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 data to display” instead of a table, then no corrective actions were required as a result of this audit. “no Criterion with desired Attainment Audit Evidence Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.2.4.2 PA Moderate Ten incident reports were sampled. Reporting Essential reporting following Notify the residents’ requirements were met in all but one of the incidents. an adverse had not GP (in a timelier The service provider In the said event, the resident had received a minor occurred in a timely manner. manner) if an injury understands their statutory injury. First aid was provided, the resident was For example: notifying the occurs following an and/or regulatory monitored and the family member was contacted. Staff GP following injury. incident. obligations in relation to were given the opportunity to debrief following the essential notification incident and a full investigation was conducted. The reporting and the correct resident’s GP was not notified at the time and did not 60 days authority is notified where review the resident until the following week. GP required. records and progress notes sampled confirmed that the injury was not serious, had been monitored appropriately, was healing and no further intervention was required. Criterion 1.3.12.6 PA Low Administration of controlled drugs was recorded in the Documentation of Document controlled drug register and on the administration administration of controlled administration of Medicine management sheet. One file reviewed did not include correct drugs is not always recorded controlled drugs information is recorded to documentation of a controlled drug on the a level of detail, and administration sheet however it was correctly
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 Finding Corrective action required and timeframe for completion (days) Criterion 1.2.4.2 The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required. PA Moderate Ten incident reports were sampled. Reporting requirements were met in all but one of the incidents. In the said event, the resident had received a minor injury. First aid was provided, the resident was monitored and the family member was contacted. Staff were given the opportunity to debrief following the incident and a full investigation was conducted. The resident’s GP was not notified at the time and did not review the resident until the following week. GP records and progress notes sampled confirmed that the injury was not serious, had been monitored appropriately, was healing and no further intervention was required. Essential reporting following an adverse had not occurred in a timely manner. For example: notifying the GP following injury. Notify the residents’ GP (in a timelier manner) if an injury occurs following an incident. 60 days Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and PA Low Administration of controlled drugs was recorded in the controlled drug register and on the administration sheet. One file reviewed did not include correct documentation of a controlled drug on the administration sheet however it was correctly Documentation of administration of controlled drugs is not always recorded Document administration of controlled drugs