Table of Contents

How to Comply with the Aged Care Quality Standards

Welcome to Aged Care Essentials: Your Practical Guide to Aged Care Compliance and the Aged Care Quality Standards.

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How to Comply with the Aged Care Quality Standards

Introduction

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Aged care is now one of the most highly-regulated and rapidly-changing industries in Australia. And one of the busiest.

 

If you’re managing or involved in management of an aged care home your priority is caring for consumers, so it can be challenging to sort through all the latest news, guidelines, laws and requirements.

 

That's why we do the sorting for you.

 

Aged Care Essentials (ACE) provides up-to-date news, tips and how-to guides to help you understand and meet the Aged Care Quality Standards, Quality Indicators and other compliance requirements. And to keep things simple, we’ve laid out what you need to know in this one, easy-to-follow Aged Care Compliance Guide. See the next section for an overview of what's covered.

Before we dive in

Contents

This Aged Care Compliance Guide is laid out in eight simple sections to help you navigate through the aged care compliance process.

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1. Understanding the Aged Care Quality Standards, Quality Indicators and Compliance Requirements

  • It’s All About Consumer-Focused Care
  • Compliance Requirements Under the Aged Care Quality Standards
  • How the Aged Care Quality Standards Interrelate - How One Finding Can Result in Multiple "Not Mets"
  • How the Old Accreditation Standards Compare with the New Aged Care Quality Standards
  • Understanding the Aged Care Quality Indicators
  • Other Compliance Requirements and Resources

2. Self-Assessments

  • Tips for Writing Your Self-Assessment

3. Assessments and Site Visits

  • Unannounced Site Visits: Here’s What Assessors Say They’re Looking For
  • How Compliance will be Assessed
  • How to Manage Aged Care Assessment Contacts
  • What Happens if You Don’t Comply?

4. Governance, Risk-Management and Compliance (GRC): The Long-Term Solution

  • What is GRC and Why Does it Matter?
  • How to Create a Compliance Culture that Helps you Demonstrate Compliance
  • Open Disclosure Explained
  • Enterprise Risk Management in Aged Care

5. How to Keep up with Legislative Change – Aged Care Law Monitor Quarterly Report

  • What is Aged Care Law Monitor?
  • Request Your Copy

6. Infection Control/COVID-19 Resources

  • Infection Control Webinar
  • Infection Control Briefing Paper
  • Audit Tools for Facilities

7. Stay Informed with Aged Care Essentials (ACE)

  • ACE: Your Free Resource for Information and News on HOW to Meet Legal and Regulatory Requirements
  • Who is Behind ACE and How to Subscribe

8. Get Help with Meeting the Standards and Requirements

  • Solutions for Continuously Meeting the Requirements of the Standards

1.

Understanding the Aged Care Quality Standards, Quality Indicators and Compliance Requirements

How to Comply with the Aged Care Quality Standards

The Aged Care Quality Standards (the Standards) became mandatory on 1 July 2019. With their eight Standards and 40+ consumer-focused requirements, the Standards are not only new, they are complex. At the same time, the Aged Care Quality Indicators and other requirements have changed and expanded.

Providers and assessors have barely begun to understand the impact these developments will have on the aged care industry.

This section of the ACE Aged Care Compliance Guide aims to give you a broad understanding of the Aged Care Quality Standards, Quality Indicators and other requirements. We cover:

  • It’s All About Consumer-Focused Care
  • Compliance Requirements Under the Aged Care Quality Standards
  • How the Aged Care Quality Standards Interrelate
  • How the Old Accreditation Standards Compare with the New Aged Care Quality Standards
  • Understanding the Aged Care Quality Indicators
  • Other Compliance Requirements and Resources

 

It’s All About Consumer-Focused Care

The Aged Care Quality Standards are not merely an elaboration on existing requirements – they represent a deep shift in the story of aged care compliance. That story, along with the whole compliance system, now revolves around a single hero: the consumer.

The Aged Care Quality Standards put consumer-focused care front and centre by positioning Standard 1 “Consumer dignity and choice” as a “foundation Standard”, and by including a statement of “consumer outcome” in every Standard.

On top of this, the Aged Care Quality and Safety Commission (ACQSC) has indicated that when conducting assessments it will be looking for evidence of consumer-focus and consumer-involvement in all aspects of aged care. 

