0 38 0 2 1 0 0 Criteria UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited 0 0 0 0 0 0 0 34 Standards 0 0 0 0 0 0 0 60 Criteria Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.1.9: Service providers communicate PA Low Communication effectively with consumers and provide an environment conducive to effective communication. HDS(C)S.2008 Criterion 1.1.9.1 Consumers have a right to full PA Low Four of 11 incident forms sampled Ensure family are informed of all 180 and frank information and open do not have evidence on the incidents. disclosure from service incident form or in the progress providers. notes that family have been informed of the incident. HDS(C)S.2008 Standard 1.3.6: Consumers receive adequate PA Moderate Service and appropriate services in order Delivery/Interventions to meet their assessed needs and desired outcomes. HDS(C)S.2008 Criterion 1.3.6.1 The provision of services and/or PA Moderate One of six files sampled did not Ensure that all risk assessment 90 interventions are consistent with, have the risk assessments required on admission are and contribute to, meeting the completed within the required time completed within the required consumers' assessed and frame time frames. desired outcomes. Two of six files sampled did not Ensure all care plans have have detailed interventions in the detailed interventions to manage care plan for identified needs. identified needs and risks. One resident using a lap belt Ensure all residents using (enabler) did not have a risk enablers have the required risk assessment or consent form assessments and consents completed for the use of the lap completed. belt. Ensure that all residents Two of three restraint monitoring restraints have the required forms sampled had at least one
Criteria 0 38 0 2 1 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 34 Criteria 0 0 0 0 0 0 0 60 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. PA Low HDS(C)S.2008 Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers. PA Low Four of 11 incident forms sampled do not have evidence on the incident form or in the progress notes that family have been informed of the incident. Ensure family are informed of all incidents. 180 HDS(C)S.2008 Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Moderate HDS(C)S.2008 Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed and desired outcomes. PA Moderate One of six files sampled did not have the risk assessments completed within the required time frame Two of six files sampled did not have detailed interventions in the care plan for identified needs. One resident using a lap belt (enabler) did not have a risk assessment or consent form completed for the use of the lap belt. Two of three restraint monitoring forms sampled had at least one Ensure that all risk assessment required on admission are completed within the required time frames. Ensure all care plans have detailed interventions to manage identified needs and risks. Ensure all residents using enablers have the required risk assessments and consents completed. Ensure that all residents restraints have the required 90
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