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 Audit Evidence Audit Finding Corrective action outcome required and timeframe for completion (days) Criterion 1.2.9.1 PA Residents are assessed within Progress do not reflect the time of entry. Ensure progress notes Low 24 hours of admission. include the time of Information is entered Documentation includes entry. into the consumer progress notes that are dated information and signed by the caregivers management system in and the RNs. Staff interviews 90 days an accurate and timely confirm that they are aware manner, appropriate to they must also record the time the service type and of entry but they report that setting. that forget to do this. Criterion 1.3.12.1 PA Six of fourteen medication (i) There was transcribing of medications on eight of 14 Ensure the practice of charts and signing sheets met required medication signing sheets. (ii) Three administration, A medicines legislative requirements. medications administered were not on the standing orders or reconciliation, and management system is There were standing orders in prescribed on the medication chart. (iii) There was no prescribing of implemented to place for each resident dated evidence of medication reconciliation for a regular respite care medication meet the manage the safe and July 2014. Regular resident. The medication chart had not been reviewed by the legislative appropriate prescribing, medications are checked on dispensing, delivery against the medication
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 Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.9.1 Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting. PA Low Residents are assessed within 24 hours of admission. Documentation includes progress notes that are dated and signed by the caregivers and the RNs. Staff interviews confirm that they are aware they must also record the time of entry but they report that that forget to do this. Progress do not reflect the time of entry. Ensure progress notes include the time of entry. 90 days Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, PA Six of fourteen medication charts and signing sheets met legislative requirements. There were standing orders in place for each resident dated July 2014. Regular medications are checked on delivery against the medication (i) There was transcribing of medications on eight of 14 required medication signing sheets. (ii) Three medications administered were not on the standing orders or prescribed on the medication chart. (iii) There was no evidence of medication reconciliation for a regular respite care resident. The medication chart had not been reviewed by the Ensure the practice of administration, reconciliation, and prescribing of medication meet the legislative