New service providers receive an orientation/induction programme that covers the essential components of the service provided. 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 1.2.7.5 (HDS(C)S.2008:1.2.7.5) A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. 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.)