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 required and outcome Rating timeframe for completion (days) Criterion 1.2.3.8 PA Moderate An internal audit schedule is reviewed (i)The person/s responsible for Provide documented evidence that list audits to be completed on a implementing corrective actions that (i)The person/s responsible A corrective action plan month-by-month basis. Internal audits and the timeframe/s for for implementing corrective addressing areas requiring have been completed as per the audit implementation of these are not actions and the timeframe/s for improvement in order to schedule. consistently documented; and implementation of these is being meet the specified (ii) there is minimal consistently documented; and (ii) Standard or requirements A shortfall was identified with documentation available to Documentation is available to is developed and development and monitoring of the indicate the corrective action indicate the corrective action have implemented. corrective action plans during the last has been completed and been completed and are audit and this has been partially monitored for effectiveness. monitored for effectiveness. addressed. Completed internal audits include corrective action plans to address shortfalls identified. 90 days Criterion 1.2.4.3 PA Moderate The facility manager advised they Provide evidence that Provide evidence that review all adverse events as well as neurological observations are neurological observations are The service provider resident’s event notes each morning being completed for all being completed for all documents adverse, when they start work. The registered unwitnessed falls, if the resident unwitnessed falls, if the resident unplanned, or untoward nurse reported they are required to has an obvious head injury, or if has an obvious head injury, or if
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 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Moderate An internal audit schedule is reviewed that list audits to be completed on a month-by-month basis. Internal audits have been completed as per the audit schedule. A shortfall was identified with development and monitoring of the corrective action plans during the last audit and this has been partially addressed. Completed internal audits include corrective action plans to address shortfalls identified. (i)The person/s responsible for implementing corrective actions and the timeframe/s for implementation of these are not consistently documented; and (ii) there is minimal documentation available to indicate the corrective action has been completed and monitored for effectiveness. Provide documented evidence that (i)The person/s responsible for implementing corrective actions and the timeframe/s for implementation of these is being consistently documented; and (ii) Documentation is available to indicate the corrective action have been completed and are monitored for effectiveness. 90 days Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward PA Moderate The facility manager advised they review all adverse events as well as resident’s event notes each morning when they start work. The registered nurse reported they are required to Provide evidence that neurological observations are being completed for all unwitnessed falls, if the resident has an obvious head injury, or if Provide evidence that neurological observations are being completed for all unwitnessed falls, if the resident has an obvious head injury, or if