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 Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.2.4.3 PA Moderate The clinical files reviewed evidenced the accident/incident The adverse events Provide evidence the forms were completed and signed off by the BCM. The are not consistently adverse events are The service provider family members are notified when adverse events occur, recorded in the consistently recorded documents adverse, this was confirmed by family interviews and the clinical file progress notes and in the residents’ unplanned, or untoward reviews. Fifteen adverse event forms and the process the neurological progress notes and the events including service followed were reviewed. There was evidence three of the recordings were not neurological recordings shortfalls in order to fifteen adverse event forms did not have a corresponding always completed are completed when identify opportunities to record of the event in the residents’ progress notes. The when required. required. improve service delivery, residents’ adverse events of unwitnessed falls did not and to identify and evidence the neurological recordings were either conducted manage risk. or, if commenced, did not continue for a period of time 90 days required. This was evidenced in nine of the nine unwitnessed fall events reviewed.
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 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Moderate The clinical files reviewed evidenced the accident/incident forms were completed and signed off by the BCM. The family members are notified when adverse events occur, this was confirmed by family interviews and the clinical file reviews. Fifteen adverse event forms and the process followed were reviewed. There was evidence three of the fifteen adverse event forms did not have a corresponding record of the event in the residents’ progress notes. The residents’ adverse events of unwitnessed falls did not evidence the neurological recordings were either conducted or, if commenced, did not continue for a period of time required. This was evidenced in nine of the nine unwitnessed fall events reviewed. The adverse events are not consistently recorded in the progress notes and the neurological recordings were not always completed when required. Provide evidence the adverse events are consistently recorded in the residents’ progress notes and the neurological recordings are completed when required. 90 days