An 'Accident/Incident Summary' is used to document all incidents, is reviewed monthly, and is provided to the quality improvement committee meetings. There is an open disclosure policy. Resident files reviewed (four hospital and three rest home) provide evidence of communication with families following adverse events involving the resident, or any change in the residents condition, confirmed by family interviews. Communication with family is documented in the resident's progress notes. Staff confirm during interview that they are made aware of their essential notification responsibilities through: job descriptions; policies and procedures; and professional codes of conduct, which was confirmed via review of staff files and other documentation. Policy and Procedures comply with essential notification reporting e.g., health and safety, human resources, infection control etc. The ARC requirements are met. Criterion 1.2.4.2 The service provider understands statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required. Evidence Attainment: FA Risk level for PA/UA: Finding Statement Corrective Action Required: Timeframe: Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. Audit Evidence Attainment: FA Risk level for PA/UA: Finding Statement Corrective Action Required: Timeframe:
An 'Accident/Incident Summary' is used to document all incidents, is reviewed monthly, and is provided to the quality improvement committee meetings. There is an open disclosure policy. Resident files reviewed (four hospital and three rest home) provide evidence of communication with families following adverse events involving the resident, or any change in the residents condition, confirmed by family interviews. Communication with family is documented in the resident's progress notes. Staff confirm during interview that they are made aware of their essential notification responsibilities through: job descriptions; policies and procedures; and professional codes of conduct, which was confirmed via review of staff files and other documentation. Policy and Procedures comply with essential notification reporting e.g., health and safety, human resources, infection control etc. The ARC requirements are met. Criterion 1.2.4.2 The service provider understands statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required. Evidence Attainment: FA Risk level for PA/UA: Finding Statement Corrective Action Required: Timeframe: Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. Audit Evidence Attainment: FA Risk level for PA/UA: Finding Statement Corrective Action Required: Timeframe:
AuditSummary_MOHI-9CK2TN.docx