Infection Control Spot Checks in Residential Aged Care: What Providers Need to Know

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The Aged Care Quality Standards: How Will Compliance Be Assessed in 2020?

In our previous article we looked at the New Aged Care Commission Rules for 2020: Key Changes Providers Need to Know. That article summarised the key changes to the Aged Care Quality and Safety Commission (ACQSC) rules and procedures that came into effect on 1 January 2020.

This week, as promised, we take a closer look at Assessment Contacts, incorporating the latest changes into this one-stop-shop summary of how aged care compliance will be assessed in 2020.

 

Why Does Assessment Happen?

Assessment can happen:

  • as part of the accreditation or re-accreditation process
  • to assess a provider’s performance against the Aged Care Quality Standards (Standards)
  • to monitor the quality of care and services, and to decide whether further assessment is necessary
  • as part of a process to check in on a service’s progress or to help them comply or improve
  • if a service has requested reconsideration of a decision made against them
  • if the ACQSC suspects that a service is not complying with the Standards
  • if the Department of Health directs the ACQSC to conduct an assessment.

For more information, see our detailed section “Why Are Assessment Contacts Conducted” below.

 

When Does Assessment Happen?

Assessment for the purposes of re-accreditation will happen “as soon as practicable” after a service has lodged its application for re-accreditation.

Other forms of assessment can happen at any time. Assessors from the ACQSC may turn up at a service’s premises on weekdays or weekends inside or outside business hours. They may turn up with or without notice.

 

What Are the Different Kinds of Assessment?

The ACQSC uses many different terms when it comes to assessment.

 

Assessment Contact

This is a “catch all” term. It covers any kind of assessment except Site Audit, Review Audit and Quality Audit. It includes contact by phone and writing, and any visit to the service’s premises that is not comprehensive enough to qualify as a Site Audit or Review Audit.

Assessment Contacts are a critical and complicated aspect of assessment that has recently changed, so we will deal with them in a more detailed section below.

 

Quality Review/Quality Audit

The ACQSC uses these terms for reviews/assessments of home care services. The terms do not apply to residential care services.

 

Review Audit

“Review Audit” is the ACQSC’s term for “a Site Audit that is not part of the re-accreditation process.” A Review Audit assesses continuing performance against the Standards and reviews the service’s accreditation status. A Review Audit might occur if the ACQSC suspects a service is not complying with the Standards or if a service has requested reconsideration of a decision made against them. A Review Audit will result in a “Review Audit Report” that sets out the assessment team’s assessment of how well the service has met the requirements in the Standards.

 

Self-Assessment

As part of the re-accreditation process a provider must submit a Self-Assessment that demonstrates their performance, measured against the Standards. But the ACQSC may also request to see a provider’s Self-Assessment outside of the re-accreditation process. In fact, they may ask to see the Self-Assessment during any Assessment Contact, even one that doesn’t involve a visit to the service. So it’s worth having a completed Self-Assessment at hand at all times. For more information see our article: How to Use the ACQSC Self-Assessment Process to Your Advantage.

 

Site Audit

A Site Audit is an essential part of the re-accreditation process. It involves an assessment team visiting a service’s premises to make a comprehensive assessment of the service’s compliance with the Standards to determine if the service should be re-accredited. A Site Audit will result in a “Site Audit Report” that sets out the assessment team’s assessment of how well the service has met the requirements in the Standards.

 

What is an Assessment Contact?

The ACQSC defines an Assessment Contact as “any form of contact other than a Site Audit, Review Audit or Quality Audit”. Under the 1 January 2020 changes, the ACQSC clarified that its Assessment Contacts will now fall into one or both of these categories:

  • Assessment Contacts (Performance Assessment)
  • Assessment Contacts (Monitoring)

Here’s a quick breakdown of what these terms mean:

Assessment Contacts (Performance Assessment)

 

Purpose is to assess a provider’s performance against the Aged Care Quality Standards.
Will result in an Assessment Contact Report.

