Standard 1.0
Standardized Assessment and Person-Centred Care
Standard 11.0
Infection Prevention and Control
Standard 12.0
Medication Management
Standard 16.0
Restraint Management
Standard 1.0-19.0
Mystery
100
If an operator does not use the InterRAI, they would use this assessment tool.
What is designated Standardized Assessment Tool?
100
On occasion, staff store items in a cardboard box on the floor.
What is nothing/do nothing? This is not part of the CCHSS.
100
The Operator provided policies and procedures that included medication labeling, assessment of clients knowledge and quality improvement. Upon closer look, the Auditor confirms that the policies and procedures were established. There is no evidence these were implemented or maintained. The Auditor would code this as Met, Unmet or NA.
What is Unmet?
100
The Operator facilitated a behaviour assessment on Ms. Truly Agitated. The Auditor would expect one or more of these
What is Review of InterRAI outcome scores Progress / Case notes Behaviour mapping Interdisciplinary team conference form
100
A tornado warning was issued and the facility implemented the emergency preparedness plan. A family was irate that the Operator never provided them with information about the emergency preparedness plan. The Auditor was able to find several documents to achieve compliance to this Standard.
What is Plans are communicated and made available to the client and their legal representative upon commencement/admission and after any update to the plan: Plans are posted or made available Client / Family council minutes Memos Client handbook / Information package Admission package
200
Pertaining to Standard 1.3, you have reviewed the Care Plan and discover it addresses the CAPS and RAPS and it does not address the unmet needs. You would mark this Standard Met, Unmet or NA.
What is Unmet?
200
The Operator provides evidence Hand Hygiene results and cleaning and disinfecting schedules. The Auditor would mark this as Met, Unmet or NA.
What is Met?
200
The Auditor reviews evidence regarding Medication Reconciliation. There are several time frames when this process is completed to include examples.
What is Medication reconciliation completed: • upon the client’s commencement of services • when the client transfers between different publicly funded operators; • as the client transfers between different levels of care within the same operator • where there are significant changes to medication during an interdisciplinary team conference
200
The Operator demonstrated evidence that the process for considering of a restraint has been initiated and communicated this to the client and their legal representative to include a risk management form that is signed and dated. The Auditor would mark this as met, unmet or NA.
What is unmet? A Risk Management form for is not used in a Restraint Management process.
200
Name four examples of Quality Improvement Initiatives you have audited.
What is ... group to give examples
300
Mr. Roll McWheelchair has a legal representative enacted which is verified in this documentation.
What is the Personal Directive or Guardianship Order, or Enduring Power of Attorney, or Trusteeship?
300
Mrs. I. Can'tremember is adamant that the site staff have never provider her or her family information on IPC policies and procedures. Her younger brother, Mr. Unforgettable, volunteers at the site and also confirms the above noted. This can be validated by reviewing evidence of compliance.
What is - Auditor conversations with staff -Electronic or printed access to policies and procedures -Client handbook -Admission package -Client/Family Council minutes -IPC signage in public area -Brochures in public area
300
The Auditor is reviewing documentation on the "8 rights" of Medications Administration principles. The Auditor lists the eight rights as follows.
What is i) right medication; ii) right Client; iii) right dose; iv) right time; v) right route; vi) right reason; vii) right documentation; and viii) right to refuse a medication
300
The Auditor would look for documentation to demonstrate the medication tapering plan for anti psychotic in these places.
What is Physician orders Medication administration records Progress / Case notes
300
An Operator of a Long-Term Care Facility must ensure that the Client’s responsible Physician or Nurse Practitioner is contacted regarding the review of the Client’s Care Plan for the purposes of providing input.
What is Documentation that the client’s responsible physician or nurse practitioner was contacted regarding the review of their client’s care plan: Documentation that the client’s responsible physician or nurse practitioner was contacted regarding the review of their client’s care plan Must demonstrate one or more of: Interdisciplinary team conference form Progress / Case notes Tracking sheet Physician orders Correspondence (fax, letter)
400
Ms. Sally McCane was invited to attend her Interdisciplinary Client Conference and provide her input in to her Care Plan. This evidence can be confirmed by checking these documents.
