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 outcome Rating and timeframe for completion (days) Criterion 1.3.3.3 PA Low An initial nursing assessment and (i) One out of five files reviewed (i) Ensure that a medical care plan was completed within showed that the GP had seen the assessment is conducted by Each stage of service 24 hours of admission. The long resident four weeks after the the GP within 48 hours of provision (assessment, term care plan was developed admission. (ii) Four out of 10 admission. (ii) Ensure that planning, provision, within three weeks of admission. medication charts reviewed showed three monthly medication evaluation, review, and In all resident files sampled the three monthly medication reviews by a reviews are completed and exit) is provided within initial nursing assessment and GP were not documented. (iii) One documented by the GP. (iii) time frames that safely resident’s long term care plans resident was transferred from the Required follow ups are meet the needs of the were completed and signed off by public hospital and the discharge plan completed following a consumer. the Clinical Nurse Leader or an required follow up by a GP in three discharge from another health RN. Six monthly reviews were days including a repeat of the lab test. service in a timely manner. conducted. The GP review was completed 12 days after the discharge. 90 days
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 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low An initial nursing assessment and care plan was completed within 24 hours of admission. The long term care plan was developed within three weeks of admission. In all resident files sampled the initial nursing assessment and resident’s long term care plans were completed and signed off by the Clinical Nurse Leader or an RN. Six monthly reviews were conducted. (i) One out of five files reviewed showed that the GP had seen the resident four weeks after the admission. (ii) Four out of 10 medication charts reviewed showed three monthly medication reviews by a GP were not documented. (iii) One resident was transferred from the public hospital and the discharge plan required follow up by a GP in three days including a repeat of the lab test. The GP review was completed 12 days after the discharge. (i) Ensure that a medical assessment is conducted by the GP within 48 hours of admission. (ii) Ensure that three monthly medication reviews are completed and documented by the GP. (iii) Required follow ups are completed following a discharge from another health service in a timely manner. 90 days
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