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 Attainment Evidence Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.1.9.1 PA Low Incident/accident forms include space Documentation in five of thirteen Ensure there is for staff to document that family are incident/accident forms fails to reflect documented Consumers have a right to being kept informed following an families being informed following an evidence of open full and frank information adverse event. Evidence of this being adverse event. disclosure with and open disclosure from documented was missing five of the families following an service providers. thirteen incident/accident forms that adverse event were randomly selected for review, unless directed although all four families interviewed otherwise by the report that they are kept informed of resident or family. their family’s health status, including following an adverse event. 90 days Criterion 1.2.3.4 PA Low A document control policy is in place Policies and procedures have not been Ensure policies and that states policies are to be reviewed reviewed since March 2013. procedures are There is a document control every two years, with designated regularly reviewed system to manage the policies targeted for review every two as per the facility policies and procedures. months. The current policies and This system shall ensure
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 Attainment Rating Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers. PA Low Incident/accident forms include space for staff to document that family are being kept informed following an adverse event. Evidence of this being documented was missing five of the thirteen incident/accident forms that were randomly selected for review, although all four families interviewed report that they are kept informed of their family’s health status, including following an adverse event. Documentation in five of thirteen incident/accident forms fails to reflect families being informed following an adverse event. Ensure there is documented evidence of open disclosure with families following an adverse event unless directed otherwise by the resident or family. 90 days Criterion 1.2.3.4 There is a document control system to manage the policies and procedures. This system shall ensure PA Low A document control policy is in place that states policies are to be reviewed every two years, with designated policies targeted for review every two months. The current policies and Policies and procedures have not been reviewed since March 2013. Ensure policies and procedures are regularly reviewed as per the facility
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