Accreditation Grant Principles 2011

EXPLANATORY STATEMENT

Issued by the authority of the Minister for Mental Health and Ageing

Aged Care Act 1997

The Aged Care Act 1997 (the Act) provides for the regulation and funding of aged care services.

Subsection 96-1(1) of the Act allows the Minister to make Principles providing for various matters required or permitted by a Part or section of the Act. Among the Principles made under subsection 96-1(1) are the Accreditation Grant Principles.

The Accreditation Grant Principles 1999 describe the role of the Aged Care Standards and Accreditation Agency Ltd (the accreditation body) which is the body corporate paid an accreditation grant for the purpose of accreditation of residential care services in accordance with the Principles.

The functions of the accreditation body include:

managing the accreditation process using the Accreditation Standards;
promoting high quality care, and helping industry to improve service quality, by identifying best practices and providing information, education and training to industry;
assessing, and strategically managing, aged care services working towards accreditation; and
liaising with the Department of Health and Ageing about services that do not comply with the standards applicable to them.

A recent review of the accreditation process (including the Accreditation Principles) found that amendments to the Accreditation Grant Principles 1999 would be desirable in order to:

remove or amend outdated provisions;
streamline the accreditation process;
make the Principles more logical, consistent and better able to be understood;
enhance consumer engagement; and
provide greater clarity and consistency of administrative processes.

Following consideration of the review and further consultation regarding proposed amendments to the Principles, new Principles have been developed to take effect from 20 May 2011.

Given the extent of the changes proposed, these Principles repeal and replace the existing Accreditation Principles with an entirely new set of Principles (Accreditation Grant Principles 2011).

The purpose of the Accreditation Grant Principles 2011 is to remove or amend outdated provisions; improve readability; streamline the accreditation process for industry; enhance consumer engagement; and provide greater clarity and consistency of administrative processes.

Consultation

In March 2008 the Government announced a comprehensive review of the accreditation process and accreditation standards.

In relation to the accreditation process, an issues paper was developed to facilitate discussion about the Accreditation Grant Principles 1999. This issues paper formed the basis of a public consultation process to provide all stakeholders with an opportunity to comment on the existing accreditation process and suggest changes for the future. In response, 147 submissions were received from a range of aged care stakeholders including peak industry and consumer groups, trade unions, approved providers, aged care services, and from individual practitioners, staff, residents and relatives.

In 2009-10, the findings of the review process were considered and further consultation occurred. A paper on various options for enhancing the accreditation process was distributed to the Ageing Consultative Committee (ACC) in March 2010. The ACC includes industry and consumer representatives. Following consideration of comments raised by the ACC, a further consultation paper (outlining the proposed changes to the Accreditation Principles) was developed and provided to the ACC in July 2010. As a result of valuable feedback, some further refinements were made to the proposals and presented to the ACC in November 2010 and again in March 2011.

The changes outlined in the Accreditation Grant Principles 2011 are consistent with the outcomes of the review, consultation with the sector and consumer groups, and supported by the ACC.

The Accreditation Grant Principles 2011 commence on 20 May 2011.

The Principles are a legislative instrument for the purposes of the Legislative Instruments Act 2003.

ATTACHMENT

Details of the Accreditation Grant Principles 2011

The Note at the beginning of the Accreditation Grant Principles summarises the matters dealt with in the Accreditation Grant Principles.

The Principles set out the procedures to be followed, and the matters to be taken into account, by the Aged Care Standards and Accreditation Agency Limited (the accreditation body) for accreditation of residential care services, the accreditation body’s responsibilities for services that have received accreditation, and the conditions to which the accreditation grant is subject.

Part 1 Preliminary

Section 2.1 – Name of Principles

This section states the name of the Principles which is the Accreditation Grant Principles 2011.

Section 2.2 – Commencement

This section provides that the Principles commence on 20 May 2011.

Section 2.3 – Revocation

Section 2.3 states that the Accreditation Grant Principles 1999 are revoked. These Principles describe the previous accreditation and re-accreditation process, and are to be replaced with the revised accreditation and reaccreditation process described in the Accreditation Grant Principles 2011.

Section 2.4 – Definitions

This section provides definitions for various words and terms used in the Accreditation Grant Principles 2011. Definitions of note include:

‘assessment contact’. This term replaces the term ‘support contact’. The new terminology and definition better reflects the purpose of the contact and the accreditation body’s role in monitoring, assessing performance and providing assistance through education and continuous improvement. An assessment contact may be announced or unannounced;
‘plan for continuous improvement’. This term refers to a written plan that explains how the approved provider will meets its obligations for continuous improvement under the Accreditation Standards and in relation to any areas identified by the accreditation body as areas in which improvements are needed to meet the Standards;
‘review audit’. A review audit is an audit of the accreditation service conducted at the premises of the service. Other matters, such as writing up the review audit report, occur off site after the on-site visit is completed.

A number of expressions used in these Principles are defined in the Aged Care Act 1997 (such as approved provider and residential care).

Section 2.5 – Commencing service

The purpose of this section is to define ‘commencing services’. The Principles distinguish between ‘commencing services’ and ‘accredited services’ because the process for accreditation differs depending on whether the service is a new or existing service. In summary, commencing services are those that have been allocated places but that are not accredited by the accreditation body and have not previously provided residential aged care for the places at the service.

Section 2.6 – Decisions made by accreditation body

This section provides that a decision made by either the chief executive officer of the accreditation body, or an employee of the accreditation body authorised by the chief executive officer, is taken to be a decision by the body.

Similarly, where these Principles require the accreditation body to be satisfied about a matter, it is sufficient that either the chief executive officer, or an employee of the accreditation body authorised by the chief executive officer, is satisfied about the matter.

Part 2 – Applications for accreditation of commencing services and
re-accreditation of accredited services

Section 2.7 – Purpose of Part 2

This section describes the purpose of the Part. Part 2 sets out how an application is made for accreditation of a commencing service or re-accreditation of an accredited service.

Section 2.8 – Application of Part 2

This section confirms that Part 2 applies to both approved providers for commencing services seeking accreditation of a service and accredited services seeking
re-accreditation.

Section 2.9 – Application for accreditation or re-accreditation

Section 2.9 provides that an approved provider may apply in writing for accreditation of a commencing service or re-accreditation of an accredited service by the accreditation body.