This increased focus on consumer care presents challenges for providers, including:

  • increased workloads
  • staff training (and retraining)
  • potential conflicts between consumer choice and consumer safety (dignity of risk issues)
  • legal liabilities
  • how to demonstrate consumer-focused care for the purposes of assessment.

ACE Tip: A good first step when implementing consumer-focused care is simply to talk to consumers. But you also want to be able to record what they say, so you can use it to make improvements and demonstrate compliance. For this reason, consider issuing and recording regular consumer surveys.

 

Compliance Requirements Under the Aged Care Quality Standards

As you can see from this infographic, when it comes to understanding the compliance requirements under the Aged Care Quality Standards, the first thing you need to know is that there’s a lot to know:

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Aged care providers are now required to comply with 42 separate requirements across the eight Aged Care Quality Standards. On top of this, the ACQSC’s Guidance and Resources for Providers to support the Aged Care Quality Standards (Guidance and Resources) sets out over 600 examples of actions and evidence that providers can use to demonstrate compliance with the 42 requirements.

This means there are over 600 individual actions and pieces of evidence that an ACQSC assessor might ask you about during an unannounced visit or at the time of a review audit. They might also ask you about any of the 214 reflective questions set out in the Guidance and Resources. Or the 204 workforce questions, the 150 consumer outcomes or the 217 organisational outcomes.

In short, the compliance requirements under the Aged Care Quality Standards are massively complex and require you to provide ACQSC assessors with a huge amount of up-to-date data immediately upon request.

ACE Tip: Complying with the Standards can seem like a daunting task but it doesn’t have to be. See our section on “Governance Risk and Compliance (GRC): The Long-Term Solution” for guidance on how to shift the heavy load of compliance off your overtaxed brain and onto a GRC system.

 

How the Standards Interrelate - How One Incident Can Lead to Multiple "Not Mets"!

Did you know that one adverse incident can lead to several findings of “not met”?

For example, a single incident of poor food quality may be seen by an assessor as a breach of Standard 4 (Services and supports for daily living), but if the consumer has clinical care needs associated with food it might also be a breach of Standard 3 (Personal care and clinical care). And if the incident involves the kitchen environment or staff behaviour then Standards 5 and 7 are also involved, as are 6 and 8 if poor food quality is an issue that has been raised before and not properly addressed. And don’t forget Standard 1, which underpins all the others!

As you can see from this chart, the Standards interrelate in complex ways:

 

Mapping Standards to Other Standards 2

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To make matters more difficult, there is a particularly complex relationship between the information your organisation collects (via feedback and complaints, incidents, audits, and self-assessment tools) and the way you use that information (for risk management, compliance and continuous improvement). This relationship simply cannot be managed through Excel spreadsheets and/or paper-based systems.

Manual systems are especially problematic for providers with multiple facilities. Not only are individual homes required to track, monitor and evaluate data, but these requirements extend across all facilities that are part of provider’s group. Consolidated reporting is required at the "group office" level in order to provide assurance to executive management and the provider’s Board of Directors.

ACE Tip: Use technology to capture, manage and report on the over 600 possible requests from Assessors during contact visits and more formal quality reviews.

 

How the Old Accreditation Standards Compare with the New Aged Care Quality Standards

The new Aged Care Quality Standards are now mandatory, so providers must ensure they have systems in place to meet the new requirements and demonstrate that they’ve met them. But this doesn’t mean you have to scrap all existing systems and start completely afresh.

The smart way to work is to pinpoint the similarities and differences between the old Accreditation Standards and the new Aged Care Quality Standards, so you can build on existing systems and knowledge and fill gaps as needed.

To help with this, we’ve developed a series of Mapping Matrix Tools for each of the new Aged Care Quality Standards. These tools map the old Accreditation Standards to the new Aged Care Quality Standards, allowing you to evaluate your current systems and practices systematically.

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Download the suite of ACQS Mapping Matrix Tools

 

The Aged Care Quality Indicators

All government-subsidised residential aged care services must abide by the National Aged Care Mandatory Quality Indicator Program. The purpose of the program is to measure certain aspects of the care services provided by aged care homes.

The program requires aged care providers to collect and provide data to the Department of Health in regard to these three “quality indicators”:

  • pressure injuries
  • use of physical restraint
  • unplanned weight loss.

According to the Department of Health, more quality indicators will be added in the future.

