the contractual requirement for admission assessments to be undertaken by an RN. Criterion 1.3.3.3 PA Low Residents in the rest home are routinely Each stage of service Evidence is provided that reviewed by the GP three monthly as evidenced provision meets GPs review residents Each stage of service in all files reviewed. timeframes, with the within the required provision (assessment, exception of GP reviews in timeframes to meet their planning, provision, was no sighted documentation to evidence the rest home. needs. evaluation, review, and exit) is the GP has verified the resident is stable and provided within time frames suitable for three monthly reviews. During that safely meet the needs of interview, the GP was unaware that all residents 90 days the consumer. had to be verified by the GP as stable and suitable for three monthly rather than monthly reviews. Criterion 1.3.4.2 PA Low The initial care plan of two residents (one Residents have their needs Provide evidence residents hospital and one rest home) recently admitted, identified through a variety are comprehensively The needs, outcomes, and/or had no documentation verifying comprehensive of information sources assessed on admission goals of consumers are assessment of skin integrity, nutrition, including the assessment and reassessed when identified via the assessment behaviour, or pressure injury risk. process; however, there is a change in process and are documented assessment condition. to serve as the basis for residents (one rest home and two hospital) documentation is not service delivery planning. who had fallen had an initial assessment always consistent with the completed following the fall, however, no residents’ required needs. 90 days documentation verifying ongoing monitoring is recorded. There was no evidence sighted on the day of audit to verify monitoring had occurred. InterRAI assessments are not updated within the six month time frame if residents’ needs change. All files reviewed had no evidence of cultural needs being assessed, or a consideration to cultural needs requiring attention in care planning. Criterion 1.3.5.2 PA Service delivery describe the required Service delivery plans are Provide evidence that Moderate support to achieve the desired outcomes; inconsistent and do not service delivery
the contractual requirement for admission assessments to be undertaken by an RN. 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 Residents in the rest home are routinely reviewed by the GP three monthly as evidenced in all files reviewed. was no sighted documentation to evidence the GP has verified the resident is stable and suitable for three monthly reviews. During interview, the GP was unaware that all residents had to be verified by the GP as stable and suitable for three monthly rather than monthly reviews. Each stage of service provision meets timeframes, with the exception of GP reviews in the rest home. Evidence is provided that GPs review residents within the required timeframes to meet their needs. 90 days Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Low The initial care plan of two residents (one hospital and one rest home) recently admitted, had no documentation verifying comprehensive assessment of skin integrity, nutrition, behaviour, or pressure injury risk. residents (one rest home and two hospital) who had fallen had an initial assessment completed following the fall, however, no documentation verifying ongoing monitoring is recorded. There was no evidence sighted on the day of audit to verify monitoring had occurred. InterRAI assessments are not updated within the six month time frame if residents’ needs change. All files reviewed had no evidence of cultural needs being assessed, or a consideration to cultural needs requiring attention in care planning. Residents have their needs identified through a variety of information sources including the assessment process; however, assessment documentation is not always consistent with the residents’ required needs. Provide evidence residents are comprehensively assessed on admission and reassessed when there is a change in condition. 90 days Criterion 1.3.5.2 PA Moderate Service delivery describe the required support to achieve the desired outcomes; Service delivery plans are inconsistent and do not Provide evidence that service delivery
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