Section 2.10 – Valid application for accreditation or re-accreditation

Section 2.10 sets out the requirements for valid applications. In summary, an application is valid if it:

is made in the form decided by the accreditation body. The approved form will be made available to approved providers;
is accompanied by the appropriate fee (application fees are described in section 2.12); and
includes an undertaking by the approved provider to undertake continuous improvement, measured against the Accreditation Standards, if the service is accredited or re-accredited.

The application may also be accompanied by self-assessment information, however, this is not mandatory. ‘Self assessment information’ is written information that demonstrates the approved provider’s performance against the Accreditation Standards. This information must be given to the accreditation body either as part of the application or prior to, or during, a site audit.

Section 2.11 – Acceptance of valid application

Section 2.11 provides that the accreditation body must not accept an application unless it is a valid application. As noted in relation to section 2.10, a valid application is one that is in the correct form, accompanied by the correct fee and includes an undertaking from the approved provider about continuous improvement against the Accreditation Standards.

Section 2.12 – Application fees

Section 2.12 sets out the fees payable for an application for various accreditation services. Broadly speaking, the amount of the fee is determined by the number of places allocated to the service.

Section 2.13 – Indexation

Section 2.13 provides for Consumer Price Index increases to the amounts payable under section 2.12 from 1 July each year. The first increase of each indexable amount is on 1 July 2011.

Part 3 – Assessment and decision – accreditation of commencing services

Section 2.14 – Purpose of Part 3

This section provides that the purpose of Part 3 is to set out how a decision is to be made on an application for accreditation of a commencing service.

Section 2.15 – Application of Part 3

Section 2.15 provides that Part 3 applies to valid applications made under section 2.9 for accreditation of a commencing service.

Section 2.16 – Accreditation decision

Section 2.16 sets out what the accreditation body must do once it receives an application in relation to a commencing service.

In summary, within 16 days of receiving the application (or such longer time as is agreed between the accreditation body and the approved provider), the accreditation body must decide whether or not to accredit the commencing service.

In making the decision, the accreditation body must take into account the application, any relevant information provided by the Secretary, and whether the approved provider will undertake continuous improvement, measured against the Accreditation Standards, if the service is accredited.

The body may also take into account any other relevant matters.

The accreditation body must record its decision about the application and the reasons for the decision.

Section 2.17 – Decision to accredit

This section provides that if the accreditation body decides to accredit the commencing service, it must accredit the service for 12 months.

The accreditation body must also decide whether there are any areas in which improvements must be made by the approved provider in order to meet the Accreditation Standards and the arrangements for assessment contacts. Assessment contacts are defined in section 2.4. In summary, assessment contacts are any form of contact (other than a site or review audit) between the accreditation body and the approved provider for the purpose of: assessing the performance of the provider against the Accreditation Standards; assisting the provider with continuous improvement; identifying the need for a review audit; or giving the provider information or education about accreditation.

The accreditation body must record its decision regarding each of the matters detailed above.

Part 4 – Assessment and decision – re-accreditation

Division 1 – Purpose and application of Part 4

Section 2.18 – Purpose of Part 4

This section provides that the purpose of Part 4 is to set out all the information relating to the procedures for decisions on applications for re-accreditation of an accredited service.

Section 2.19 – Application of Part 4

Section 2.19 states that Part 4 applies to valid applications made under section 2.9 for re-accreditation of an accredited service.

Division 2 – Site audit

Section 2.20 – Action on receipt of valid application

Section 2.20 sets out what must be done by the accreditation body on receipt of a valid application. The section requires that as soon as practicable after receiving the application, the accreditation body must create an assessment team to undertake the site audit of the accredited service and prepare a site audit report. The accreditation body is also required to consult with the approved provider about when the team will undertake the site audit.

Section 2.21 – Notification of site audit

This section provides that within 28 days after receiving the application, the accreditation body must tell the approved provider the date/s for the site audit and the full names of each member of the assessment team. The members of the assessment team must meet the eligibility criteria (set out in section 2.37) and the approved provider may object to the appointment of a person to the team if the person does not meet the eligibility criteria (refer section 2.40).

To facilitate increased consumer involvement in the accreditation process, the accreditation body must also give the approved provider:

a form of words to be used to notify residents of the site audit; and
a poster that must be displayed by the approved provider in a prominent place or places within the service. The purpose of the poster will be to inform residents about the site audit and the fact that they may provide information to the accreditation team as part of the site audit.

Section 2.22 – Approved provider must tell residents about site audit

This section outlines what the approved provider must tell residents about the site audit. The section provides that after being told by the accreditation body when the site audit will start, the approved provider must, at least 21 days before the start of the site audit, take all reasonable steps to ensure that residents (or their representatives) are aware that:

a site audit of the service will be carried out (in other words, when the site audit is proposed to start and finish); and
they will have an opportunity to talk to members of the assessment team.

In order to ensure that residents and their representatives are aware of the site visit, the approved provider must, as a minimum:

provide written information about the site audit to each resident or their representative, including any specific wording provided by the accreditation body; and
display copies of the poster provided by the accreditation body in a prominent place or places within the residential care service.

If the applicant is provided with less than 21 days notice of the site audit, the approved provider must take the steps mentioned above as soon as possible after being told of the date.

Section 2.23 – Self-assessment information

This section outlines the requirements for the provision of self-assessment information. The section provides that the approved provider must, prior to or during the site audit, give the assessment team written information that demonstrates its performance, in relation to the accredited service, against the Accreditation Standards.

Section 2.24 – Undertaking site audit

Section 2.24 provides that the assessment team must undertake a site audit of the accredited service in accordance with any directions given to the assessment team by the accreditation body.

In carrying out the site audit, the assessment team must:

act consistently with any provisions of the Accountability Principles applying to the audit;
assess the quality of care and services provided at the service against the Accreditation Standards;
consider any information about the quality of care and services at the service, given by a resident or former resident (or by their representatives);
consider any relevant information received from the Secretary about the approved provider; and
consider any information received from the approved provider, including its
‘self-assessment information’.

