Reminder notice and application
Q: When will an approved provider receive a reminder notice advising the date to submit the application for re-accreditation?
A: The reminder notice is sent approximately seven months prior to expiry of the current period of accreditation. The Aged Care Quality and Safety Commission (the Commission) administers this to provide for enough time to:
(a) receive and validate the application for re-accreditation
(b) make a decision on the provider’s application for re-accreditation of the service before the end of the current accreditation period.
Q: Why is a provider asked to provide the number of aged care consumers (consumers) with public guardians or trustees listed as their representative?
A: During a site audit, the assessment team is required to meet with at least 10 per cent of consumers of the service, or their nominated representatives. This may require the Assessment Team to contact a consumer’s guardian to seek their views on the quality of care and services being delivered to the person under an order.
The Commission may also seek to verify whether the provider has advised these entities of opportunities to talk to members of the assessment team, as required under the Aged Care Quality and Safety Commission Rules 2018 (the Rules).
Having details on the number of consumers with public guardians or trustees listed as their representative assists the Commission to understand the vulnerability of service users, complexity of care needs and assist with the pre-planning of the site audit.
Q: What happens if a provider sends in a late application?
A: Section 47 of the Rules outlines the consequences of an application being made late.
The vast majority of approved providers submit their applications before the current application due date.
When an application for re-accreditation is made late, the Aged Care Quality and Safety Commissioner (Commissioner) is not required under the Rules to complete the re-accreditation process before the period of accreditation of the service ends. To avoid a gap in accreditation status, provider applications must be lodged by the date specified in the reminder notice.
Q: How much does re-accreditation cost and what additional cost will there be for providers?
A: The Aged Care Quality and Safety Commission Act 2018 (Commission Act) provides legal authority for the Commissioner to charge fees for services provided in the performance of functions. The Commission publishes fees for accreditation through the annual Cost Recovery Implementation Statement (CRIS) on the Commission’s website.
The current CRIS describes the arrangements by which residential aged care services will pay fees for the full cost of accreditation.
Dates considered not suitable
Q: Is an approved provider able to request that the Commission not conduct an unannounced site audit on a certain date?
A: Approved providers are able to request specific dates be excluded for unannounced activities (excluded dates) in residential aged care. Although the Commission does not guarantee visits will not occur on those days, the Commission will consider these dates in scheduling activities such as unannounced site audits.
Refer to the Regulatory Bulletin - Exclusion of specific dates for unannounced visits for further details on the exclusion of specific dates for unannounced visits.
Self-assessment
Q: When does an approved provider have to submit its self-assessment?
A: Providers are to submit self-assessment information at the time of submitting their application for re-accreditation. The specified date by which the provider is to submit their application for re-accreditation and self-assessment is included in their reminder notice. It is usually about 28 days from the date of the reminder notice.
Q: Can the self-assessment tool be used as an ongoing monitoring and improvement tool?
A: Self-assessment is an active process to support quality improvement and should be updated on an ongoing basis rather than be seen as a task that to be completed only for re-accreditation. It is a framework for the approved provider to evaluate and review the performance of the service in relation to the Aged Care Quality Standards (Quality Standards). This will also assist with updating the plan for continuous improvement of the service.
Q: Does the approved provider have to use the self-assessment template provided by the Commission?
A: A self-assessment tool and other supporting information is available on the Commission website. Approved providers are not required to use the template provided by the Commission and are encouraged to use whatever template best supports their individual business needs. However, self-assessment information must demonstrate the provider’s performance in relation to the service against the Quality Standards, so review of the Commission’s self-assessment tool for guidance is recommended.
Q: What happens if the self-assessment does not demonstrate adequate information about the provider’s performance against the Quality Standards?
A: There is no standalone evaluation by the Commission of the adequacy of the self-assessment. However, the Commission will provide the self-assessment to the Assessment Team which is conducting the site audit. The self-assessment forms part of overall assessment of the quality of care and services against the Quality Standards during the site audit and may also be considered by a delegate of the Commissioner in the development of a performance report.
