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 Audit Evidence Finding Corrective action required desired outcome Rating and timeframe for completion (days) Criterion 1.2.3.6 PA Low Quality improvement activities Data relating to 17 incident reporting forms for Ensure that all incident include completion of the internal December 2015 has not been collected or entered reports are collated and Quality schedule, feedback from on to the SWAY data base. analysed to identify improvement data residents, families and staff via opportunities for are collected, complaints and surveys, complaints improvement. analysed, and process and incidents and evaluated and the accidents. Incident reports are results completed by care staff and 90 days communicated to registered nurses and are then service providers reviewed by the nurse manager. and, where The incident data is then entered on appropriate, to a Summerset data base (SWAY). consumers. On review of the previous three months, it was noted that not all incident report forms have been entered on to the data base. Criterion 1.3.3.3 PA Care plan documentation is still in i) Two out of five files reviewed did not have interRAI i)Ensure that interRAI Moderate progress. InterRAI assessments assessments completed within 21 days of admission. assessments are completed were not completed as required for Interview with the clinical nurse lead, the nurse within 21 days of admission;
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 Rating Audit Evidence Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Quality improvement activities include completion of the internal schedule, feedback from residents, families and staff via complaints and surveys, complaints process and incidents and accidents. Incident reports are completed by care staff and registered nurses and are then reviewed by the nurse manager. The incident data is then entered on to a Summerset data base (SWAY). On review of the previous three months, it was noted that not all incident report forms have been entered on to the data base. Data relating to 17 incident reporting forms for December 2015 has not been collected or entered on to the SWAY data base. Ensure that all incident reports are collated and analysed to identify opportunities for improvement. 90 days Criterion 1.3.3.3 PA Moderate Care plan documentation is still in progress. InterRAI assessments were not completed as required for i) Two out of five files reviewed did not have interRAI assessments completed within 21 days of admission. Interview with the clinical nurse lead, the nurse i)Ensure that interRAI assessments are completed within 21 days of admission;
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