Section 2.25 – Site audit meetings

This section sets out the requirements for site audit meetings. These requirements include that:

the assessment team must meet with the approved provider daily during the site audit to discuss the progress of the audit; and
the assessment team must meet at least 10% of the residents of the service (or their representatives) to discuss the care and services they are receiving.

If a resident (or their representative) asks to meet the assessment team during the site audit, the approved provider must allow the team to meet the person privately.

Section 2.26 – Report on major findings

Section 2.26 sets out the requirements for the report of major findings. The section provides that the assessment team must, on the last day of the site audit, give the approved provider a written report detailing the major findings of the site audit.

The approved provider may, within 14 days after receiving the report, give the accreditation body a written response to the report.

Section 2.27 – Information to be given to accreditation body

Section 2.27 provides that the assessment team must give the accreditation body a copy of the report on major findings and the site audit report, within 14 days of the last day of the site audit.

This site audit report must include an assessment of the approved provider’s performance against the Accreditation Standards and may also include any other matters the assessment team considers relevant.

Division 3 – Decision on application for re-accreditation

Section 2.28 – Re-accreditation decision

This section requires the accreditation body to decide, within 28 days of receiving the site audit report (or such later time as is agreed between the body and the approved provider), whether or not to re-accredit the service.

In making the decision, the accreditation body must take into account:

the site audit report;
any information received from the approved provider in response to the report of major findings given to the approved provider (see section 2.26);
any information received from a resident, or former resident of the accredited service;
any relevant information about the approved provider given by the Secretary; and
whether it is satisfied that the approved provider will undertake continuous improvement, measured against the Accreditation Standards, if the service is
re-accredited.

The body may also take into account any other relevant matter.

The body must record its decision about the application and the reasons behind the decision.

Section 2.29 – Decision to re-accredit

Section 2.29 provides that if the accreditation body decides to re-accredit the service, it must also decide:

the further period for which the service is to be accredited;
whether there are any areas in which improvements must be made to meet the Accreditation Standards; and
the arrangements for assessment contacts. Assessment contacts are defined in section 2.4 of the Principles. Essentially an assessment contact is any form of contact (other than a site or review audit) between the accreditation body and an approved provider for the purposes of: assessment of performance against the Standards; assistance with continuous improvement; identifying whether a review audit is required; or giving the approved provider information or education about the accreditation process and requirements.

The accreditation body must record its decision. The important details of the decision are communicated to the approved provider (and the Secretary) in accordance with Part 5.

Section 2.30 – Decision not to re-accredit

This section provides that if the accreditation body decides not to re-accredit an accredited service, it must decide:

whether there are any areas in which improvements to the service would be necessary to meet the Accreditation Standards; and
the arrangements for assessment contacts. As noted in relation to section 2.29, assessment contacts are contacts between the accreditation body and the approved provider, other than site or review audits.

As for decisions to accredit, the accreditation body must record its decision not to
re-accredit. It must also notify the approved provider and the Secretary of its decision in accordance with Part 5.

Section 2.31 – Decision to revoke existing accreditation

This section describes the circumstances in which the accreditation body may decide to revoke the existing accreditation of an approved provider (in relation to a service).

Section 2.31 provides that if the accreditation body decides not to re-accredit an accredited service, the body may also revoke the service’s existing accreditation.

If the body decides to revoke the existing accreditation it must also decide the date on which the revocation takes effect. Part 5 sets out the requirements for notifying the approved provider and the Secretary of the revocation decision.

Part 5 – Notification of decision on application for accreditation or
re-accreditation

Section 2.32 – Purpose of Part 5

Section 2.32 provides that the purpose of Part 5 is to describe how the accreditation body must notify the approved provider, and the Secretary, of its decisions on applications for accreditation or re-accreditation.

Section 2.33 – Notification of decision to accredit or re-accredit

This section outlines the process for notification of decisions to either accredit a commencing service or re-accredit an accredited service.

Within 14 days of deciding to accredit a commencing service, the accreditation body must tell the approved provider, in writing, about:

the decision;
the reasons for the decision;
the period of accreditation;
any areas in which improvements must be made in order to meet the Accreditation Standards (and the timetable for making the improvements);
the arrangements for assessment contacts (that is, contacts between the accreditation body and the approved provider, other than site or review audits);
the circumstances in which a review audit may be undertaken; and
the arrangements for how the approved provider may apply for further accreditation of the service.

If a site audit was conducted, the accreditation body must also give the approved provider a copy of the site audit report. The site audit report will not contain any confidential information that is unable to be disclosed to the approved provider because of the operation of confidentiality provisions under section 2.86.

In relation to decisions to re-accredit existing services, the accreditation body must also tell the approved provider each of the matters detailed above and must also tell the approved provider how it may apply for reconsideration of the further period of accreditation. This additional requirement is not required in relation to notification of decisions to accredit commencing service because section 2.17 mandates that the initial period of accreditation for commencing services must be 12 months.

Within 14 days after making the decision, the body must also tell the Secretary, in writing, about the decision, the reasons for the decision and the period of accreditation or further accreditation.

The body must also give the approved provider a certificate of accreditation stating the period of accreditation or further period of accreditation. No time period is stipulated for the provision of this certificate. This is because the certificate is generally issued once the time period for requesting reconsideration of the decision has expired. This removes the need to issue two certificates, should a decision change on re-consideration.

Section 2.34 – Notification of decision not to accredit or not to re-accredit

Section 2.34 describes the requirements for notification of decisions not to accredit or to re-accredit a service.

This section states that within 14 days of deciding not to accredit or to re-accredit a service, the accreditation body must tell the approved provider for the service, in writing, about the decision, the reasons for the decision, any areas in which improvements to the service would be necessary to meet the Accreditation Standards and how the approved provider may apply for reconsideration of the decision not to accredit the service or not to re-accredit the service.

If the service is an accredited service (that is, the service is not a commencing service), the body must also tell the approved provider the arrangements for assessment contacts

Within the same time period (14 days), the body must also:

give the approved provider a copy of any information received from the Secretary that influences the body’s decision on the application and, if a site audit was conducted, a copy of the site audit report; and
tell the Secretary, in writing, about the decision and the reasons for the decision.

Section 2.35 – Notification of decision to revoke existing accreditation

Section 2.35 describes the requirements for the notification of a decision to revoke existing accreditation.