Pre-audit feedback
Q: Is feedback received prior to the site audit considered by the Assessment Team conducting the site audit?
A: All relevant feedback received by the Commission from consumers, former consumers or their representatives prior to the site audit will be provided to the Assessment Team which is conducting the site audit. The Assessment Team must consider this information in conducting the site audit and then in preparing the site audit report.
Q: Can consumers or their representatives talk to the Assessment Team if they have provided feedback prior to the site audit?
A: Yes. The Assessment Team is required to take all reasonable steps to meet privately with any consumer or their representative who asks to meet with them during the site audit, even if they have already provided feedback prior to the site audit.
Q: Do consumers or their representatives have to provide their contact details including the name of the aged care service if they provide feedback prior to the site audit?
A: No. Consumers and their representatives are able to provide feedback anonymously or confidentially at any time. If feedback is provided anonymously no identifying details are provided to the Commission. If feedback is provided confidentially a name and contact details are provided to the Commission but are not disclosed to the relevant provider unless there is a risk of harm to a consumer.
Callers will be requested to provide details of the aged care service so that information can be provided to an Assessment Team to inform a site audit.
Notifying consumers and their representatives of a site audit
Q: Why is the Commission asking questions about appointed guardians and advocates? The public guardian in our state never responds to our calls.
A: Public guardian agencies protect adults who have a disability that impairs their capacity to make decisions and manage their affairs.
The Rules require approved providers to notify each consumer and their nominated representative at the time of application about the audit process and again when the Assessment Team arrives on site to conduct a site audit. This notification requirement extends to appointed advocates or guardians of consumers.
It continues to be the responsibility of the provider to notify consumer representatives including public guardians. In some circumstances the team will seek to contact the guardian to seek their views on the quality of care and services being delivered to the person under an order.
Q: Why is it the responsibility of the provider to inform consumers and their representatives about the Commission’s Assessment Team arriving on site?
A: Providers must take reasonable steps to inform consumers and their nominated representatives (including public guardians or advocates where applicable) that the site audit has commenced. This should occur as soon as practicable after the start of the audit. Reasonable steps will be relative to the capacity of the service.
Reasonable steps must include displaying the poster that the Assessment Team gives to the provider. This poster will inform consumers and their representatives that the site audit has commenced.
Reasonable steps may also include:
- informing consumers while attending to their care
- sending consumer representatives an email or text message to tell them that the audit has commenced
- in some instances, contacting individual consumer representatives by phone, (particularly, if they have advised that they wish to meet with the assessment team and cannot be contacted by other means).
Providers should enable consumers and their nominated representatives who wish to meet with assessment team to do so privately. This includes providing the Assessment Team with details of consumers and representatives who have asked to meet with them.
Q: What about the confidentiality and privacy of the representatives?
A: Representatives have given their authority and consent to be contacted by the Commission by nominating themselves as the consumer’s representative and by giving their contact details to the service.
Q: Can a provider send the consumer/representative notification out in a newsletter?
A: Providers are required to give information in writing to each consumer and their representatives using words provided by the Commission. The form of words includes information about the site audit and advises consumers and their representatives how to contact the Commission prior to the site audit.
In that context, the Assessment Team will assess whether consumers and their representatives have been made aware of the site audit and whether reasonable steps as outlined above have been taken to meet the requirements of the Rules.
Consent to enter
Q: What is the process for an approved provider granting consent for an Assessment Team to enter the premises for a site audit?
A: An approved provider has a responsibility under the Aged Care Act 1997 to cooperate with a person who is exercising powers under the Part 8 of the Commission Act. Failure to comply with that responsibility may result in a sanction being imposed on the approved provider under the Aged Care Act 1997.
Upon arrival at the premises the Assessment Team will request consent to enter the premises and exercise the Commission’s search powers for regulatory purposes. The Assessment Team will show their credentials and give the person in charge at the service a letter confirming the visit.
An Assessment Team must not enter the premises of a service unless consent has been granted.
If consent is withdrawn during a site visit the Assessment Team must immediately leave the premises.