Assessment Contacts (Monitoring)

 

Purpose is to monitor the quality of a provider’s care and services.
Includes such things such as an ACQSC delegate attending a provider’s board meeting or calling them on the phone to discuss a performance assessment, plan for continuous improvement or a change in compliance expectations.
Also includes a visit by an ACQSC delegate to a service to conduct Consumer Experience Interviews (CEI).
Will not result in an Assessment Contact Report but could lead to a decision to conduct an Assessment Contact (Performance Assessment).

 

Why are Assessment Contacts Conducted?

The ACQSC might initiate an Assessment Contact for one or more of the following reasons:

 

Results from a Previous Audit or Assessment Contact

Where a provider was found to be non-compliant, the ACQSC may decide to conduct an Assessment Contact (Performance Assessment).

Where there were identified areas for improvement, the ACQSC may conduct an Assessment Contact (Monitoring) to ensure the provider is implementing their PCI.

 

The ACQSC has Received Information from a Complaint or Via Compulsory Reporting

Where the ACQSC receives information that suggests a risk of harm to consumers, they might conduct an Assessment Contact (Performance Assessment). If the information suggests a problem that does not involve risk of harm to consumers, the ACQSC might simply conduct an Assessment Contact (Monitoring).

 

As Part of a Broader Investigation to Address Systemic Risks Across the Sector

The Royal Commission in to Aged Care Quality and Safety, for example, identified several systemic issues, including the use of restrictive practices and psychotropic medications. Such issues are likely to be the focus of, and the prompt for, Assessment Contacts.

 

To Undertake Structured Consumer Experience Interviews (CEIs) and Reports

The ACQSC may undertake CEIs during an Assessment Contact for the purpose of monitoring compliance. At residential services, this will be in the form of an unannounced site visit. Where the ACQSC receives the prescribed minimum number of responses to a CEI, the results will be published on the ACQSC’s website.

 

There Have Been Legislative or Regulatory Changes

The ACQSC may conduct an Assessment Contact (Monitoring) to ensure providers have PCIs to meet the new compliance requirements

 

What to Expect with Assessment Contacts

Prior to Assessment Contacts

Assessment Contacts can be announced or unannounced and can occur outside of business hours or on weekends. Where the Assessment Contact is announced, providers are expected to notify consumers either verbally or by displaying a poster, provided by the ACQSC, in a prominent location within the Home.

The ACQSC will take a “risk-based approach” to decide the:

  • purpose(s) of the Assessment Contact
  • scope of the Assessment Contact
  • type of contact i.e. site visit or phone call
  • timeframe for completing the Assessment Contact.

 

Conducting the Assessment Contact

Assessment Contacts can come in many forms. They may involve site visits, emails, phone calls or visits by ACQSC regulatory officials to a provider’s management or board meeting. They may be conducted to obtain information or to discuss requirements or key issues. Where the ACQSC regulator officials do not visit a provider’s premises, they may still request documents or information relating to an Assessment Contact.

Where there is a site visit, the ACQSC assessment team will show their identification on arrival and request consent to enter the premises. They cannot enter without consent, and providers may refuse to give consent, withdraw consent at any time, or limit the consent to a certain period.

Providers should remember, and will be reminded by the assessment team, that they have a legal duty to cooperate with regulatory officials who are exercising their powers under the Aged Care Quality and Safety Commission Act 2018 (Cth) (Commission Act). Failure to comply with this duty can result in sanctions, such as revocation or suspension of accreditation. It is therefore unlikely providers can refuse consent without adequate reason.

If an Assessment Contact (Performance Assessment) is being conducted, an entry meeting will be held at the start of the visit. Providers are expected to make key documents available as soon as possible, and no later than within one hour of the conclusion of the entry meeting. Providers should have these documents pre-compiled and regularly updated so they are readily available, even when an unannounced visit occurs.

The assessors will then collect information to assess the service’s performance against the Standards. Information will be drawn from three potential sources of evidence:

  • interviews with consumers, visitors, staff and anyone else who is involved with the service
  • observation of the environment and staff interactions with consumers
  • review of documents and records.