This provision states that within 14 days of making the decision to revoke existing accreditation, the body must tell the approved provider for the service, in writing, about:

the decision;
the reasons for the decision;
the date the revocation takes effect;
any areas in which improvements to the service would be necessary to meet the Accreditation Standards in relation to the service;
the arrangements for assessment contacts; and
how the approved provider may apply for reconsideration of the decision.

Within 14 days, the body must also advise the Secretary, in writing, about the decision (and the reasons for it) and the date the revocation takes effect.

Part 6 – Assessment teams

Section 2.36 – Purpose of Part 6

This section describes the purpose of Part 6. Part 6 sets out how assessment teams for site and review audits are constituted, the process for objecting to the appointment of a person to an assessment team, and appointment of replacement members.

Section 2.37 – Eligibility for appointment to assessment team

This section sets out the eligibility requirements for appointment to an assessment team.

The accreditation body may only appoint a person to an assessment team if he/she is a registered quality assessor and is available to complete the audit.

In order to avoid any actual or perceived conflict of interest, the accreditation body must not appoint a person to an assessment team if:

in the 3 years before the assessment team is created, the person either directly, or through a company, was employed or engaged or otherwise provided services to the approved provider; or
the person has a financial or other interest that could conflict with a proper audit of the service.

The intention of this exclusion is that any registered assessor who has worked for the approved provider in the previous 3 years (in whatever capacity and regardless of whether they were a volunteer, contactor or employee) will not be appointed to an assessment team undertaking an audit of one of that approved provider’s services.

Section 2.38 – Constitution of assessment team

This section provides that, for site audits, the accreditation body must create a team that has one or more members. While the accreditation body would normally appoint two team members to undertake a site audit, this provision provides flexibility for the appointment of team members (for example, only one member may be appointed for a site review of a very small or remote service).

By contrast, for review audits the team must have a minimum of 2 members.

Section 2.39 – Replacement of assessment team member

Section 2.39 provides that if a member of an assessment team becomes unavailable during the audit, the accreditation body may appoint a replacement team member. However, if the team was created for a review audit, and only 2 persons were appointed to the team, the body must appoint another person to the assessment team.

The intent of the provision is that:

if only one member has been appointed to a team (to conduct a site audit) and that person becomes unavailable, then a team no longer exists and the body must

re-create a team (with one or more members);

if there are two or more members of a team for a site audit, and one becomes unavailable then it is up to the accreditation body whether they proceed with one team member or appoint another team member; and
if there are two members of a review audit team and one member becomes unavailable, the accreditation body must appoint a replacement member (because a review audit can not be conducted with less than two team members).

If the accreditation body appoints a replacement member, the body must tell the approved provider (for the service that is to be audited) the full name of the replacement member as soon as possible after the appointment.

Section 2.40 – Objection to appointment of site audit team member

This section enables an approved provider to object to the appointment of a member of an assessment team for a site audit, if the approved provider considers that the person is not eligible for appointment.

The approved provider must make the objection, in writing, to the accreditation body within 14 days after the approved provider is told the name of the site audit assessment team member.

If an approved provider makes an objection, the body must, within 14 days of the objection being made, notify the approved provider of the decision to:

accept the objection (and remove the person from the team). In this case, the body may appoint another person to the team to replace a person removed; or
reject the objection. In this case the approved provider making the objection may seek reconsideration of a decision to reject the objection (refer Part 9).

Approved providers do not have the opportunity to object to members of review audit teams (noting that review audits often occur on an unannounced basis) nor do they have the opportunity to object to replacement members. For example, an assessor could not undertake the audit (for example, because of illness), the approved provider can not object to the replacement member. This is for practical reasons because in these circumstances an imminent audit could be delayed by up to 21 days in order for the approved provider to object and for the accreditation body to consider the objection.

Part 7 – Monitoring of accredited services

Division 1 - Preliminary

Section 2.41 – Purpose of Part 7

Section 2.41 describes the purpose of Part 7 which is to set out the responsibilities, following accreditation of a residential care service, of both the accreditation body and the approved provider for the service.

Division 2 – Compliance and continuous improvement

Section 2.42 – Approved provider’s obligations of compliance and continuous improvement

This section requires that an approved provider for an accredited service must:

comply with the Accreditation Standards and the approved provider’s other responsibilities under the Act; and
undertake a process of continuous improvement for the service, measured against the Accreditation Standards.

Section 2.43 – Approved provider must have a plan for continuous improvement

This section requires an approved provider for an accredited service to have a plan for continuous improvement of the service.

A ‘plan for continuous improvement’ is defined in section 2.4 of the Principles and means a written plan that explains how the approved provider will meets its obligations for continuous improvement under the Accreditation Standards and in relation to any areas identified by the accreditation body as areas in which improvements are needed to meet the Standards.

Section 2.44 – Making the plan available to accreditation body and assessment teams

This section describes when plans for continuous improvement must be made available to the accreditation body or an assessment team.

The section requires that if the accreditation body requests a copy of the plan for continuous improvement, the approved provider must give a copy of the plan to the body. Similarly, if an assessment team, conducting a site audit or review audit, requests a copy of the plan, the approved provider must give a copy of the plan to the assessment team.

Aside from the circumstances detailed above, there is no ongoing requirement for approved providers to provide the latest copies of their plan to the accreditation body.

Division 3 – Assessment contacts

Section 2.45 – Assessment contacts

Section 2.45 outlines the requirements for assessment contacts, the purpose of which is to:

assess the approved provider’s performance against the Accreditation Standards;
assist the approved provider’s process of continuous improvement;
identify whether there is a need for a review audit; and
give the approved provider additional information or education about the accreditation process and requirements.

This section requires that the accreditation body must undertake assessment contacts with an approved provider for an accredited service. However, the form that the assessment contact takes is up to the accreditation body and this may include phone discussions, emails or site visits. Given the wide variety of possible assessment contacts, the body is not required to give notice to the approved provider before an assessment contact takes place.

Section 2.46 – Variations to assessment contacts arrangements

This section describes the way in which the accreditation body may vary arrangements for assessment contacts.

The accreditation body may vary the arrangements for assessment contacts with an approved provider by notifying the approved provider and telling the approved provider, in writing, about any new arrangements for assessment contacts.

