processes are documented available to the public and prospective requirements identified in the all relevant information as and clearly communicated new residents is not currently fully funding contract with the District identified in the funding contract. to consumers, their meeting the requirements stated in the Health Board. (E4.1b) family/whānau of choice contract with the District Health Board. where appropriate, local 90 days communities, and referral agencies. Criterion 1.3.3.3 PA Moderate Three residents receiving dementia Not all residents receiving All residents who receive level of care had their personal files dementia level of care have 24 dementia level of care to have 24 Each of service reviewed during the on-site audit. Two hour challenging behaviour hour challenging behaviour provision (assessment, of the three residents did not have 24 management plans on record. management plans in place to planning, provision, hour challenging behaviour help guide service providers in evaluation, review, and management plans to guide staff in the service delivery when residents exit) is provided within time management of challenging behaviour, present with challenging frames that safely meet the on record. behaviour. needs of the consumer. 90 days Criterion 1.4.2.1 PA Low An electronic database is used to (i)Electrical equipment is not Provide documented evidence record maintenance requests. The displaying current electrical that (i) testing and tagging of All buildings, plant, and general manager is interviewed and safety testing tags; and (ii) the electrical items is current; and (ii) equipment comply with advised the maintenance person electronic maintenance register the electronic maintenance legislation. checks this electronic database each is not updated to reflect the register is updated as day. The electronic maintenance status of the maintenance maintenance requests are register was reviewed and maintenance request. actioned. requests are not marked as being completed. Some of the maintenance requests on this register were reviewed 60 days and maintenance has been completed. Electrical items sighted have electrical test tags with the next test date recorded as due by 24 May 2014. Biomedical equipment and scales have current performance verification stickers in place.
processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies. available to the public and prospective new residents is not currently fully meeting the requirements stated in the contract with the District Health Board. requirements identified in the funding contract with the District Health Board. (E4.1b) all relevant information as identified in the funding contract. 90 days Criterion 1.3.3.3 Each of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Moderate Three residents receiving dementia level of care had their personal files reviewed during the on-site audit. Two of the three residents did not have 24 hour challenging behaviour management plans to guide staff in the management of challenging behaviour, on record. Not all residents receiving dementia level of care have 24 hour challenging behaviour management plans on record. All residents who receive dementia level of care to have 24 hour challenging behaviour management plans in place to help guide service providers in service delivery when residents present with challenging behaviour. 90 days Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low An electronic database is used to record maintenance requests. The general manager is interviewed and advised the maintenance person checks this electronic database each day. The electronic maintenance register was reviewed and maintenance requests are not marked as being completed. Some of the maintenance requests on this register were reviewed and maintenance has been completed. Electrical items sighted have electrical test tags with the next test date recorded as due by 24 May 2014. Biomedical equipment and scales have current performance verification stickers in place. (i)Electrical equipment is not displaying current electrical safety testing tags; and (ii) the electronic maintenance register is not updated to reflect the status of the maintenance request. Provide documented evidence that (i) testing and tagging of electrical items is current; and (ii) the electronic maintenance register is updated as maintenance requests are actioned. 60 days
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