Site Audit Frequently Asked Questions
Reminder notice and application
Q: When will we receive our reminder notice advising the date to submit our application for re-accreditation?
A: The reminder notice is sent approximately 7 months prior to expiry of your 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: Can you explain how the Commission decided on the ‘specified date’ and timeframe for sending reminder notices?
A: The date by which an approved provider is to submit an application form allows time for all the required steps to be taken prior to the date of expiry of accreditation. The steps include the pre-planning stage of the audit, undertaking the site audit, meeting procedural fairness requirements and time for decisions and reconsideration of decisions.
Q: Why are we being asked to provide the number of care recipients 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 care recipients of the service, or their nominated representatives. This may require a team to contact a care recipient’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 care recipients 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 audit.
Q: What happens if we send in a late application?
A: Section 47 of the Rules outlines the consequences of an application being made late.
When an application for re-accreditation is made late the Aged Care Quality and Safety Commissioner is not required to complete the re-accreditation process before the period of accreditation of the service ends. To avoid a gap in accreditation status, applications must be lodged by the date specified in the reminder notice.
The vast majority of approved providers already submit their applications before the current application due date.
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 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: Am I 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 for further details on the exclusion of specific dates for unannounced visits.
Self-assessment
Q: When do I have to submit my 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 tool?
A: Self-assessment is an active process to support improvement and should be updated on an ongoing basis rather than a task that is completed just for re-accreditation. It is a framework for the approved provider to evaluate and review the performance of the service in relation to the expected outcomes of the Accreditation Standards. This will also assist with updating the plan for continuous improvement of the service.
Q: Do we have to use the self-assessment template provided by the Commission ?
A: A self-assessment tool and other supporting information is available, however approved providers are not required to use the template provided. Self-assessment information must demonstrate the provider’s performance in relation to the service against the Accreditation Standards.
Q: What happens if my self-assessment does not demonstrate adequate information about the provider’s performance against the Accreditation Standards?
A: There is no standalone evaluation of the adequacy of the self-assessment. However, the Commission will provide the self-assessment to the assessment team conducting the audit. It forms part of assessment of the quality of care and services against the Accreditation Standards during the site audit.
Pre-audit feedback
Q: Would feedback prior to the site audit be counted as part of the Consumer Experience Report?
A: All relevant feedback received from care recipients or former care recipients by the Commission prior to the site audit will be provided to the assessment team conducting the audit. The assessment team must consider this information in conducting the audit.
The feedback is not included in the Consumer Experience Report (because the report relies on a random sample during the audit) but may be reflected in the site audit report. Only Consumer Experience Report interviews conducted during the site audit are reflected in the Consumer Experience Report.
Q: Can care recipients 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 care recipient or their representative that asks to meet with them during the site audit even if they have already provided feedback prior to the site audit.
Q: Do care recipients 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: Care recipients and their representatives are able to provide feedback anonymously or confidentially. If feedback is provided anonymously the Commission will not be provided with a name or contact details. If feedback is provided confidentially a name and contact details are provided to the Commission but are not disclosed to the relevant provider.
Callers will be requested to provide details of the aged care service so that information can be provided to an assessment team as part of a site audit.
Notifying care recipients and their representatives
Q: Why is the Commission asking questions about appointed guardians and advocates? The public guardian in our state never responds to our calls.
A: The Rules require approved providers to notify each care recipient and their nominated representative at the time of application about the audit process and again when the team arrives on site. This requirement extends to appointed advocates or guardians of care recipients.
Public guardian agencies are to protect adults who have a disability that impairs their capacity to make decisions and manage their affairs.
It continues to be the responsibility of the provider to notify 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.
The Commission is engaging with state based public guardians through a number of forums to share information and build closer relationships.
Q: Why is it the responsibility of the provider to inform care recipients and their representatives about you arriving on site?
A: Providers must take reasonable steps to inform care recipients and their nominated representatives that the site audit has commenced. This will need to 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 the provider. This poster will inform care recipients and representatives that the audit has commenced.
Reasonable steps may also include:
- informing care recipients while attending to their care
- sending care recipient representatives an email or text message to tell them that the audit has commenced
- in some instances, contacting individual care recipient 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 will need to enable care recipients and their nominated representatives who wish to meet with assessment team to do so privately. This includes providing the assessment team with details of care recipients 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 representative of a care recipient and by giving their contact details to the service.
Q: Can a provider send the care recipient/representative notification out in a newsletter?
A: Providers are required to give information in writing to each care recipient and their representatives using words provided by the Commission. The form of words includes information about the audit and advises care recipients and their representatives how to contact the Commission prior to the site audit.
In that context, the team will assess whether care recipients and their representatives have been made aware of the audit and whether reasonable steps have been taken to meet that requirement of the Rules. For example, if the form of words were included in a newsletter, is the provider able to demonstrate that the newsletter was provided to all care recipients and their representatives.
Q: Are we obligated to contact families on the day of an unannounced site audit to let them know about the visit that is about to take place?
A: Providers must take reasonable steps to inform care recipients and their representatives (including public guardians or advocates where applicable) that the site audit has commenced. This will need to occur as soon as practicable after the start of the audit.
Reasonable steps will be relative to the capacity of the service but must include displaying the poster that the assessment team gives the provider. This poster will inform care recipients and representatives that the audit has commenced.