Under the Accreditation Grant Principles 1999, assessment contacts were referred to as ‘support contacts’. In order to enable the accreditation body to vary arrangements for support contacts (for those approved providers whose schedule of support contacts was established prior to the revocation of the Accreditation Grant Principles 1999 and the replacement of those with these new Principles), section 2.46 also enables the accreditation body to vary arrangements for support contacts.

Section 2.47 – Informing residents of assessment contact

This section requires that if the accreditation body undertakes an assessment contact in the form of a visit to the service, the accreditation body must give the approved provider a poster to inform the residents of the service about the assessment contact. The poster must be displayed as soon as practicable (in advance of the visit), in a prominent place or places within the service.

If the accreditation body gives the approved provider advance notice of the visit to the service then the poster can be displayed in advance of the visit. But if the visit is unannounced, the accreditation body would provide a copy of the poster at the time of the visit and this would be displayed in the service on the day of the visit.

Section 2.48 – Action following assessment contact

This section provides that within 21 days after an assessment contact with an approved provider, the accreditation body must tell the approved provider, in writing, about the arrangements for future assessment contacts and any areas in which improvements must be made to meet the Accreditation Standards (including the timetable for making the improvements).

Division 4 – Review audit

Section 2.49 – When a review audit is to be conducted

Section 2.49 describes when an accreditation body may arrange for a review audit of a service to be conducted.

The accreditation body may arrange for a review audit of an accredited service if:

it believes, on reasonable grounds, that the approved provider may not be meeting the Accreditation Standards or other responsibilities under the Act;
there has been a change that the approved provider must tell the Secretary about under section 9.1 of the Act. Section 9.1 of the Act requires the approved provider to tell the Secretary about a change in circumstances that affects the approved provider’s suitability to provide aged care, and about a change to the approved provider’s key personnel;
under section 16‑1 of the Act, there has been a transfer of allocated places; or
the premises at which the service is conducted have changed since the service was accredited;
the service has not complied with the arrangements made for assessment contacts (or support contacts under the Accreditation Grant Principles 1999); or
the approved provider has requested reconsideration of certain decisions.

The accreditation body must also arrange for a review audit at the Secretary’s request.

Section 2.50 – Creation of assessment team

Section 2.50 provides for the creation of an assessment team to conduct the review audit. This section provides that if the accreditation body decides to arrange a review audit (or is required to arrange such an audit) it must create an assessment team to undertake the review audit and prepare a review audit report.

Section 2.51 – Informing residents of review audit

This section outlines the requirements for informing residents of the review audit. Consistent with similar provisions relating to assessment contacts and site audits, this section requires the accreditation body or the assessment team to give the approved provider a poster to inform the residents of the review audit. Approved providers must display this poster as soon as practicable, in a prominent place or places, within the service.

This means that if the accreditation body gives the approved provider advance notice of the review audit, the poster must be displayed in advance of the review audit. But if the review audit is unannounced, the accreditation body would provide a copy of the poster at the time of the review audit and this must be displayed in the service on commencement of the review audit.

Section 2.52 – Carrying out review audit

Section 2.52 outlines the requirements for carrying out a review audit. In line with similar provisions for site audits, this section states that in undertaking the audit, the assessment team must:

act consistently with any provisions of the Accountability Principles 1998 applying to the audit;
assess the quality of care and services provided by the approved provider against the Accreditation Standards;
visit the premises of the service;
consider any information about the quality of care and services received by residents, former residents or their representatives;
during the review audit, meet with at least 10% of residents (or their representatives) to discuss the care and services provided at the service (as required in section 2.53);
consider any relevant information about the approved provider that is received from the Secretary; and
consider any information received from the approved provider.

Section 2.53 – Review audit meetings

Section 2.53 outlines the requirements for review audit meetings. The section provides that the assessment team must:

meet the approved provider daily during the review audit to discuss the progress of the audit;
during the review audit, meet at least 10% of the residents of the service (or their representatives) to discuss the care they are receiving. If a resident or their representative asks to meet the team during the review audit, the approved provider must allow the team to meet the person privately.

Section 2.54 – Report of major findings

Section 2.54 requires that, on the last day of the review audit, the assessment team must give the approved provider, a written report of the major findings of the review audit.

Under this provision, the approved provider may, within 7 days after receiving the report, give the accreditation body a written response to the report.

Section 2.55 – Information to be provided by assessment team

Section 2.55 outlines the requirements for the provision of various documents by the assessment team to the approved provider and to the accreditation body.

This section requires that, within 7 days of the completion of the review audit, the assessment team must give a review audit report to the accreditation body and to the approved provider.

The review audit report must include an assessment of the approved provider’s performance against the Accreditation Standards and may also include any other matters the assessment team considers relevant.

The assessment team must also give the accreditation body a copy of the report on major findings. This report was already given to the approved provider in accordance with section 2.54 but the assessment team has a longer period of time within which to provide this to the accreditation body.

Division 5 – Decision following review audit

Section 2.56 – Decision on receipt of review audit report

Section 2.56 outlines the steps that the accreditation body must take after receiving a review audit report from an assessment team.

In summary, within 14 days after receiving a review audit report, the accreditation body must decide whether to:

revoke the accreditation of the service (and if so, the date the revocation takes effect); or
not to revoke the accreditation. If the accreditation body decides not to revoke the accreditation, the body can leave the accreditation arrangements as they are (that is, by not varying the period of accreditation). Alternatively, the accreditation body can decide to vary the period of accreditation by fixing a new date from which the accreditation ceases.

In making a decision, the accreditation body must take into account:

the review audit report;
any information received from the approved provider in response to the report on major findings;
any information received from residents or former residents of the residential care service (or their representatives);
any relevant information received from the Secretary; and
whether it is satisfied that the approved provider will undertake continuous improvement, measured against the Accreditation Standards.

The body may also take into account any other relevant matter and it must record its decision and the reasons for its decision.

Section 2.57 – Decision to revoke

Section 2.57 outlines some additional requirements if the accreditation body decides to revoke accreditation.

If the accreditation body decides to revoke the accreditation of an accredited service, it must also decide:

whether there are any areas in which improvements to the service would be necessary to meet the Accreditation Standards; and
the arrangements for assessment contacts. Despite the fact that the accreditation is being revoked, assessment contacts might continue particularly where the service is still providing care and services to residents.