 

Other Compliance Requirements and Resources

The new Aged Care Quality Standards add to the existing aged care compliance regime, they don’t replace it. This means there’s still a raft of Commonwealth, state and territory laws that aged care providers must follow, including:

  • Commonwealth Aged Care Act 1997 - Aged Care Act 1997 (Cth), User Rights Amendment (Charter of Aged Care Rights) Principles 2019
  • Privacy Act - Privacy Act 1988 (Cth), Schedule 1, Australian Privacy Principles
  • State and Territory Mental Health Legislation
  • State and Territory Guardianship and Administration Legislation
  • State and Territory Enduring Power of Attorney
    and Medical Directive Legislation
  • State and Territory Work Health and Safety Legislation
  • Commonwealth Anti-discrimination Legislation
  • Fair Work Act 2009 (Cth)
  • Racial Discrimination Act 1975 (Cth)
  • Sex Discrimination Act 1984 (Cth)

ACE Tip:  See section 5 to learn more about Aged Care Law Monitor, a quarterly report designed to help Residential aged care facility leaders and boards keep up with legislative change.

2.

How to Manage Self-Assessments

How to Comply with the Aged Care Quality Standards

The ACQSC provides a range of resources to help providers demonstrate compliance with the Aged Care Quality Standards. One of the most important and least understood of these resources is the Self-Assessment Tool.

 

Tips for Writing your Self-Assessment

The ACQSC describes self-assessment as an “active process” that is linked closely to the development and planning of continuous improvement. Issues and opportunities for improvement that arise from the self-assessment should be included in the plan for continuous improvement (PCI).

So, is your self-assessment current and completed through an “active process” or does it require some attention?

For tips and guidance, check out our article on How to Use the ACQSC Self-Assessment Process to Your Advantage.

3.

How to Manage Assessments and Site Visits

How to Comply with the Aged Care Quality Standards

In our survey of the main challenges and concerns of aged care providers, unannounced site visits were top of the list, with one respondent likening them to “raids normally conducted for criminals.”

Even announced visits and other less-intrusive forms of assessment can provoke enormous stress in aged care staff. In this section we hope to lessen some of that stress by giving you practical guidance on:

  • Unannounced Site Visits: Here’s What the Assessors Say They’re Looking For
  • How Compliance will be Assessed
  • How to Manage Assessment Contacts
  • What Happens if you Don’t Comply?

 

Unannounced Site Visits: Here’s What Assessors Say They’re Looking For

The ACQSC is running a structured campaign of assessment contacts with aged care providers, with unannounced visits occurring 24/7. The ACQSC has announced through its Bulletin (issued January 2020) that its key areas of focus during announced and unannounced assessment contacts are known areas of risk, which may include:

  • a single Quality Standard, or a number of requirements of one or more of the Quality Standards, generally with the highest rates of non-compliance across teh sector
  • areas identified from previous assessments
  • in areas identified in response to the risk-based questions and responses at the entry meeting.

ACQSC assessors are questioning the Board, management and staff on current aged care industry developments (including the Aged Care Quality Standards) , their knowledge of these changes and what has been implemented to effect change within their Residential Aged Care Home.

Based on industry feedback, since 1 July 2019, some key areas of focus by ACQSC assessors from a practical perspective have been:

  • restraint management, in particular chemical restraint
  • infection control
  • education of staff, contractors, volunteers, contractors and board members
  • continuous improvement
  • the system to support consumers emotionally following an allegation of sexual assault
  • knowledge of the Aged Care Quality Standards.

ACE Tip: For more information on what Assessors are looking for, see our article: Aged Care Quality and Safety Commission –Themes from Assessor Visits.

 

How Compliance will be Assessed

The ACQSC website provides a huge amount of information on how the Commission will assess a residential care service’s compliance with the new Aged Care Quality Standards. But much of that information is scattered across multiple pages, so it’s not always easy to find what you need. That’s why we’ve done the searching for you and summarised the key points in this simple guide:

The New Aged Care Quality Standards: How Will Compliance Be Assessed?

 

How to Manage Assessment Contacts

Assessment Contacts are one of the most important tools that the ACQSC uses to monitor the quality of aged care services. Through Assessment Contacts the ACQSC Assessors collect and evaluate evidence to determine how well an Aged Care Home has complied with the Quality Standards.

