Audit Tips – Common findings in audits
Audits in the aged residential care sector in New Zealand are assessed against their ability to comply with a raft of legislation, standards and contractual requirements.
Below are common findings which continue to be reported on during audits:
Gaps in meeting full compliance
· Complaints management processes not completed as per requirements. Eg; not being logged on the complaints register, time-frames not being met, lack of evidence of resolution.
· Not completing internal audits
· Not evidencing completion of regular meetings
· Corrective action plans not being developed or completed
· Lack evidence of investigation
· Lack evidence of family notifications of adverse events
· Lack evidence of reference checks at time of employing new staff
· Lack of 1st Aid certified staff member on each duty in each work area – this must consider the size, and layout of your building.
· No signed employment agreement or job description
· Lack evidence of timely completion of orientation
· Annual appraisals not completed for all staff
· Lack of timely clinical assessment
· Lack of assessment and care-planning related to behaviours of concern (challenging behaviours)
· Lack of evidence in progress notes of Registered Nurse input
· Lack of evidence in progress notes of interventions from long term care plan
· Lack of evidence of family / residents input
· Lack of evidence of outcomes from clinical assessments (including InterRai) being used to inform the care plan
· Transcribing of medications in care plans
· Doctor’s instructions in medical notes not followed / implemented
· Wound assessment chart not updated as per wound care plan
· Neurological observations not completed following falls where there was a possibility of the resident having sustained a head injury
· GP reviews not recorded at time-frames determined in ARRC
· Lack of evidence of RN acting on caregivers reporting of adverse health symptoms in progress notes.
Safe and Appropriate Environment
· Lack of evidence of medical calibration of equipment
· Hoists not checked and verified as fit for use.
· Surfaces unable to be cleaned adequately
· Non labelled or decanted chemicals
· Lack of evidence of hot water temperatures not exceeding 45 degrees
|Restraint minimisation and safe practice – 2.0
· No evidence of enabler monitoring
· Lack of evidence of incomplete restraint register.
|Infection prevention and control
· Infection control nurse in care facilities who have not completed training in infection prevention and control and therefore cannot demonstrate relevant knowledge on which to base practice and monitor staff performance.
· Not all infections are noted on the infection register. Your policy and procedure should include the internationally recognised definitions for infections on which to base your monitoring. For those of you using the HCSL policies and procedures, these definitions are noted within the Anti- microbial Policy – document code IC1.
Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of your service.
For more assistance with this contact us.