These decisions must be recorded by the accreditation body and also communicated to the approved provider in accordance with the notification requirements in section 2.59.

Section 2.58 – Decision not to revoke

Section 2.58 outlines some additional requirements if the accreditation body decides not to revoke the accreditation. If the accreditation body decides not to revoke the accreditation of the accredited service, it must also decide:

whether there are any areas in which improvements must be made to the service to meet the Accreditation Standards and the timetable for making the improvements; and
the arrangements for assessment contacts.

This section applies whether or not the body decides to vary the accreditation period of the service.

The accreditation body must record its decision.

Division 6 – Notification of decision following review audit

Section 2.59 – Notification of decision to revoke accreditation

Section 2.59 describes the requirements for the notification of a decision to revoke accreditation of a service.

This section provides that within 14 days of receiving the review audit report, the accreditation body must tell the approved provider, in writing, about:

the decision and the reasons for the decision;
the date on which the revocation takes effect;
the areas in which improvements would be necessary to meet the Accreditation Standards. Given that the accreditation body has decided to revoke the accreditation, the approved provider is not required to address the areas of deficiency in accordance with a particular timeframe. However, information about the deficiencies is given to the approved provider so that they are aware of those areas in which improvement must be made should the matter be reconsidered by the accreditation body;
the arrangements for assessment contacts; and
how to apply for reconsideration of the decision.

Within 14 days of receiving the report, the body must also tell the Secretary, in writing, about the decision, the reasons for the decision and the date on which the revocation takes effect.

Section 2.60 – Notification of decision not to revoke accreditation and not to vary accreditation period

Section 2.60 sets out the requirements for the notification of decisions not to revoke accreditation and not to vary the accreditation period.

The section provides that, within 14 days after receiving the review audit report, the accreditation body must:

tell the approved provider, in writing, about:

– the decision and the reasons for the decision;

– any areas in which improvements must be made to the service to meet the Accreditation Standards, and the timetable for making the improvements; and

– the arrangements for assessment contacts.

tell the Secretary, in writing, about the decision and the reasons for the decision.

Section 2.61 – Notification of decision not to revoke accreditation and to vary accreditation period

Section 2.61 sets out the requirements for notification of a decision not to revoke accreditation and to vary the accreditation period.

This section provides that within 14 days after the accreditation body receives the review audit report, the accreditation body must:

tell the approved provider for the service, in writing, about:

– the decision and the reasons for the decision;

– the date the service’s accreditation period will cease;

– the areas in which improvements to the service must be made to meet the Accreditation Standards, and the timetable for making the improvements;

– the arrangements for assessment contacts; and

– how the accredited provider may apply for reconsideration of the decision to vary the accreditation period.

tell the Secretary, in writing, about the decision, the reasons for the decision and the date the service’s accreditation period will cease.

The body must also give the approved provider a new certificate of accreditation for the service stating the new period of accreditation. In line with section 2.33(3), no time period is stipulated for the provision of this certificate as it is generally issued once the time period for requesting reconsideration of the decision has expired.

Part 8 – Dealing with non-compliance

Section 2.62 – Purpose of Part 8

Section 2.62 describes the purpose of Part 8 which is to set out how the accreditation body should deal with non-compliance by an approved provider with the approved provider’s responsibilities under the Act and the Accreditation Standards.

Section 2.63 – Evidence of non-compliance with Act

Section 2.63 provides that if the accreditation body becomes aware of evidence of a failure by an approved provider to comply with one or more of the approved provider’s responsibilities under the Act, the body must (as soon as it becomes aware of the evidence) tell the Secretary in writing about the evidence.

Section 2.64 – Failure to meet Accreditation Standards

Section 2.64 sets out the steps to be taken by the accreditation body if it finds that an approved provider has failed to meet the Accreditation Standards.

In summary, the section provides that if the accreditation body identifies a failure to meet the Accreditation Standards, the body must, as soon as practicable, decide whether the failure has placed, or may place, the safety, health or wellbeing of residents of the service at serious risk.

If the body decides that the failure creates such a risk, the body must, as soon as practicable, give the Secretary and the approved provider in writing:

specific information about the reason for the risk;
evidence of the risk; and
a statement of any other standard in the Accreditation Standards that the approved provider may have failed to meet.

The body must also give the approved provider a written notice about the failure to meet the Accreditation Standards and direct the approved provider to revise their plan for continous improvement to demonstrate how the approved provider will meet the standards. This must be achieved by the approved provider within 14 days of receiving the notice.

If the accreditation body requests a copy of the revised plan of continuous improvement, the approved provider must make a copy of the revised plan available to the body.

Section 2.65 – Action if improvements not satisfactory

Section 2.65 sets out the action required if the accreditation body has given an approved provider a timetable for improvements and the improvements are not satisfactory.

This section provides that if the accreditation body has decided a timetable for improvements in relation to a service and at the end of that timetable, the accreditation body is not satisfied that the level of care and services provided by the service comply with the Accreditation Standards, the body must:

tell the Secretary and the approved provider, in writing, the reasons why it is not satisfied; and
give a copy of any relevant information to the Secretary, and the approved provider.

The body must also give the Secretary and the approved provider details of the evidence the body relies on to support its finding.

Part 9 – Reconsideration and review

Section 2.66 – Purpose of Part 9

Section 2.66 states the purpose of the Part which is to provide for reconsideration and review of certain decisions made under the Principles.

Section 2.67 – Decisions that may be reconsidered

Section 2.67 describes those decisions that may be reconsidered.

In summary:

the approved provider for a commencing service may seek reconsideration of a decision by the accreditation body to refuse accreditation of the commencing service; and
the approved provider of an accredited service may seek reconsideration of a decision by the accreditation body:

– to reject an objection to the appointment of a member of an assessment team for a site audit;

– to refuse to re-accredit an accredited service;

– regarding the further period of accreditation;

– to revoke the accreditation of an accredited service; or

– to vary the period of accreditation.

A registered assessor may also seek reconsideration of a decision by the registrar to remove the person’s name from the register of quality assessors.