What is Interdisciplinary Team Conference Form, or Progress/Case notes, Admission records, or letters, or invitations to care conferences?
400
At a Home Care staff meeting, staff report they have not been provided with necessary equipment and supplies to carry out the policies and procedures in Standard 11.1. An Auditor is on site this same day and the manager is able to provide evidence to disprove the above noted.
What is Observation of: • Equipment and supplies are available o Biohazard bins, where appropriate o Isolation carts, where appropriate o Personal protective equipment at point of care o Disinfectant wipes for shared equipment • Signage o Outbreak/isolation signage, where appropriate o Donning and doffing of personal protective equipment
400
Acceptable evidence of documentation for client's non-adherence to the medication management program.
What is Managed risk agreement Care plan Progress / Case notes Behaviour support plan / managed risk agreement Coding on medication administration records (MAR)
400
The time frames for reviewing restraints at a minimum, according to InterRAI are indicated.
What is Restraints are reviewed, at a minimum, according to InterRAI timelines: • Upon admission, • Quarterly and annually for Long-Term Care, • Annually for Supportive Living and Home Care, and • Upon significant change in the client’s health status
400
Summarize your understanding of Standard 5.0 and include examples of evidence.
What is Where an Operator provides Palliative and End-of-Life Care services, an Operator must: a) establish, implement and maintain documented policies and procedures identifying what specific Palliative and End-of-Life Care services it provides; and b) make these policies and procedures available to the Client, the Client’s legal representative, if applicable, and Staff. Palliative and end-of-life care policies and procedures outline the services provided Staff are made aware of policies and procedures on palliative and end-of-life care -In-service material and attendance sheets -Staff access to palliative care resources Clients and their legal representative are made aware of policies and procedures on palliative and end-of-life care -Client / Family council minutes -Client handbook / Information packages -Admission conference document or admission check list An Operator must ensure that a Client and the Client’s legal representative, if applicable, are provided with information on Palliative and End-of-Life Care based on the Client’s Health Status and assessed Health Care needs. Client and their legal representative are provided with information on palliative and end-of-life care based on their health status or health care needs Consult / Referral Progress / Case notes Interdisciplinary team conference form Admission checklist Palliative care resources Client handbook / Information package Standard 5.3 An Operator must ensure the following are documented in a Client’s Care Plan: a) the Client’s Palliative and End-of-Life Care goals; and b) any relevant instructions pertaining to Palliative and End-of-Life Care listed in any legal documents made known to the Operator. Minimum timelines for an interdisciplinary team conference are: • Within 6 weeks of admission, • Annually, and • Upon significant change in the client’s health status Goals of care are reviewed at interdisciplinary team conferences. As appropriate to the client’s health status, their care plan contains palliative and end-of-life goals and any relevant instructions as per legal documents Standard 5.4 An Operator must ensure that all Health Care Providers providing Palliative and End-of-Life Care to a Client have access to the Client’s necessary Health Information, including the Client’s Palliative and End-of-Life Care goals, subject to 7.1. Auditor conversations with staff confirming they have access to and are aware of necessary client health information
500
Mr. I Gottago now requires a one person transfer for toileting. This is communicated to the client, Interdisciplinary Team and Health Care providers.
What is progress note, or forms, or letters, or IDT Form, or revised Care Plan, or Task List, or Tracking Tool, or Service Authorization?
500
Ms. Too-the-point proudly talks about the components of her teams sharps program.
