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 Attainment Audit Evidence Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.1.10.7 PA Low All resident files sampled contained an advance Two of six sampled Ensure that all advance directive. In four of six files the form was contained advance directives that directives are valid. Advance directives that completed by the resident and the general were not valid. The two forms are made available to practitioner (GP) had co-signed and confirmed that had been signed by the GP that service providers are the resident was competent to have completed the resident was not competent 90 days acted on where valid. this. The form that was in use on the day of the to make an advance directive audit did not allow for a clinically indicated for and was documented as for ‘not ‘not resuscitation’ decision. It is designed to be signed resuscitation’, but there was no by a competent resident only. Two forms had indication that this was a been signed by the GP that the resident was not clinically-indicated decision. competent to make an advance directive, and was documented as for resuscitation’, but there ‘not was no indication that this was a decision. Criterion 1.1.9.1 PA Low Residents and families interviewed confirmed that Five of fifteen accident/incident Ensure documentation they are kept informed. Missing was documented forms and associated progress evidences families Consumers have a notes failed to indicate that (and/or EPOA) kept right to full and frank
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 1.1.10.7 Advance directives that are made available to service providers are acted on where valid. PA Low All resident files sampled contained an advance directive. In four of six files the form was completed by the resident and the general practitioner (GP) had co-signed and confirmed that the resident was competent to have completed this. The form that was in use on the day of the audit did not allow for a clinically indicated ‘not for resuscitation’ decision. It is designed to be signed by a competent resident only. Two forms had been signed by the GP that the resident was not competent to make an advance directive, and was documented as ‘not for resuscitation’, but there was no indication that this was a decision. Two of six sampled contained advance directives that were not valid. The two forms had been signed by the GP that the resident was not competent to make an advance directive and was documented as ‘not for resuscitation’, but there was no indication that this was a clinically-indicated decision. Ensure that all advance directives are valid. 90 days Criterion 1.1.9.1 Consumers have a right to full and frank PA Low Residents and families interviewed confirmed that they are kept informed. Missing was documented Five of fifteen accident/incident forms and associated progress notes failed to indicate that Ensure documentation evidences families (and/or EPOA) kept
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