Section 2.68 – Requests for reconsideration

Section 2.68 sets out the requirements for requests for reconsideration. Requests for reconsideration must be in writing and include a statement of the grounds on which reconsideration is sought. The request must be given to the accreditation body within 14 days after the person making the request is notified of the decision.

Section 2.69 – Reconsideration decision

Section 2.69 sets out the requirements for reconsideration decisions.

This section requires that if a request for reconsideration of a decision is made, the accreditation body must reconsider the decision and confirm, vary or set the decision aside and substitute a new decision.

Different time periods for different types of reconsideration decisions apply. In summary, the accreditation body must tell the Secretary and the person requesting reconsideration, in writing, of the body’s decision:

within 56 days of the request for reconsideration, if the reconsideration relates to a decision by the accreditation body to:

– refuse accreditation of the commencing service;

– refuse to re-accredit an accredited service;

– revoke the accreditation of an accredited service; or

within 14 days of the request for reconsideration, if the reconsideration relates to a decision by the accreditation body:

– to reject an objection to the appointment of a member of an assessment team for a site audit;

– regarding the period of accreditation;

– to vary the period of accreditation; or

– to remove a person’s name from the register of quality assessors.

If the body decides, on reconsideration, to:

accredit a commencing service, or re-accredit an accredited service, the body must give the approved provider a certificate setting out the accreditation period;
vary the period of accreditation for an approved service, the body must give the approved provider a replacement certificate setting out the new accreditation period.

Section 2.70 – Reconsideration on accreditation body’s own initiative

Section 2.70 sets out the requirements for when the accreditation body may reconsider its own decision, if it decides it is appropriate to do so, regardless of whether there has been a request for reconsideration.

This section provides that if the body decides to reconsider a decision, the body must provide written notice of the reconsideration to the Secretary and relevant person (as mentioned in section 2.67).

The body must, on reconsideration of the decision confirm, vary or set aside the decision and substitute a new decision.

Different time periods for different types of reconsideration decisions apply.

Consistent with the timeframes for reconsideration on matters following a request for reconsideration, the accreditation body must make a decision in relation to an ‘own initiative’ reconsideration:

within 56 days, if the reconsideration relates to a decision by the accreditation body to:

– refuse accreditation of the commencing service;

– refuse to re-accredit an accredited service;

– revoke the accreditation of an accredited service; or

within 14 days, if the reconsideration relates to a decision by the accreditation body:

– to reject an objection to the appointment of a member of an assessment team for a site audit;

– regarding the period of accreditation;

– to vary the period of accreditation; or

– to remove a person’s name from the register of quality assessors.

If the body decides on reconsideration to:

accredit a commencing service, or re-accredit an accredited service, the body must give the approved provider a certificate setting out the accreditation period;
vary the period of accreditation for an accredited service, the body must give the approved provider a replacement certificate setting out the new accreditation period.

Section 2.71 – Review by the Administrative Appeals Tribunal

Section 2.71 describes the circumstances in which a request for review may be made to the Administrative Appeals Tribunal (AAT). The section provides that a person may apply to the AAT for review of a decision of the accreditation body only following reconsideration of that decision by the accreditation body. In other words, the approved provider must have first sought reconsideration of a decision by the accreditation body (in accordance with Part 9) prior to seeking review by the AAT.

Part 10 – Promoting quality care in residential care services

Section 2.72 – Purpose of Part 10

Section 2.72 provides that the purpose of Part 10 is to set out the accreditation body’s responsibilities for promoting quality care in residential care services, and to provide for charging by the accreditation body for related services.

Section 2.73 – Promoting and encouraging quality of care

Section 2.73 provides that the accreditation body must promote and encourage quality care in residential care services. In doing so, the accreditation body may provide information, education, training and support for approved providers and identify and encourage best practice for approved providers.

Section 2.74 – Fees for materials

Section 2.74 outlines the fees the accreditation body may charge relating to the cost of providing manuals, documents and other items it supplies.

This section provides that the fee the body may charge for each manual or document is the lesser of the cost of obtaining and supplying the manual or document and $75.

Similarly, the fee for any other item is the lesser of the cost of obtaining and supplying the item and $55.

Section 2.75 – Fees for seminars or conferences

This section outlines the fees the accreditation body can charge for the cost of arranging or presenting seminars or conferences.

The fee the accreditation body may charge is the lesser of the cost of arranging and presenting the seminar or conference (less any cost that is covered by a fee charged under section 2.74) and $400 per day for a person attending the seminar or conference.

The accreditation body is not required to charge a fee, or the same fee, for every person attending a seminar or conference. The requirements of section 2.74 also do not prevent the accreditation body from charging a fee for providing manuals, documents or services in the course of the seminar or conference.

Part 11 – Conditions on accreditation grant

Section 2.76 – Purpose of Part 11

Section 2.76 explains the purpose of Part 11 (to provide for conditions on accreditation grants).

Section 2.77 – Accreditation grant conditions

Section 2.77 outlines the conditions applicable to accreditation grants, including:

if the Minister asks the accreditation body for information about an aspect of the body’s operations, the body must give that information to the Minister; or
if the Secretary asks the accreditation body for protected information, the accreditation body must give the information to the Secretary.

Part 12 – Registration of quality assessors

Section 2.78 – Purpose of Part 12

Section 2.78 provides that the purpose of Part 12 is to provide for the registration of quality assessors.

Section 2.79 – Appointment of registrar

Section 2.79 states the requirements for the appointment of a registrar. This section provides that the accreditation body must appoint, in writing, a person or body as a registrar to keep a register of quality assessors and to register persons as quality assessors.

Section 2.80 – Application for registration as quality assessor

Section 2.80 provides that a person may apply to the registrar, in writing, to be registered as a quality assessor.

Section 2.81 – Decision on application for registration

Section 2.81 provides that the registrar must register the applicant as a quality assessor if the registrar is satisfied that the applicant:

has been interviewed, and recommended to the accreditation body, by the Aged Care Industry Panel which consists of persons with expertise in accreditation systems or management in aged care;
has successfully completed a course about aged care quality assessment approved by the accreditation body and listed on its website;
has participated in an orientation programme delivered by the accreditation body;
has, after making the application for registration, obtained a police certificate. The police certificate must not record any conviction for murder or sexual assault or any conviction (and sentence to imprisonment for) any other form of assault;
for an applicant who, at any time after the applicant turned 16, was a citizen or permanent resident of a country other than Australia - has made a statutory declaration, at the time of making the application for registration, that the person has never been convicted of murder or sexual assault or convicted of, and sentenced to imprisonment for, any other form of assault; and
has fulfilled any other registration requirements agreed by the accreditation body and the Registrar and published by the accreditation body on its website.