The Commission Act gives extensive powers to ACQSC assessors, including the power to do any of the following during the visit:

  • search the premises and any thing on the premises
  • examine or observe any activity on the premises
  • take photographs or make any recording of the premises or any thing on the premises
  • inspect, examine, take measurements of, or conduct tests on, any thing on the premises
  • inspect any document on the premises
  • take extracts from, or make copies of, any such document.

Assessors can also ask any person on the premises to answer any questions and produce any documents or records. The way a particular assessment is conducted will differ in accordance with the new “Evidence Domains” that have been introduced to assist the ACQSC in deciding what kinds of evidence they will collect. We will provide further guidance on what occurs during site visits, and how to prepare for them, in a future article.

 

After the Assessment Contact

If an Assessment Contact (Performance Assessment) was conducted, the assessment team will produce an Assessment Contact Report. This report assesses a provider’s performance against the Standards and scores each requirement as either “Met” or “Not Met”.

It’s important at this stage to remember that the ACQSC Assessment team is different from the ACQSC Delegate. The Assessment team conducts the assessment, but it is the ACQSC Delegate who ultimately makes the decisions that affect providers.

Once the Assessment team have completed their Assessment Contact Report, they deliver a copy to the ACQSC Delegate and a copy to the provider. This report includes a deadline for the provider to submit a response before the ACQSC Delegate makes a decision (14 days after the report is received).

The ACQSC advises that when drafting a response, providers should stick to presenting factual information about the actions they’ve taken and the plans they’ve put in place to meet any unmet requirements. The ACQSC’s Regulatory Bulletin advises this information should be put in the form of a PCI.  

The ACQSC Delegate will then consider the Assessment Contact Report as well as the provider’s response and write a report setting out their decisions. This report is known as the Final Performance Report. It includes:

  • an assessment of the provider’s performance against the Standards, scored as either compliant or non-compliant
  • areas for improvement, where applicable
  • any other “relevant matters” (the ACQSC does not explain what this means).

If the Final Performance Report finds non-compliance, the ACQSC might decide to take “regulatory action”, which can include a direction to amend a PCI, a sanction or revocation of accreditation. A “risk-based and proportionate” approach will be taken to make this decision. 

From 1 July 2020, all Final Performance Reports will be published on the ACQSC website.

 

Summary of the Changes Made 1 January 2020

You can see an overview of all the key changes in our previous article, but for now here’s a short summary of the changes to the way the ACQSC deals with Assessment Contacts:

  • Assessment Contacts now fall into two categories: Assessment Contact (Performance Assessment) and Assessment Contact (Monitoring).
  • The ACQSC is no longer required to give written notice of an Assessment Contact.
  • New “Evidence Domains” have been introduced.
  • Any provider of any service can now be the subject of an Assessment Contact. That is, even previously accredited services that have had their accreditation revoked, but are still providing services, can be the subject of an Assessment Contact.
  • The ACQSC can now make a single Assessment Contact that covers all of a provider’s services.
  • New terminology has been introduced to clarify the different kinds of reports: “Assessment Contact Reports” are written by Assessment Teams; “Performance Reports” are written by ACQSC Delegates.
  • New publishing procedures have been introduced: from 1 January 2020, Performance Reports will be published on the ACQSC website following a Site Audit or a Review Audit; from 1 July 2020, Performance Reports developed following an Assessment Contact (Performance Assessment) or Quality Review will also be published on the ACQSC website.

 

Conclusion

This article is designed to incorporate the latest ACQCS updates into an easy-to-use summary of how the Aged Care Quality Standards will be assessed in 2020. In future articles, we will provide some practical tips on how to prepare for Assessments Contacts, including unannounced site visits.

For more information on what happens during Assessment Contacts, see our previous article on Themes from Assessor Visits.


About the Authors

Mark BryanMark B-1

Mark is a Legal Research Consultant at CompliSpace. 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.

Jennifer MaJennifer

Jennifer Ma is a Content Development Assistant at CompliSpace. She recently completed the Juris Doctor at the University of Sydney, and is currently completing her PLT to be admitted as a legal practitioner. She also has an undergraduate degree in Medical Science from the University of Sydney.

ACE Editorial Team
ABOUT THE AUTHOR | 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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