Criterion The provision of services PA Moderate of the rest home files sighted; Ensure that interventions are (a) 60 1.3.6.1 and/or interventions are interventions are recorded in the entered into the care plans, and consistent with, and evaluations and progress notes and not (b) are detailed, to guide staff contribute to, meeting the transferred to the body of long term care consumers' assessed needs, plan. and desired outcomes. Four (one of the hospital, one of the dementia and two of the PG unit) do not have detailed interventions recorded to guide the staff: a) the initial care plan for the hospital resident’s wound management needs do not have the frequency of wound dressing changes or renew dates of the dressing changes recorded; b) the resident in the dementia unit presents with challenging behaviour; however no individualised management strategies are recorded on the long term care plan; c) one resident in the PG unit has interventions recorded on the falls risk assessment and not transferred to the body of the long term mobility care plan; d) another resident in the PG unit has a wound assessment /care plan with no review date ,frequency of dressing changes or outcome recorded. Standard Consumers' service delivery PA Moderate 1.3.8: plans are evaluated in a comprehensive and timely manner. Criterion Where progress is different PA Moderate (i)Three of three rest home residents` files (i)Ensure that the long term care 60 1.3.8.3 from expected, the service evidence that progress different from the plan reflect any changes to responds by initiating expected goal are documented in the interventions and goals if the changes to the service evaluation section and not transferred to progress be different from the delivery plan. the body of the long term care plan: a) outcome. (ii) Ensure that short one resident is evaluated to need term care plans are utilised for supervision when toileting however the all acute or short term issues. long term care plan stated that she needs no supervision; b) one resident is
Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Moderate of the rest home files sighted; interventions are recorded in the evaluations and progress notes and not transferred to the body of long term care plan. Four (one of the hospital, one of the dementia and two of the PG unit) do not have detailed interventions recorded to guide the staff: a) the initial care plan for the hospital resident’s wound management needs do not have the frequency of wound dressing changes or renew dates of the dressing changes recorded; b) the resident in the dementia unit presents with challenging behaviour; however no individualised management strategies are recorded on the long term care plan; c) one resident in the PG unit has interventions recorded on the falls risk assessment and not transferred to the body of the long term mobility care plan; d) another resident in the PG unit has a wound assessment /care plan with no review date ,frequency of dressing changes or outcome recorded. Ensure that interventions are (a) entered into the care plans, and (b) are detailed, to guide staff 60 Standard 1.3.8: Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Moderate Criterion 1.3.8.3 Where progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Moderate (i)Three of three rest home residents` files evidence that progress different from the expected goal are documented in the evaluation section and not transferred to the body of the long term care plan: a) one resident is evaluated to need supervision when toileting however the long term care plan stated that she needs no supervision; b) one resident is (i)Ensure that the long term care plan reflect any changes to interventions and goals if the progress be different from the outcome. (ii) Ensure that short term care plans are utilised for all acute or short term issues. 60
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