Specific results for criterion 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 1.2.8.1 PA Low The staffing levels policy is the Registered nurse staffing levels do not Ensure there is documented rationale for determining meet the requirements for a hospital and There is a clearly documented 1. A registered staffing levels and mixes for safe a psychogeriatric unit. There are two and implemented process which nurse rostered on service delivery. The hospital has an registered nurses on duty for two determines service provider duty in the hospital RN on duty 24/7 who covers the mornings a week only (clinical manager levels and skill mixes in order to between the hours psychogeriatric unit. The clinical and a registered nurse). For five provide safe service delivery. of 7am and 10pm manager/RN is an additional RN two mornings a week there is one registered days per week. Staffing requirements nurse on duty and for afternoon shifts 2. A registered on night duty meet contractual there is one RN on duty to cover both the rostered on duty in requirements. psychogeriatric and hospital units. There the psychogeriatric is one RN on duty overnight. The risk is unit between the considered to be low due to low resident hours of 7am and numbers currently in the hospital unit. 10pm There has been ongoing communication 3. If the total between the provider and occupancy is DHB/HealthCERT regarding the RN below 50, there is staffing levels in this small facility. one registered
Specific results for criterion 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 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low The staffing levels policy is the documented rationale for determining staffing levels and mixes for safe service delivery. The hospital has an RN on duty 24/7 who covers the psychogeriatric unit. The clinical manager/RN is an additional RN two days per week. Staffing requirements on night duty meet contractual requirements. Registered nurse staffing levels do not meet the requirements for a hospital and a psychogeriatric unit. There are two registered nurses on duty for two mornings a week only (clinical manager and a registered nurse). For five mornings a week there is one registered nurse on duty and for afternoon shifts there is one RN on duty to cover both the psychogeriatric and hospital units. There is one RN on duty overnight. The risk is considered to be low due to low resident numbers currently in the hospital unit. There has been ongoing communication between the provider and DHB/HealthCERT regarding the RN staffing levels in this small facility. Ensure there is 1. A registered nurse rostered on duty in the hospital between the hours of 7am and 10pm 2. A registered rostered on duty in the psychogeriatric unit between the hours of 7am and 10pm 3. If the total occupancy is below 50, there is one registered
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