comply with current legislation, and temperatures of these appliances were not for all fridges and guidelines. monitored. freezers. 90 days Criterion 1.3.3.3 PA Low In the six files reviewed an initial care plan and Four of six resident files Ensure that initial assessment had been completed. The registered sampled did not have a date assessments and Each of service provision nurse/interim manager reported these are always or signature on the initial care are (assessment, planning, provision, completed on the day of admission. However, the assessment and care plan completed within evaluation, review, and exit) is newly developed initial assessment and care plan (the newly developed initial required provided within time frames that form does not require a date or signature, so this assessment and care plan timeframes and safely meet the needs of the could not be confirmed. form does not require a date signed and dated consumer. or signature, so completion to demonstrate date could not be confirmed). this. 90 days Criterion 1.3.3.4 PA Low Progress notes, GP notes and notes from visiting Four of six files sampled had Ensure progress allied health professionals are documented in the intervals of between nine notes are recorded The service is coordinated in a electronic database. Most entries are made by the days and fourteen days over regularly to manner that promotes continuity in previous manager (who left one week prior to the the previous two months demonstrate a service delivery and promotes a team audit) or the registered nurses with a minority of where no progress notes had record of the approach where appropriate. entries from the caregivers. Not all files been recorded. resident’s ongoing demonstrated consistent entry of progress notes. progress. 90 days Criterion 1.4.2.1 PA Low Scheduled maintenance occurs with sub-contractors Hot water temperature Provide evidence providing fire testing, electrical and plumbing work. records for April and May that hot water is All buildings, plant, and equipment Staff inform the maintenance person of any issues evidence that resident hot provided to comply with legislation. that require attention. Monthly hot water checks are water has been delivered residents at conducted in the laundry, kitchen and in a sample of consistently above 45 appropriate resident rooms. The hot water records for the past degrees Celsius (46-50). temperature five months were reviewed and evidence that Corrective actions have not levels. January to March temperatures are within the
comply with current legislation, and guidelines. temperatures of these appliances were not monitored. for all fridges and freezers. 90 days Criterion 1.3.3.3 Each of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low In the six files reviewed an initial care plan and assessment had been completed. The registered nurse/interim manager reported these are always completed on the day of admission. However, the newly developed initial assessment and care plan form does not require a date or signature, so this could not be confirmed. Four of six resident files sampled did not have a date or signature on the initial assessment and care plan (the newly developed initial assessment and care plan form does not require a date or signature, so completion date could not be confirmed). Ensure that initial assessments and care are completed within required timeframes and signed and dated to demonstrate this. 90 days Criterion 1.3.3.4 The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. PA Low Progress notes, GP notes and notes from visiting allied health professionals are documented in the electronic database. Most entries are made by the previous manager (who left one week prior to the audit) or the registered nurses with a minority of entries from the caregivers. Not all files demonstrated consistent entry of progress notes. Four of six files sampled had intervals of between nine days and fourteen days over the previous two months where no progress notes had been recorded. Ensure progress notes are recorded regularly to demonstrate a record of the resident’s ongoing progress. 90 days Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low Scheduled maintenance occurs with sub-contractors providing fire testing, electrical and plumbing work. Staff inform the maintenance person of any issues that require attention. Monthly hot water checks are conducted in the laundry, kitchen and in a sample of resident rooms. The hot water records for the past five months were reviewed and evidence that January to March temperatures are within the Hot water temperature records for April and May evidence that resident hot water has been delivered consistently above 45 degrees Celsius (46-50). Corrective actions have not Provide evidence that hot water is provided to residents at appropriate temperature levels.
AuditSummary_PRMS_CommunicatePublish_000003304001.docx