Site audit
Q: When will a site audit occur?
A: The Commission will conduct an unannounced site audit at any time between the submission of an application for re-accreditation and the expiry of the service’s period of accreditation.
Q: Will the approved provider be told at the entry meeting how long the site audit will take?
A: During the entry meeting, the Assessment Team will give an indication of how many days the team may be on-site. It should be noted that the timing may change depending on circumstances of the service at the time of the site audit.
Q: Will an audit schedule be provided by the Assessment Team during the entry meeting?
A: Assessment teams are not required to develop audit schedules for unannounced site audits and as a result an audit schedule will not be provided during the entry meeting. Instead, the Assessment Team will explain:
- how the site audit will be carried out
- the process for the regular review of the site audit progress
- arrangements for information gathering such as availability of documents and records and how to access them
- arrangements for interviews with staff and consumers.
There will be an opportunity during the entry meeting for the person in charge to ask the Assessment Team questions about the site audit.
This approach enables the Assessment Team flexibility and to change its approach if required in order to address any emerging issues or to accommodate the needs of the service, the availability of staff or to minimise disruption to consumers.
Q: Will site audits only be conducted during business hours on weekdays?
A: No. The Commission may conduct a site audit outside of business hours or on weekends when there is a need to do so.
Q: Can the ‘person in charge’ change throughout the site audit?
A: Yes. At each service, there is a role or individual who is deemed to be in charge of running the service on a particular day. That person will be the person who has responsibility for managing the service on that day or during that shift. The person in charge of the service on the day of the site audit may therefore change daily throughout the site audit or change with different shifts on the same day.
The person in charge will be the contact for the Assessment Team and should have information on the site audit. It will be important for the person in charge to have access to the application and self-assessment information.
The person in charge will be the person who the team will approach to verify certain information detailed in the self-assessment document, to access certain policies and staffing information, or any other evidence requested by the Assessment Team to measure the service’s performance against the Quality Standards.
Where there is a change in the person in charge, this should be advised to the Assessment Team during the entry meeting.
Q: What happens if the service has an outbreak when the Assessment Team arrive?
A: If the service has an outbreak and the service is in lock down, the Commission will make a decision to proceed or not to proceed with the site audit. If the Commission decides not to proceed, the site audit will be conducted on another date determined by the Commission.
Q: What if the Assessment Team needs to discuss a service that is outsourced to another company such as food preparation or laundry services?
A: The Assessment Team will be seeking information to determine the mechanism the approved provider has in place to monitor and ensure the quality of those outsourced services.
If it is necessary to follow a line of enquiry identified in the site audit with an external contractor, the Assessment Team can arrange to contact them directly by phone or Skype. This may be done after hours if necessary. The approved provider should provide contact details for the external contractor to assist with this line of enquiry.
Q: On the day of a site audit should the routine of the day be disrupted or changed to accommodate the Assessment Team, or does the day continue as planned?
A: Providers should ensure that care and services continue to be provided to consumers of the service as planned during a site audit. The presence of the Commission for a site audit should not disrupt the usual quality of care and services provided by the approved provider to consumers.
Exit Meetings
Q: Will the Assessment Team provide any feedback before the exit meeting?
A: Yes. The Commission has an open and transparent audit approach and as a result there should be no surprises at the exit meeting.
The Assessment Team will ask the person in charge for more information during the site audit if any key issues are identified. The person in charge will have an opportunity to provide further information in relation to any matters raised by the Assessment Team, or to seek clarification on any issue, at this time.
Q: Who can attend the exit meeting?
A: The Assessment Team must meet with the person in charge on the last day of the site audit to communicate key issues that the Assessment Team has identified during the site audit. The person in charge may choose to have other people or consumer representatives also attend the exit meeting.
Q: Will the person in charge be told if there is a recommendation of ‘not met’ at the exit meeting?
A: No. The Assessment Team will make their findings based on evidence gathered during the site audit. The Assessment Team will then prepare a site audit report to give to the Commissioner within 7 calendar days of the site audit. A copy of the audit report will then be given to the approved provider as soon as practicable.
