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 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, appropriate, consumers. PA Low Data that is collected each month including (but not limited to) residents’ falls, challenging behaviour, infections, pressure areas, and wounds are collated and compared on a month-by-month basis. Results are analysed and evaluated. The village manager and clinical manager report that this data is then communicated to staff in the full staff meetings and in the RN meetings although meeting minutes do not consistently reflect this finding. Missing in the meeting minutes is documented evidence of communicating quality and risk activities and findings with The village manager reports steps were undertaken in December 2014 to ensure that staff meeting minutes consistently reflect quality and risk management information. Ensure discussions relating to quality and risk are documented in the applicable meeting minutes. 180 days Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and communicated to consumers at a PA Low The previous audit identified issues with the standard of documentation which related to the charting of medicines by medical staff and the signing by nursing staff on the administration chart. This audit found that improvements have been made in both areas, however further The following shortfalls in documentation were identified: (i) the allergy status of 2 of 29 residents receiving dementia services (sample extended) was not recorded; and (ii) 1 of 20 residents (sample extended) receiving hospital services did not have photographic Ensure the documentation of medicines management meets policy.
frequency and detail to comply with legislation and guidelines. improvements are identified which relate to the standard of documentation. identification (which was corrected on the day of audit). 90 days 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 Low The previous audit noted that several interventions were not being documented to manage all residents’ needs including medical needs where appropriate. A review of seven clinical records confirmed that further improvement is required to address incomplete documentation. Care was not documented according to policy in three of the seven clinical records reviewed, which included (1) no documentation of a resident’s weight on admission; (2) initial assessments for one resident not being dated and signed by the assessing staff member; and (3) a physiotherapy intervention specified by a physiotherapist was not documented in the resident’s plan of care (although staff were carrying out the physiotherapist’s treatment order). Ensure clinical care is documented according to policy. 90 days