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 is a message data to display” instead of a table, then no corrective actions were required as a result of this audit. “no Citerion with desired outcome Audit Evidence Audit Finding Corrective action required and Rating timeframe for completion (days) Criterion 1.2.3.4 PA Policies and procedures are available for staff in There are examples of Ensure policies both hard copy and electronically on the file’. policies and procedural are procedures ‘share There is a document control system to The review and updating responsibilities are manuals in use which are are sufficiently manage the policies and procedures. designated. Some of the policies sighted were overdue for review. Some detailed to guide This system shall ensure documents current and clearly detail staff responsibilities. updated policies have not yet staff practice and are approved, up to date, available to However there are a number of policy/procedure replaced the previous version document control service providers and managed to documents that have not been developed as yet, or of the PDF policy located on processes preclude the use of obsolete were overdue for review. Examples include: the share file and accessible consistently documents. by staff. implemented. The electronic emergency management policy in the share file is not the current version (dated are multiple versions of 2012/2013). maternity policies available for 90 days staff. The intravenous therapy manual on the file is dated 2009 (due for review in 2011). There are insufficient policy and procedures available that While there are procedures to guide admission detail the organisation’s processes this does not include clear criteria expectations related to some regarding the decision making process for aspects of practice. The
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 is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Citerion with desired outcome Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.4 There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents. PA Policies and procedures are available for staff in both hard copy and electronically on the ‘share file’. The review and updating responsibilities are designated. Some of the policies sighted were current and clearly detail staff responsibilities. However there are a number of policy/procedure documents that have not been developed as yet, or were overdue for review. Examples include: The electronic emergency management policy in the share file is not the current version (dated 2012/2013). The intravenous therapy manual on the file is dated 2009 (due for review in 2011). While there are procedures to guide admission processes this does not include clear criteria regarding the decision making process for There are examples of policies and procedural manuals in use which are overdue for review. Some updated policies have not yet replaced the previous version of the PDF policy located on the share file and accessible by staff. are multiple versions of maternity policies available for staff. There are insufficient policy and procedures available that detail the organisation’s expectations related to some aspects of practice. The Ensure policies are procedures are sufficiently detailed to guide staff practice and document control processes consistently implemented. 90 days
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