Aged Care Law Monitor January 2021: A Tool to Help you Stay Up to Date with Legal Changes

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Aged Care Compliance: The Most Common Reasons for a Finding of "Not Met" by the ACQSC

This week, with the help of Critical Success Solutions (CSS)*, ACE has gathered on-the-ground information from Aged Care Providers on their first-hand experiences with Aged Care Quality and Safety Commission (ACQSC) Assessment Contacts.

Based on these findings we’ve compiled this list of the common reasons for a finding of “not met” in regard to each of the Aged Care Quality Standards (Quality Standards).

*Critical Success Solutions is an Australian company that helps businesses, including residential aged care homes, access fresh and innovative approaches to business quality and system solutions.


Standard 1 – Consumer dignity and choice

Common reasons for a finding of “not met” included:

  • Diversity and inclusion: no diversity plan or demonstrated commitment to diversity.
  • Pre-admission communication and orientation: no conversation with the consumer in the pre-admission process regarding the Quality Standards. No formal process for consumer orientation. Charter of Aged Care Rights not read/understood/signed by all consumers.
  • Consumer preferences: care staff not understanding the consumers’ likes/dislikes/who they are and their preferences.
  • Consumer choice: team members not explaining daily tasks and events to consumers. Consumers with capacity not included in making decisions related to their care or preferences and not signing their own documentation and consent forms.
  • Privacy: private information being left in unsupervised areas.


Standard 2 – Ongoing assessment and planning with consumers

Common reasons for a finding of “not met” included:

  • Consumer preferences and choice: limited input from consumers on their care plans and risk assessments, including consumers not approving or signing off on initial care plans and services or subsequent reviewed plans.
  • Poor care and service planning documentation: documentation that is not “consumer goal” orientated, not readily accessible to consumers or their representatives, and not up to date.
  • Palliative care and end of life: advanced care/health directives not in place or reviewed in line with changed consumer needs and preferences. Management of personal care and clinical care at end of life not satisfactory and not reflected in the individual consumer’s care and services plan.
  • Clinical directives: complex health care directives not always signed by RN. Not all directives considered and in place,for example, diabetes management including BGL assessment, and infection control e.g. MRSA or VRE management.
  • Post hospitalisation review: no post hospitalisation review in place. Unable to demonstrate changes in care post hospitalisation.


Standard 3 – Personal care and clinical care

Common reasons for a finding of “not met” included:

  • Best practice and tailored care: leadership team and RN unable to demonstrate how they are informed of changes to best practice, legislation and regulation changes, including how relevant documents are updated and how staff are informed.
  • High prevalence and high impact risk: clinical leadership team and RNs not able to identify the high impact or high prevalent risk areas as stated in the ACQS guidance and resources. Clinical risks not effectively monitored and actioned through the clinical indicator program and clinical governance framework.
  • Nutrition, hydration, weight, choking and dysphagia: not identifying risks and deterioration associated with dysphagia and choking. International Dysphagia Diet Standardisation Initiative (IDDSI) not understood or implemented. Insufficient process to monitor and manage weight loss effectively.
  • Restraint and behaviour management: not identifying relevant psychotropics as chemical restraints. No regular review of restraints and restrictive practices. No risk assessments for restraints including bedrails, bed against wall, lo-lo beds. Inappropriate use of emergency restraint processes. RNs and clinical leaders not aware of restraint legislation. Poor external reporting and poor use of external agencies to assist in the management of behaviour. Staff not identifying and assessing unmet needs (eg boredom) of consumers.
  • Pain: staff not properly recognising, reporting and recording consumers in pain. Pain treatment not properly monitored and reviewed.
  • Wound management: cross contamination occurring due to poor infection control practices. The wound trolley not being set up correctly. Referrals not being made to external specialists. Wound swabs not collected. Many simple wounds not healed within four weeks.
  • Medication: not undertaking best practice right checks prior to medication administration. Consumer photos not updated annually. Medications missed or not administered not treated as incidents and no evidence of follow up or closing out. Staff dispensing medication without the medication chart.
  • Delivery of care: Staff are “rushing”, remain task orientated rather than person-oriented. Consumers left in bed too often (including during meals) rather than getting out and sitting in a chair.
  • Infection control and anti-microbial stewardship:
    • No designated Outbreak Coordinator or lack of training when Coordinator is assigned role.
    • Vaccination requirements not communicated to staff, consumers, health professionals.
    • No consent obtained for vaccination or vaccination records.
    • Non-accredited RNs administering vaccinations.
    • Non-compliant cold chain management of vaccinations.
    • No formalised process of monitoring and analysis of infection data. Inadequate preparedness for the management of COVID-19 outbreak.
    • Unable to describe or provide evidence as to how antimicrobial stewardship (AMS) procedures have impacted antibiotic prescribing, training for RNs or communication and education for consumers.
    • Ineffective education on AMS – Leadership and staff unable to define AMS.
    • Staff not understanding best practice infection screening processes.
    • No system for allied health and hospitality staff to be informed where consumers have an infection, e.g. MRSA, VRE.
    • No thorough investigation of deaths that have occurred during an outbreak, i.e. use of Root Cause Analysis.
    • No evidence of debriefing or review meeting post outbreak.
    • No evidence of staff training education provided during outbreak.
    • Poor PPE management and practices– poor application and no competency-based assessments
    • Staff observed not following standard precautions for isolated consumers despite signage.