What is A sharps program contains the following components: • assessment of the current setting (review of safety devices used i.e. safety engineered needles), access to sharps containers, staff readiness and cultural influences • education • process for selecting and evaluating devices • process for reporting and analyzing injuries related to sharps • process for monitoring, evaluating and improving outcomes of the sharps program (i.e. reduction in needle stick injuries) (Centers for Disease Control and Prevention, 2008)
500
The RN has assessed Mr. Reliable as being able to competently self-administer his medications. Typically, the RN dispenses the medications, places them in a paper cup, gives it to the resident and leaves. Based on past experience, the RN knows the resident will take his medications between eating his oatmeal and drinking his cranberry juice, as always done. Mr. Reliable did not sleep well last night resulting in him falling asleep at the table. The new resident sitting beside him, Mr. Opportunity, mistakenly takes the Mr. Reliable medication. Standard 12.1 and 12.2 and would be marked met, unmet or NA.
What is unmet for 12.1 (m-roles and responsibilities of Regulated Health Care Providers) and met for 12.2 as met (assessed as being competently able to self-administer medications).
500
Supportive interventions are positive, non-restrictive and non-pharmacological to include...list three
What is a) meaningful activity participation; b) assessment and management of the Client’s pain; c) assisting the Client to the toilet; d) assisting the Client with repositioning; e) social interaction; or f) environmental interventions.
500
Summarize the Standard 9.0 Staff Training and provide examples of evidence and any time frames that are important.
What is Standard 9.1 An Operator must ensure that the training materials used to provide training are current in relation to the legislation, regulations, standards, and guidelines listed in 9.2 and 9.3 -Training materials for the training listed in Standards 9.2 and 9.3 Standard 9.2 An Operator must establish, implement and maintain documented policies and procedures to ensure: a) training for all Staff in: i) Person Centered Care; ii) prevention, recognition and management of Responsive Behaviours; iii) infection prevention and control practices; and iv) emergency preparedness, pandemic preparedness and service continuity. b) training for Health Care Aides involved in the provision of Medication Management are trained in Medication Reminders and Medication Assistance; c) training for any Staff working with a Client with dementia are trained in care of Clients with dementia; d) training for Health Care Providers in: i) Risk Management; ii) fall prevention and management; iii) cardiopulmonary resuscitation (CPR) where their job description requires they must be trained in CPR; iv) Palliative and End-of-Life Care where providing such care; v) safe lifts and transfers where providing such care; vi) restraint use and management where they may be required to implement or manage Restraints; and vii) methods to ensure safe bath and shower water temperatures where involved in assisting Clients with bathing; e) Training in nutrition and hydration assistance techniques, including choking prevention and response, for any Unregulated Health Care Provider or volunteer involved in assisting a Client in meeting the Client’s nutrition and hydration needs; and f) the training in 9.2(a) through 9.2(e) occurs within six months from the date of hire, and every two years thereafter. -Policies and procedures related to training Auditor conversations with staff and volunteers Documentation demonstrating the required training is provided to applicable staff and volunteers • Within 6 months of hire, and • Every two years, thereafter -Training calendars and sign in sheets -Tracking system of employee and volunteer training -Training records on employee and volunteer files -Orientation materials and checklists Standard 9.3 An Operator must establish, implement and maintain documented policies and procedures to ensure: a) training for all Health Care Providers in; i) the CCHSS; ii) Health Information management; iii) the Health Information Act and the Freedom of Information and Protection of Privacy Act; iv) the prevention and reporting of Client abuse; and v) incident reporting pursuant to 19.2, 19.3 and 19.4; b) training for registered nurses, licensed practical nurses and Health Care Aides on Personal Directives, Enduring Power of Attorney, guardianship and trusteeship in the provision of Health Care; and c) the training in 9.3(a) and 9.3(b) occurs within six months of the date of hire and within three months of any significant update or revisions to the related training materials. Documentation demonstrating the required training is provided to applicable staff within: • 6 months of hire, and • Within 3 months of any significant update or revisions to the related training materials -Training calendars and sign in sheets -Tracking system of employee and volunteer training -Training records on employee and volunteer files -Orientation materials and checklists Standard 9.4 An Operator must document compliance with the requirements in 9.1, 9.2, and 9.3. -specific training requirements list for 9.4.
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