Reasonable steps may also include:
- informing care recipients while attending to their care
- sending care recipient representatives an email or text message to tell them that the audit has commenced
- contacting individual care recipient 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 will need to enable care recipients and representatives who wish to meet with the assessment team to do so. This includes providing the assessment team with details of care recipients and representatives who have asked to meet with them.
Consent to enter
Q: What is the process for granting consent for an assessment team to enter premises for a site audit?
A: Upon arrival at the premises the assessment team will request consent to enter premises and exercise 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.
Q: Can consent be withdrawn during 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 Aged Care Quality and Safety Commission Act 2018. Failure to comply with that responsibility may result in a sanction being imposed on the approved provider under the Aged Care Act 1997.
If consent is withdrawn during a visit the assessment team must immediately leave the premises.
Site audit
Q: When will my site audit occur?
A: The Commission will conduct an unannounced site audit at any time between the submission of your application for re-accreditation and the expiry of the service’s period of accreditation.
Q: Will we be told how long the site audit will take place at the entry meeting?
A: During the entry meeting, the assessment team will give an indication of how many days they will be on-site. However this may change depending on circumstances of the service at the time of the 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 this means that a 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; and arrangement of interviews with staff and care recipients.
This approach enables the assessment team to be flexible and change its approach if required, to address any emerging issues or to accommodate the needs of the service, the availability of staff or to minimise disruption to care recipients.
Q: Will site audits only be conducted during business hours on weekdays?
A: 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: 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 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.
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.
It will be this 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 team to measure performance against the standards.
Q: What happens if our 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 audit. If we decide to not 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 we outsource to another company such as food preparation or laundry services?
A: The question the team will be asking is ‘what mechanism does the approved provider have in place to monitor and ensure the quality of those outsourced services’?
If it is necessary to follow a line of inquiry 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.
Q: On the day of an unannounced 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 care recipients of the service.
During the entry meeting the assessment team will explain how the site audit will be carried out and the process for the regular review of the site audit progress. The team will also determine any arrangements for information gathering such as the availability of staff and care recipients for interviews and the availability of documents and records, and how to access them. There will be an opportunity during the entry meeting for the person in charge to ask the assessment team questions about the site audit.
The person in charge is a key contact for the assessment team and this person may change throughout the site audit. Where there is a change in the person in charge, this should be advised to the assessment team.
Exit Meetings
Q: Will the assessment team provide any feedback before the exit meeting?
A: 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 potential problems are identified. The person in charge will have an opportunity to provide further information in relation to any matters raised by the assessment team.
If the person in charge does not understand a question, or why the assessment team is seeking or reviewing something, they should ask the team for clarification.
Q: Will the person in charge be told if there is a recommendation of ‘not met’ at the exit meeting?
A: No. An exit meeting will be held with the person in charge at the service on the last day of the site audit to communicate key issues that the team identified during the audit.
Importantly, there are no changes to audit methodology and the responsibility of the assessment team to discuss any concerns or deficits with the person in charge during the audit. Any issue presented at the exit meeting will have previously been identified and discussed.
The assessment team will continue to be objective and fair and will make their findings based on evidence gathered during the audit.
The full site audit report will be given by the assessment team to the Commissioner within 7 calendar days of the audit. A copy of the report will then be given to the provider as soon as practicable.
If the provider wishes to respond to the audit report they will have 14 calendar days to do so after they receive the report. The provider will have an opportunity to detail any concerns in its response to the team’s recommendations. That is the appropriate avenue for providers to raise concerns about process, evidence and findings.
The audit report and the provider’s response to the report, along with other relevant information, will be taken into account in making the accreditation decision by the Commission .
Q: Who can attend the exit meeting?
A: The assessment team must meet with the person in charge. The person in charge may choose to have other provider or care recipient representatives also attend the meeting.
Q: Will assessment teams be able to receive and consider additional information following the exit meeting once they have left the service?
A: It will depend on a number of factors including the type of information.
In certain circumstances, if there have been unforeseen difficulties locating information on the day(s) of the site audit it may be appropriate to give the provider an opportunity to submit that information to the team after they have left the site.
If it is information that the provider should reasonably have been able to locate and give to the team while on site (and when requested) then it is highly unlikely the team will accept that information after the exit meeting.
Note that the onus remains on the provider to demonstrate that it meets the Accreditation Standards.
The self-assessment provides an opportunity for providers to present evidence to the team prior to the site audit, in particular on governance and regulatory compliance. Each team is allocated time to review and consider the evidence in the self-assessment. This will be verified during the site audit.
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, care recipients 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 theCommission . 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 then 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 and may include contacting the provider to disclose the conflict – these options will not change with the move to unannounced.
Q: What should a provider do if the assessment team arrives for a site audit and a member of the 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 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. We have recently published a paper on our website called ‘The way we manage quality and safety’.
When assessing providers we are broadening our focus. As well as checking whether policies and procedures comply with the standards we are now focusing more on the quality of consumer experience as well as on the prevention of harm. This involves listening more closely to consumers, giving them better information and building our use of intelligence about services.
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 those receiving care from providers. Where care consumers are especially vulnerable, the Commission will seek greater assurance about their care and safety. Where we see issues or practices of concern, we will communicate it more broadly to the sector to enable providers to assess their own practices and proactively make improvements.