0 90 0 2 1 0 0 Criteria UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited 0 0 0 0 0 0 0 5 Standards 0 0 0 0 0 0 0 8 Criteria Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.3: The organisation has an PA Low Quality And Risk established, documented, and Management maintained quality and risk Systems management system that reflects continuous quality improvement principles. Criterion 1.2.3.8 A corrective action plan PA Low (i)Review of internal audits Provide documented evidence 180 HDS(C)S.2008 addressing areas requiring indicates that corrective action that: (i) corrective action improvement in order to meet plans are not being consistently are being developed, the specified Standard or documented to address all areas implemented, monitored and requirements is developed and identified as requiring signed off as having been implemented. improvement, (ii) The name / completed that addresses all designation of the person/s areas identified as requiring responsible for implementation improvement, (ii) the name / of the corrective action/s and the designation of the person/s timeframe/s are not being responsible for the corrective consistently documented in action plan/s is documented internal audits, (iii) Evidence of along with timeframes for the monitoring and sign off of corrective actions, (iii) resident corrective action plans in internal infection logs are being audits and resident infection logs monitored and signed off for is not consistently documented. each episode of infection. HDS(C)S.2008 Standard 1.3.8: Consumers' service delivery PA Evaluation are evaluated in a Moderate comprehensive and timely manner. Criterion 1.3.8.2 Evaluations are documented, PA The person centred care plan Provide evidence of the care 90 HDS(C)S.2008 consumer-focused, indicate the Moderate evaluations do not always plan evaluations recording all
Criteria 0 90 0 2 1 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 5 Criteria 0 0 0 0 0 0 0 8 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low HDS(C)S.2008 Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low (i)Review of internal audits indicates that corrective action plans are not being consistently documented to address all areas identified as requiring improvement, (ii) The name / designation of the person/s responsible for implementation of the corrective action/s and the timeframe/s are not being consistently documented in internal audits, (iii) Evidence of monitoring and sign off of corrective action plans in internal audits and resident infection logs is not consistently documented. Provide documented evidence that: (i) corrective action are being developed, implemented, monitored and signed off as having been completed that addresses all areas identified as requiring improvement, (ii) the name / designation of the person/s responsible for the corrective action plan/s is documented along with timeframes for the corrective actions, (iii) resident infection logs are being monitored and signed off for each episode of infection. 180 HDS(C)S.2008 Standard 1.3.8: Evaluation Consumers' service delivery are evaluated in a comprehensive and timely manner. PA Moderate HDS(C)S.2008 Criterion 1.3.8.2 Evaluations are documented, consumer-focused, indicate the PA Moderate The person centred care plan evaluations do not always Provide evidence of the care plan evaluations recording all 90