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 1.2.7.5 PA Low An education and training programme is i) On-line training has not been embedded i) Ensure staff established and reviewed annually. Since into practice with low attendance rates. complete all online A system to identify, the previous audit, staff have attended a education and training plan, facilitate, and ii) The designated health and safety officer range of training including (but not limited topics that are record ongoing has not attended any formal health and to) open disclosure, complaints required. education for service safety training. management and food safety (kitchen providers to provide ii) Ensure the health staff). Individual staff attendance records iii) Cultural training has not been provided safe and effective and safety officer are maintained. The education and for staff. services to consumers. attends external training hours available to staff exceeds health and safety iv) InterRAI assessments are behind eight hours per annum. Only one RN is training. schedule due to a lack of RN accessibility to trained in InterRAI due to staff turnover and InterRAI training. the lack of availability of InterRAI training iii) Ensure cultural courses. training is included in the annual education Online in-service training was initiated in and training plan. 2016. completion rates for mandatory topics are below acceptable limits. A iv) Ensure there are corrective action plan has been developed adequate numbers of around this with a goal of achieving 80% InterRAI trained RNs. attendance in 2017. Other gaps in
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 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low An education and training programme is established and reviewed annually. Since the previous audit, staff have attended a range of training including (but not limited to) open disclosure, complaints management and food safety (kitchen staff). Individual staff attendance records are maintained. The education and training hours available to staff exceeds eight hours per annum. Only one RN is trained in InterRAI due to staff turnover and the lack of availability of InterRAI training courses. Online in-service training was initiated in 2016. completion rates for mandatory topics are below acceptable limits. A corrective action plan has been developed around this with a goal of achieving 80% attendance in 2017. Other gaps in i) On-line training has not been embedded into practice with low attendance rates. ii) The designated health and safety officer has not attended any formal health and safety training. iii) Cultural training has not been provided for staff. iv) InterRAI assessments are behind schedule due to a lack of RN accessibility to InterRAI training. i) Ensure staff complete all online education and training topics that are required. ii) Ensure the health and safety officer attends external health and safety training. iii) Ensure cultural training is included in the annual education and training plan. iv) Ensure there are adequate numbers of InterRAI trained RNs.
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