Electronic records are protected from unauthorised access. Hard copy records are held securely. Residents’ files demonstrate service integration. Entries are legible, timed, dated and signed by the relevant caregiver or nurse, including designation. Electronic records clearly identify staff member and time. Standard 1.3.1: Entry To Services FA The service has admission policies and processes in place. Residents receive an information pack outlining services able to be provided, the admission Consumers' into services is facilitated in a process and entry to the service. The service screens all potential residents competent, equitable, timely, and respectful prior to entry and records all admission enquires. Residents and relatives manner, when their need for services has been interviewed confirmed they received information prior to admission and had identified. the opportunity to discuss the admission agreement with the manager. The admission agreement form in use aligns with the requirements of the ARRC contract. Registered nurses assess all residents on entry to service. Initial information gained is paper based and is included in the resident computer based system. RNs interviewed could describe the entry and admission process. The GP is notified of a new admission. Standard 1.3.10: Transition, Exit, Discharge, Or FA The service has a policy that describes guidelines for death, discharge, Transfer transfer, documentation and follow-up. A record of transfer documentation is kept on the resident’s file. All relevant information is documented and Consumers experience a planned and coordinated communicated to the receiving health provider or service. The procedures transition, exit, discharge, or transfer from services. include a transfer/discharge form and yellow envelope’ is used. The RNs ‘the report that they include copies of all the required information in the envelope. Standard 1.3.12: Medicine Management FA are comprehensive policies and procedures in place for all aspects of medication management, including self-administration. The service utilises Consumers receive medicines in a safe and timely two-weekly robotic rolls. All medications were securely and appropriately manner that complies with current legislative stored. Registered nurses administer medications and had completed annual requirements and safe practice guidelines. medication competencies and education. Caregivers who act as second checker had a medication competency. There was one resident on the day of audit. Self-medication competencies for that resident had been completed. There is a signed agreement with the pharmacy. Medications are checked on arrival and any pharmacy errors recorded and fed back to the supplying pharmacy. The medication folders include a list of specimen signatures and competencies.
Electronic records are protected from unauthorised access. Hard copy records are held securely. Residents’ files demonstrate service integration. Entries are legible, timed, dated and signed by the relevant caregiver or nurse, including designation. Electronic records clearly identify staff member and time. Standard 1.3.1: Entry To Services Consumers' into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified. FA The service has admission policies and processes in place. Residents receive an information pack outlining services able to be provided, the admission process and entry to the service. The service screens all potential residents prior to entry and records all admission enquires. Residents and relatives interviewed confirmed they received information prior to admission and had the opportunity to discuss the admission agreement with the manager. The admission agreement form in use aligns with the requirements of the ARRC contract. Registered nurses assess all residents on entry to service. Initial information gained is paper based and is included in the resident computer based system. RNs interviewed could describe the entry and admission process. The GP is notified of a new admission. Standard 1.3.10: Transition, Exit, Discharge, Or Transfer Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services. FA The service has a policy that describes guidelines for death, discharge, transfer, documentation and follow-up. A record of transfer documentation is kept on the resident’s file. All relevant information is documented and communicated to the receiving health provider or service. The procedures include a transfer/discharge form and ‘the yellow envelope’ is used. The RNs report that they include copies of all the required information in the envelope. Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. FA are comprehensive policies and procedures in place for all aspects of medication management, including self-administration. The service utilises two-weekly robotic rolls. All medications were securely and appropriately stored. Registered nurses administer medications and had completed annual medication competencies and education. Caregivers who act as second checker had a medication competency. There was one resident on the day of audit. Self-medication competencies for that resident had been completed. There is a signed agreement with the pharmacy. Medications are checked on arrival and any pharmacy errors recorded and fed back to the supplying pharmacy. The medication folders include a list of specimen signatures and competencies.
AuditSummary_PRMS_CommunicatePublish_000005954001.docx