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 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 Audit Evidence Audit Finding Corrective action Rating required and timeframe for completion (days) Criterion 1.1.10.4 PA Low Six of nine files reviewed had Not all files included Ensue that consent is informed consent for outings consent for outings, documented for The service is able to demonstrate that written documented and signed. information sharing and use treatment, information consent is obtained where required. Three of the nine files of photographs. sharing, transportation reviewed had consent for e.g. for outings and use information sharing. of photographs. Six of the nine files had consent for use of 180 days photographs in place. Criterion 1.1.9.1 PA Low Nineteen incident forms in Four of the incident forms in Ensure that total were reviewed in the rest the rest home did not documentation is Consumers have a right to full and frank information home, hospital and inpatient include documentation that completed confirming and open disclosure from service providers. area. Five of the nine incident family had been notified and that family have been forms reviewed in the rest progress notes did not notified in a timely home and all incident forms in evidence this. manner after an the inpatient and hospital incident has occurred. included documentation that
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 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 Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.10.4 The service is able to demonstrate that written consent is obtained where required. PA Low Six of nine files reviewed had informed consent for outings documented and signed. Three of the nine files reviewed had consent for information sharing. Six of the nine files had consent for use of photographs in place. Not all files included consent for outings, information sharing and use of photographs. Ensue that consent is documented for treatment, information sharing, transportation e.g. for outings and use of photographs. 180 days Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers. PA Low Nineteen incident forms in total were reviewed in the rest home, hospital and inpatient area. Five of the nine incident forms reviewed in the rest home and all incident forms in the inpatient and hospital included documentation that Four of the incident forms in the rest home did not include documentation that family had been notified and progress notes did not evidence this. Ensure that documentation is completed confirming that family have been notified in a timely manner after an incident has occurred.
AuditSummary_PRMS_CommunicatePublish_000001004005.docx