UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited 0 0 0 0 0 0 0 27 Standards 0 0 0 0 0 0 0 40 Criteria Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.1.9: Service providers communicate PA Low Communication effectively with consumers and provide an environment conducive to effective communication. HDS(C)S.2008 Criterion 1.1.9.1 Consumers have a right to full PA Low Accident/incident do not have a Family notification following 60 and frank information and open section to indicate if family have a change in health status is disclosure from service been informed (or not) of an recorded. providers. accident/incident. Five files reviewed did not report family notification has occurred following a change in resident health status. Interview with the nurse manager informs she notifies family, however this is not always recorded in resident notes. HDS(C)S.2008 Standard 1.2.1: The governing body of the PA Low Governance organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. HDS(C)S.2008 Criterion 1.2.1.1 The purpose, values, scope, PA Low There is no evidence of formalised Establish and implement a 60 direction, and goals of the reporting to the director, and/or reporting structure to monitor organisation are clearly reporting of progress against goals. progress against goals identified and regularly outlined in the various plans. reviewed. HDS(C)S.2008 Standard 1.2.3: The organisation has an PA Moderate Quality And Risk established, documented, and Management maintained quality and risk Systems management system that
UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 27 Criteria 0 0 0 0 0 0 0 40 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. PA Low HDS(C)S.2008 Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers. PA Low Accident/incident do not have a section to indicate if family have been informed (or not) of an accident/incident. Five files reviewed did not report family notification has occurred following a change in resident health status. Interview with the nurse manager informs she notifies family, however this is not always recorded in resident notes. Family notification following a change in health status is recorded. 60 HDS(C)S.2008 Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. PA Low HDS(C)S.2008 Criterion 1.2.1.1 The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed. PA Low There is no evidence of formalised reporting to the director, and/or reporting of progress against goals. Establish and implement a reporting structure to monitor progress against goals outlined in the various plans. 60 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 PA Moderate