Assessment Contacts can happen announced or unannounced, any time, any day of the week, and can cover any of the requirements in the Quality Standards. The prospect can be daunting and stressful, but these tips can help you feel a little more cool and confident:

How to Manage Aged Care Assessment Contacts Part 1: Preparing for the Entry Meeting

How to Manage Aged Care Assessment Contacts Part 2: Making the Most of your Human Resources

How to Manage Aged Care Assessment Contacts Part 3: What Evidence are Assessors Looking for?

 

What Happens if You Don’t Comply?

Given the scale, complexity and sheer unfamiliarity of the new Standards, some residential aged care services may not be able to comply. What happens then?

That question was put to Christina Bolder from the ACQSC during a Department of Health webinar on 6 June 2019. We’ve quoted and summarised the key points of her answer in this article, supplemented by information from the ACQSC website.

What Happens if You Do Not Comply with the New Aged Care Quality Standards?

4.

Governance, Risk Management and Compliance: The Long-Term Solution

How to Comply with the Aged Care Quality Standards

So far we’ve focused on immediate and basic concerns such as how to get your head around the new requirements and deal with assessments.

Isn’t that enough? Shouldn’t providers just tick the boxes and get the compliance stuff out of the way as quickly as possible so they can get on with the real business of caring for consumers?

No. Here are three reasons to stop thinking of compliance as an irritating chore and start seeing it as an integral part of your operations:

  • You can’t pass an assessment just by “ticking the boxes” – ACQSC assessors want to see whether you have adequate systems in place to continuously provide good outcomes for a diverse and dynamic group of consumers.
  • The more you integrate and systematise compliance, the easier it becomes.
  • Compliance is not separate from the business of caring for consumers. In fact, consumer care is better with a good compliance system.

 

This section introduces the concept of Governance, Risk Management and Compliance (GRC) and provides tips on how to build a strong GRC system and compliance culture that will make your life easier and improve outcomes for consumers. We cover:

  • What is Governance Risk and Compliance (GRC) and Why Does it Matter?
  • How to Create a Compliance Culture that Helps you Demonstrate Compliance
  • Open Disclosure Explained
  • Enterprise Risk Management in Aged Care

 

What is Governance, Risk Management and Compliance (GRC) and Why Does it Matter?

Governance refers to the operational systems and processes that control and monitor, or in other words "govern", an organisation. This is not a new area to the aged care industry - however, the Aged Care Quality Standards now contain a specific Standard related to this area: Standard 8 (Organisational Governance). 

Traditionally, the term "governance" is associated exclusively with corporate areas of an organisation such as finance, quality, workforce and regulatory compliance.

In the Aged Care Quality Standards, the meaning of "governance" needs to be widened to include an accountability for areas such as risk management, feedback and complaints and clinical governance.

For more information see our articles:

What's Governance got to do with It?

How to Meet Your Aged Care Governance Obligations Part 1 - Organisational Governance?

How to Meet Your Aged Care Governance Obligations Part 2 - Organisational Governance?

 

 

How to Create a Compliance Culture that Helps you Demonstrate Compliance

For each of the Quality Standards requirements, Quality Assessors from the ACQSC will be expecting organisations to demonstrate that they:

  • understand the requirement
  • apply the requirement
  • monitor how it’s being applied
  • review outcomes and adjust practices accordingly.

This article explores how to create a culture of compliance to help you meet these requirements:

How to Demonstrate that you Understand, Apply, Monitor and Continuously Improve ACQS Requirements.

 

Open Disclosure Explained

The Aged Care Quality Standards require aged care providers to have systems in place that support an "Open Disclosure" process for responding to incidents that cause harm, or potential harm, to a consumer.

Understanding the Open Disclosure process can not only help you meet the requirements of the Standards, it also provides a practical context in which to develop your understanding of consumer engagement more generally.

The ACQSC explains what Open Disclosure means in its 44-page Open Disclosure: Framework and Guidance. But if you don’t have time to read the whole guide, or need a quick overview before diving in, click here to read The Aged Care ‘Open Disclosure’ Process Explained in Five Points.

 

Enterprise Risk Management in Aged Care

Risks are a normal part of life in an Aged Care Home, and risk management is something that aged care staff do every day whether they realise it or not. Recording a dose of medication is risk management. So is training new staff and cleaning a kitchen.

But there are key differences between everyday, ad hoc risk management and Enterprise Risk Management (ERM).