Q: How does an approved provider respond to the site audit findings?
A: An approved provider has 14 calendar days after it receives the report in which to respond to the findings of the site audit. The approved provider then has the opportunity to detail a response to the Assessment Team’s recommendations. The response should present factual information and evidence about how the service meets the Quality Standards, and what actions have been taken or are planned to meet the Quality Standards to ensure adequate and sustainable services for consumers.
Approved providers should consider all information provided in reports when preparing a response or in planning continuous improvement to the care and services to consumers.
The audit report and the approved provider’s response to the report, along with other relevant information, will then be taken into account by the Commission in developing a performance report and making the accreditation decision.
Q: Can the Assessment Team receive and consider additional information following the exit meeting once they have left the service?
A: This is dependent on a number of factors.
In certain circumstances, if there have been unforeseen difficulties locating required information on the day(s) of the site audit it may be appropriate to give the approved provider an opportunity to submit that information to the Assessment Team after they have left the site.
If it is information that the approved provider should reasonably have been able to locate and give to the Assessment Team while on site and when requested, then it is highly unlikely the Assessment Team will accept that information after the exit meeting.
The Assessment Team will consider each circumstance on its merits before determining whether to accept information after leaving the site. The provider will be notified of the reasons to accept or not accept this information.
Conflict of Interest
Q: How will the Commission deal with Conflicts of Interest?
A: The Commission has a clear policy on how to manage any real or apparent conflicts in relation to quality assessors.
The Conflict of Interest Policy:
- provides clear guidelines on what is a conflict
- requires quality assessors to notify the Commission on an annual basis of any conflicts of interest as well as at any other point in time that a real or apparent conflict of interest is identified
- outlines how conflicts will be managed by the Commission including possible actions following a breach.
Q: What about a conflict which may arise unexpectedly on the day of the site audit?
A: It is crucial for quality assessors to be objective and impartial and that they are seen to be as such by service staff, consumers and representatives.
Where a real or apparent conflict of interest is identified by a quality assessor prior to or during a site audit this must be immediately brought to the attention of the Commission.
The disclosed conflict of interest will be managed on a case by case basis by the Commission based on:
- the nature and seriousness of the conflict
- the significance of any relationship or interest.
If the Commission determines that there is a conflict of interest, the appropriate management action will be taken to maintain the integrity of the audit process. The Commission has a range of options on how to manage conflicts which may include contacting the provider to disclose the conflict.
Q: What should an approved provider do if the Assessment Team arrives for a site audit and a member of the Assessment Team is a previous employee?
A: Quality assessors are required to immediately advise the Commission of a real or apparent conflict of interest that is identified during a site audit. Where this has not occurred, the approved provider or person in charge of the service is able to contact the Commission and advise of the conflict of interest. The Commission will manage the conflict and determine appropriate actions for the site audit, such as replacing the Assessment Team member.
Any concerns regarding real or apparent conflicts of interest should be discussed with the Commission.
Assessing risk
Q: When is the Commission going to publish how it assesses risk? How do we assess risk?
A: The Commission has undertaken considerable work on strengthening its approach to risk. The Commission has published its Regulatory Strategy which outlines its approach to managing risk. The Regulatory Strategy can be found here.
When assessing providers compliance with the Quality Standards, the Commission is broadening its focus on outcomes for consumers, the quality of consumer experience and the prevention of harm. This involves listening more closely to consumers, giving them better information and building the Commission’s use of regulatory intelligence and risk about individual services and providers.
Q: What does the Commission mean by ‘tighter profiling of services to identify potential care and safety risks’? Will these profile criteria be communicated to the sector?
A: The Commission is working closely with the Department of Health to better understand the profile of consumers receiving care from providers. Where aged care consumers are especially vulnerable, the Commission will seek greater assurance about their care and safety. Where the Commission sees issues or practices of concern, it will communicate this more broadly to the sector to enable providers to assess their own practices and proactively make improvements.