Standard 4 – Services and supports for daily living

Common reasons for a finding of “not met” included:

  • Social and wellbeing: Lifestyle plan not tailored to consumer preference. No cultural days where specific to individual consumers. Lifestyle program has no budget allocation.
  • Cleaning: no evidence to show any preferences regarding how consumers are involved in or asked how often they would like their room cleaned. No system in place to communicate to auxiliary staff that consumers are palliating or at end of life and are not to enter a room.
  • Laundry: no systematic process for labelling clothes. Evidence of large amounts of lost property. Poor laundry cleaning process. Laundry cleaning system not evident .
  • Meals and Dining: no evidence of flexible mealtimes. No clear system for considering where someone is absent from the Home’s dining area, has not received a meal service and/or needs a meal. Insufficient variety and consumer choice. Poor food presentation – food bland and cool when provided to consumers.

Standard 5 – Organisation’s service environment

Common reasons for a finding of “not met” included:

  • Service environment: poor air flow and poor regulation of temperature, especially in older buildings. Access to outside areas restricted – consumers unable to access freely and staff unable to evidence how consumers are supported to access outdoor areas (unless the consumer requests). Design principles not considered for consumers living with dementia.
  • Safe environment: contractor management system not in place or not accessible from site. Poor turnaround time in completing reactive maintenance tasks. Business Continuity Plan not in place and/or not tested annually. Preventative maintenance records – no records and no evidence of follow up when contractors do not undertake preventative service. Environmental hazards not identified in internal audits.
  • Fire, evacuation and emergency: fire equipment and fire doors obstructed with linen skips, lifters or purposely kept open by contractors undertaking building works.
  • Equipment: no program on admission and/or ongoing for consultation with the consumer by the Home regarding the maintenance, servicing and cleaning of their equipment. Ineffective program to maintain consumer equipment. No assessment for consumers in electric wheelchairs or using mobility devices, no information provided to the consumer regarding their responsibilities

Standard 6 – Feedback and complaints

Common reasons for a finding of “not met” included:

  • Education, training and competence: leadership and staff not clear about the meaning and practices of open disclosure. No education of management and staff in relation to complaints and open disclosure. Advocacy poorly understood by management and staff.
  • Analysis: no trending or analysis of complaints and no understanding of the themes from complaints. No follow up of effectiveness of actions following any analysis.
  • Records: no evidence in records of the use of open disclosure.


Standard 7 – Human resources

Common reasons for a finding of “not met” included:

  • Education, training and competence: staff having poor knowledge and understanding of ACQSC. Education not reflective of best practice or Quality Standard requirements.
  • Staffing: consumer feedback stating that workforce numbers are insufficient, staff are rushed and not sufficiently skilled. No evidence of a workforce plan.
  • Recruitment and orientation: no evidence of orientation or induction such as a checklist or designated program. No evidence of reference checks.
  • Monitoring of the workforce: performance appraisals not completed within annual timeframe. No system for regular review of contractors and volunteers. Poor contractor non-compliance management.


Standard 8 – Organisational governance

Common reasons for a finding of “not met” included:

  • Consumer consultation: no clear evidence of consultation and outcome/improvement as a result of consumer engagement.
  • Organisational governance: no clear evidence of Board monitoring to ensure evidence of consumer consultation or where applicable, receiving feedback from consumers. Poor reporting systems to the Senior Leadership Team and Board – no formal monthly report to indicate areas of risk, operational issues etc. Board has poor understanding of the Quality Standards and their accountability.
  • Workforce governance: no workforce plan or is not specific to aged care; or has not been implemented. No evidence of review of the workforce plan.
  • Risk management: no process to complete the risk-based questions and leaders not able to provide clear data and process regarding risks. No risk management education – poor understanding by management and staff. No organisation and/or local risk management plans.
  • Continuous improvement and quality: no system to action and close out non-compliant issues or areas for improvement, including surveys and audits. Continuous Improvement Plan not current. No link from complaints and incidents to continuous improvement to demonstrate system improvements that have occured. No trending and analysis of quality data or clinical data.
  • Regulatory compliance: policies and procedures not current/ not in place/ not updated in a timely manner. Leaders not able to evidence the system for receiving and actioning regulatory compliance updates. No consideration of changes in legislative requirements eg. restraint/ restrictive practices. Providers not meeting regulatory compliance requirements due to COVID-19 demands which have impacted on their time and resources.
  • Clinical governance: Leaders not aware of how the clinical governance process works within the Home/organisation and how clinical issues are escalated from Home level to Board/Executive level. Clinical governance framework not in place. Inconsistencies in monthly reports and the management of national clinical indicator reporting.


About the Authors

Critical Success SolutionsCSS-01-01

Critical Success Solutions is a wholly owned Australian company that was established in July 2002. Critical Success Solutions was developed in response to an identified need for businesses to be able to access fresh and innovative approaches to business quality and system solutions.

Mark BryanMark-B-2

Mark is a Legal Research Consultant at CompliSpace and the editor for ACE. Mark has worked as a Legal Policy Officer for the Commonwealth Attorney-General’s Department and the NSW Department of Justice. He also spent three years as lead editor for the private sessions narratives team at the Royal Commission into Institutional Responses to Child Sexual Abuse. Mark holds a bachelor’s degree in Arts/Law from the Australian National University with First Class Honours in Law, a Graduate Diploma in Writing from UTS and a Graduate Certificate in Film Directing from the Australian Film Television and Radio School.

ACE Editorial Team
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. Critical Success Solutions is an Australian company that specialises in helping Aged Care and Disability Services manage their regulatory and legal requirements.

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