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 outcome Attainment Audit Evidence Audit Finding Corrective action Rating required and timeframe for completion (days) Criterion 1.2.9.9 PA Low Registered nurses and care givers In five files reviewed Ensure the time is report resident progress in files. All clinical staff have not recorded when making All records are legible and the name relevant aspects of care are recorded entered the time progress entries into progress and designation of the service provider and entries are dated and signed notes were being notes. is identifiable. including staff designation. recorded. 90 days Criterion 1.3.12.1 PA Low Medication charts are pharmacy There are no indications Ensure as required generated. The prescribing of regular for use documented for as medications have an A medicines management system is medications meets legislative required medications on indication for use implemented to manage the safe and prescribing requirements. four out of 10 medication prescribed on the appropriate prescribing, dispensing, charts sampled. medication chart. administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, 90 days protocols, and guidelines.
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 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low Registered nurses and care givers report resident progress in files. All relevant aspects of care are recorded and entries are dated and signed including staff designation. In five files reviewed clinical staff have not entered the time progress notes were being recorded. Ensure the time is recorded when making entries into progress notes. 90 days Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA Low Medication charts are pharmacy generated. The prescribing of regular medications meets legislative prescribing requirements. There are no indications for use documented for as required medications on four out of 10 medication charts sampled. Ensure as required medications have an indication for use prescribed on the medication chart. 90 days
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