ERM is an organisation-wide process that helps organisations predict future events that may impact (positively or negatively) on their activities, and take appropriate actions to address the impact of these events. Unlike ad hoc risk management, ERM is a proactive and strategic process that provides boards, management and staff with a common language and process to help them efficiently and collectively manage risk.

To learn more, check out Aged Care Homes and the Risk in Not Practising Enterprise Risk Management.

5.

How to Keep up with Legislative Change

Aged Care Law Monitor Quarterly Report

Aged Care Law Monitor is a quarterly report that summarises key legal, regulatory and compliance changes that affect the aged care industry.

The purpose of this report is to help aged care boards and leaders more effectively monitor the large number of laws, regulations, guidelines and codes that apply to aged care operations.

Aged Care Law Monitor is designed to be incorporated into an aged care facility’s board and executive reports and includes links to key reference material that will help you understand what your obligations are and how you can meet them. 

Aged Care Law Monitor is published by CompliSpace. CompliSpace-Make-it-Work-logo

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6.

Infection Control/COVID-19

Resources for Facilities

The combination of the current global pandemic situation, the continued need to deliver quality care and services to consumers, and continued need to comply with the Aged Care Quality Standards under the scrutiny of the Commission mean that Residential Aged Care Facilities are under more pressure than ever.

A recent Aged Care Essentials survey revealed that whilst all responding Residential Aged Care facilities had an infection control plan, over half wanted more information about creating a sustainable plan that considered other critical areas of operational risk and compliance.

We've put together a collection of resources to help you during these times.

 

Webinar Recording

In this Webinar, we covered:

  • How your COVID-19 infection prevention control systems – and outbreak management plan – relate to other key areas of operational risk and compliance
  • Which of these interrelated areas are most often missed by residential aged care facilities, and what are the potential risks and consequences
  • The role of active surveillance and risk management in identifying gaps and areas to improve
  • How to stay on top of change and adapt quickly to best practice updates and new legislative requirements.
  • How to efficiently and cost-effectively keep up with continual change so that your systems and processes produce the outcomes needed now and in the future

Request the Recording

 

COVID-19 Briefing Paper

The briefing paper outlines four key elements to include in your Home’s outbreak management plan:

  1. Prevent: Infection prevention, detection and control planning
  2. Prepare: Considerations include leadership, workforce management, training and competency, communication strategy and product supply management
  3. Respond: Developing your outbreak management plan
  4. Recovery: Evaluation once the outbreak has been contained

Request the Briefing Paper

 

Audit Tools

In our Webinar, we dicussed two helpful audit tools:

Download the Outbreak COVID-19 Preparedness Audit Tool

Download the Outbreak Management COVID-19 Audit Tool

7.

Stay Informed with ACE

How to Comply with the Aged Care Quality Standards

Aged Care Essentials is the go-to resource for Australian Aged Care Providers looking to understand HOW to meet their ever-changing and ever-increasing legal and regulatory obligations. 

ACE provides feature articles about this topic as well as a Weekly Wrap summary of relevant aged care articles published across Australia.

You will also find resources such as briefing papers, webinars and links to other resources produced by trusted industry organisations and leaders.

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Who is Behind ACE?

ACE is published by CompliSpace and Critical Success Solutions.

CompliSpace is an Australian company that specialises in helping organisations manage their legal and regulatory obligations. They serve clients in such industries as residential aged care, non-government schools, not-for-profits and financial services. CompliSpace are the publishers of Aged Care Essentials and Aged Care Law Monitor

Critical Success Solutions is an Australian company that provides expertise for all areas of an Aged Care facility including, management and operational business systems, mentoring, new Standards updates, audits, bootcamps, expert witness, training and education.

 

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8.

Get Help with Meeting the Standards and Requirements

How to Comply with the Aged Care Quality Standards

How to Get Help with Meeting the Aged Care Quality Standards and Other Requirements

Complying with the Aged Care Quality Standards and other requirements may seem like a daunting task, but there are products and services available to help you take control and get it done.

CompliCare is a one-stop solution for simplifying your risk, compliance and policy management so you can focus on caring for consumers. It gives you regularly updated, specialist aged care content via easy-to-use online tools. It’s a complete, ready-made system that helps you demonstrate that you have met your obligations and that you have firmly embedded compliance as an integral part of your organisational culture.

CompliCare

 

For more information go to Complicare