The registrar must refuse to register the applicant as a quality assessor if the registrar is not satisfied that the applicant meets these requirements.

If the registrar registers the applicant as a quality assessor, the registrar must register the applicant for 1 year and give the applicant written notice of the applicant’s obligations as a quality assessor.

The registrar must tell the applicant and the accreditation body, in writing, about the registrar’s decision.

Section 2.82 – Application for registration for further period

Section 2.82 outlines the requirements for applications for registration as a quality assessor for a further period, including that the application must be made in writing and not later than one month before the end of the assessor’s registration period.

The application must be accompanied by evidence that the assessor has completed any mandatory training and not less than 15 hours of professional development approved by the accreditation body. Evidence of relevant audit experience must also accompany the application.

Section 2.83 – Decision on application for further registration

Section 2.83 outlines the requirements for decisions on application for further registration, including that the registrar must ask the accreditation body for advice on the assessor’s performance in relation to any assessment contacts or site or review audits undertaken by the assessor.

The section provides that the registrar must register the assessor for a further year if the registrar is satisfied that the assessor has:

complied with the assessor’s obligations as notified to the assessor by the registrar;
completed any mandatory training required by the accreditation body and at least 15 hours professional development approved by the accreditation body (including any mandatory training);
relevant audit experience gained during the assessor’s most recent registration period; and
a police certificate issued not more than 3 years before the application was made that does not record that the person has been convicted of murder or sexual assault or convicted of (and sentenced to imprisonment for) any other form of assault.

If the registrar is not satisfied that the assessor meets the requirements detailed above, the registrar may remove the assessor’s name from the register.

If the registrar makes a decision to re-register an assessor or to remove the assessor’s name from the register, the registrar must tell the person and the accreditation body, in writing, about the decision and the reasons for the decision.

Section 2.84 – Removal of person’s name from register – certain criminal convictions

Section 2.84 provides that the registrar must remove the name of a person from the register if they are satisfied that a police certificate, or statutory declaration made by the person, states that the person has been convicted of murder or sexual assault or has been convicted of, and sentenced to imprisonment for, any other form of assault.

If the registrar removes the name of a person from the register, the registrar must tell the person and the accreditation body, in writing, about the removal of the person’s name and the reasons for the removal.

In these circumstances the person can seek reconsideration of the decision in accordance with Part 9 of the Principles.

Part 13 – Other matters

Section 2.85 – Purpose of Part 13

Section 2.85 explains the purpose of the Part. Part 13 deals with the protection of information, publication of decisions and transitional matters.

Section 2.86 – Identifying information

Section 2.86 outlines the provisions for the protection of certain identifying information provided to the accreditation body or the assessment team.

The section operates such that:

if a resident or former resident (or either person’s representative) provides information to the accreditation body or an assessment team, the body or team must not disclose the identity of the person to the approved provider; and
if any other person requests the accreditation body or the assessment team to keep their identity confidential, the body or team must not disclose their identity to the approved provider.

This ensures that the identity of residents and their representative always remain confidential and the identity of others may be kept confidential if this is the express wish of the person providing the information.

The only exceptions to this rule are:

if the person expressly consents to the body or assessment team disclosing their identity. For example, a resident may advise the accreditation body that they are happy to have their name disclosed to the approved provider in connection with information they gave to the accreditation body about the quality of care they receive at the service; or
if not disclosing the information would place the safety or wellbeing of a resident at risk.

Under either of these circumstances, the body or team must take all reasonable steps to tell the person who provided the information about the proposed disclosure before it occurs.

Section 2.87 – Publication of decisions

Section 2.87 outlines the requirements for the publication of the accreditation body’s decisions, including decisions to:

accredit or not to accredit a commencing service;
re-accredit or not to re-accredit an accredited service;
to revoke or not to revoke the accreditation of an accredited service; and
vary the period of accreditation of an accredited service.

If no request for reconsideration is made within the time mentioned under section 2.68, the accreditation body must, as soon as practicable after the decision is made, publish the decision and any site audit report or review audit report considered in the making of the decision. However, the accreditation body must not publish, or otherwise make available, protected information (as defined in the Act) unless the publication is authorised under that Part.

The publication must be made within 28 days after the last day when a request for reconsideration of a decision could be made.

Section 2.88 – Publication of reconsideration decisions

Section 2.88 outlines the requirements for the publication of reconsideration decisions by the accreditation body.

The section requires that within 28 days after making the reconsideration decision, the accreditation body must publish the reconsideration decision and any site audit report or review audit report considered in making the reconsideration decision.

However, the accreditation body must not publish, or otherwise make available, protected information (as defined in the Act) unless the publication is authorised under that Part.

This provision also requires that if a person applies for review by the AAT of the reconsideration decision, the accreditation body must publish a notice that the reconsideration decision is subject to review by the AAT.

Section 2.89 – Publication of AAT decisions

Section 2.89 outlines the requirements for the publication of AAT decisions to review reconsideration decisions, including that the accreditation body must publish the outcome of the AAT’s review. However, the accreditation body must not publish, or otherwise make available, protected information (as described in the Act) unless the publication is authorised under that Part.

Section 2.90 – Transitional

Section 2.90 sets out the transitional arrangements that apply to applications for accreditation or re-accreditation of residential care services made before or after
20 May 2011.

This section, in practice, will mean that the Accreditation Grant Principles 2011 will apply to all applications for accreditation or reaccreditation that are made to the accreditation body on or after 20 May 2011. Applications that have been made before that time, and are still under consideration by the accreditation body as at
20 May 2011, will continue to be dealt with under the Accreditation Grant Principles 1999.

Similarly, if a person has applied before 20 May 2011 to the registrar for registration as a quality assessor, the registrar will consider the application in accordance with the Accreditation Grant Principles 1999. All applications that are made on or after
20 May 2011 will be considered in accordance with the Accreditation Grant Principles 2011.

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