As the industry is no doubt aware, the Aged Care Quality and Safety Commission (Commission) has ramped up its regulatory activity in both residential and home care over the last few months. With unprecedented staffing shortages, many providers, including those with previously flawless compliance histories, are being found to be non-compliant with one or more of the Aged Care Quality Standards.
A finding of “Not Met” with any of the Quality Standards can trigger further regulatory powers and lead to sanctions, or in extreme cases, the revocation of accreditation or even approved provider status. As Notices of Non-Compliance are published, it can affect a providers’ reputation. It is important for providers to take any finding of non-compliance very seriously and do what they can to overturn the finding.
The importance of responding to a Report from a reputational perspective is even more critical due to the new proposed “Star Ratings” system which was announced on Wednesday under the Aged Care and Other Legislation Amendment (Royal Commission Response) Bill 2022.If this Bill is passed in its current form, the Department of Health will publish an overall rating, as well as a rating for each of the following categories.
- the existing quality indicators(these are medication management, pressure injuries, physical restraint, unplanned weight loss and falls and major injury)
- a homes compliance related to regulatory activities undertaken by the Aged Care Quality and Safety Commission (eg Site Audits).
- Consumer experience information to be collected from face-to-face interviews
- staff minutes of care.
These ratings will be made publicly available so that consumers can view a provider’s performance.
The aged care team at Russell Kennedy is regularly asked to help providers respond to the Commission so we want to share six of our top tips for what to do if you receive an adverse finding from an Assessment Team.
Tips for responding to a Assessment Team Report
1. Do a response
The first thing providers need to know is that you only get one chance to overturn a finding of “Not Met”, and that is by responding to the Assessment Team’s Report. Many providers assume that all they need to do is to provide a copy of the updated Plan for Continuous Improvement (PCI).
However that may not be sufficient. If the Assessment Team have assessed you as non-compliant with any of the Standards, this is your only chance to have it overturned. By the time the Performance Report is published it is too late to reverse a “Not Met” finding. The most you can then do is challenge the accreditation decision – eg by arguing for a longer period.
On occasions we have seen providers choose not to respond to an Assessment Team’s report at all. In our view, you should always respond to a Report, even if it is to simply acknowledge it and submit your PCI. It is important that you demonstrate to the Commission that you have taken the findings very seriously and have insight into your non-compliance.
2. Act quickly
The statutory timeframe for a provider to respond to an Assessment Team’s Report is 14 days. You should immediately start working on your response as soon as you receive the Report, particularly if there are multiple findings of non-compliance. Even better, if issues are raised by the Assessment Team during the Audit/review or exit meeting, you should immediately act to rectify these.
3. Make sure the Assessor’s Report is accurate
Do not just take the Assessment Team’s Report as gospel, have your team check every finding and example of non-compliance to make sure it is correct. We often find the Assessors make mistakes throughout the Report, sometimes these are minor and sometimes these are much larger inaccuracies. Ensure that what the Assessors have said is true, and in accordance with your policy. For example the Team might have found that a particular consumer should have been referred to a GP, whereas your policy says referral is only required after a certain amount of days.
At times, the Assessors can also make legal errors and it is important to identify and point these out.
However, bringing trivial mistakes to the Commission’s attention is not advisable as it can demonstrate a lack of insight. Significant mistakes are worth noting and could assist to overturn a “Not Met”.
Recently we have seen the Commission refer to 5-15 consumers throughout reports to provide evidence for a finding of non-compliance. It’s important to note that the Aged Care Quality and Safety Commission Rules 2018 specifically state that the Assessment Team must meet at least 10% of the consumers of the service, or their representatives. This is significant as it strengthens the Commission’s position to find your Service non-compliant. However, with an increased reference to multiple consumers, we have seen an increase in factual errors.
4. Rectify your areas of non-compliance by the time the response is due
In is important that you are able to demonstrate that the issues identified by the Assessment team have already been rectified, or there is at least a plan in place to rectify them. For example if the Assessment Team have observed that consumers’ care plans were out of date, make sure they are updated by the time you submit your response.
This will likely include planned education for your staff. Make sure you are able to provide details as to what that training would entail and how you will roll that training out.
5. Make sure your PCI is realistic
Where the Assessors find lots of issues, the temptation for providers is to commit to a huge list of improvements in their PCI. Whilst your PCI needs to be comprehensive, it also needs to be realistic and achievable. There is no use going to great lengths to overturn the Commission’s findings only to then be unable to fulfil your PCI. Be aware that the Commission may follow up once the timeframes in your PCI have elapsed and ask you to provide evidence of completion.
As such it is important that you set realistic deadlines for competition of the PCI and keep track of its progress. It is also prudent to maintain records that your PCI action items have been completed.
6. Apply your improvement across you entire organisation
For providers with multiple homes or service outlets, being found non-compliant in one site or outlet can lead to non-compliances at others, particularly if there are issues found in relation to Standard 8 – Governance. The improvements you implement in response to an Assessment Team’s Report should be applied to all other homes/outlets. Not only will this reduce the likelihood of further findings of non-compliance, but it also demonstrates your commitment to continuous improvement.
How we can help
Please contact Victor Harcourt, Anita Courtney, Johanna Heaven, and Matthew Goessler or any member of our Aged Care Team for assistance.
If you would like to keep up to date with Alerts, news and Insights from our aged care team, you can subscribe to our mailing list here.
Other useful resources
Key Personnel obligations for all approved aged care providers take effect 1 December 2022
Russell Kennedy Key Personnel Package of Documents: Russell Kennedy has developed a range of resources that approved providers can purchase individually or as a pack to ensure compliance with the new requirements of key personnel. We have a Key Personnel Suitability Matters Information and Assessment Form and Guide to assist with gathering and assessing the information. We have letters and guides for key personnel explaining the changes, the regulatory context and their key obligations. We have also developed a template policy, as well as clauses for agreements and contracts.
Download our flyer here to find out about the key personnel package, and email rkagedcare@rk.com.au to find out about pricing and to purchase all or any of the resources available.