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Frequently Asked Questions
This website contains information for both the general community and
the aged care industry about Agency contact details, accreditation processes
and education. Listed below are some answers to frequently asked questions
that may be useful for those involved in the aged care industry. If you
have any other questions about accreditation, please click
here for the contact details for your state Agency office.
What triggers a spot check by the Agency?
The Agency conducts both random and targeted spot checks. Spot checks are either support contact
visits or review audits, where access to the home is sought within 30 minutes of notice being given.
Targeted spot checks are conducted where the Agency has reasonable grounds to believe there may be
non-compliance, whereas random spot checks are conducted where there is no indication of risk or
non-compliance. About 10 per cent of the Agency’s non-accreditation visits are conducted as spot
checks.
The Agency appreciates that spot checks may not always be convenient to the home. However, we also
appreciate that the Australian community – to whom the Agency is also accountable – has high expectations
of aged care providers, and expects that homes should be able show that they provide high quality care
at any time of day, any day of the week.
The Agency’s program of spot checks benefits aged care providers because it provides a strong reassurance
to the community that homes consistently meet high quality standards.
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The Agency says that a home may be awarded three years accreditation if it complies with ‘all or
almost all’ expected outcomes. What is meant by this? Are there some expected outcomes that are less
important than others?
The Aged Care Act 1997 specifies that accreditation is a requirement of Commonwealth-funding for
residential aged care services. The Act makes it clear that approved providers are expected to comply
with the Accreditation Standards, which comprise 44 expected outcomes.
The Agency expects homes to comply with all 44 expected outcomes, however there may be occasions when
the Agency will award three years accreditation where there is some minor non-compliance.
All Agency decisions are ‘merits-based’. This means that every decision takes into account all the facts
and circumstances of the particular case – there is no numeric equation that relates the number of
compliant expected outcomes to the period of accreditation.
The degree to which any non-compliance will influence the period of accreditation will depend on the
extent and severity of the non-compliance, its impact on residents, the home’s undertaking of continuous
improvement and other relevant matters such as the history of the home’s compliance with the Standards.
Thus, it is not a matter of ‘which’ expected outcomes are not met, but rather the impact: how many, to
what extent, for how long and why, and what evidence can be given to show when the non-compliance will
be remedied.
Conversely, a home may have achieved 44 compliant expected outcomes at site audit, but the achievement
of compliance is weighed against a recent history of extensive non-compliance, and may result in a
decision to accredit for a period of less than three years.
The Accreditation Guide Issue 2 includes guidelines about the periods of accreditation that may be awarded.
Transparency is built into the accreditation process through the separate roles of teams and the
Agency – teams conduct audits, the Agency makes decisions, based on the team’s report and any other
relevant information, including information from the approved provider in response to the draft site
audit report.
Where the Agency makes a decision that there is non-compliance, it will give the approved reasons for
this. Also, where the Agency makes a decision to accredit an aged care home for less than three years,
it will give the approved provider written reasons and the approved provider can request reconsideration
of that decision.
Regular self-assessment by the home is critical, because it ensures that a home is able to recognise any
issues before they become problems. Also, the better a home understands its own performance, the better it
can undertake continuous improvement, and the more fully the home can participate in the accreditation audit
by showing the Agency what it does to meet the expected outcomes.
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| Within 28 days after receiving the application for accreditation by day 28 |
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| Within 49 days after accreditation body received application by day 49 |
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| Agency to decide whether to continue with the application |
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| Within 7 days of receiving the desk audit report by day 56 |
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| Agency to advise applicant of decision to proceed to site audit |
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| Within 7 days of making the decision to proceed by day 63 |
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| Complete site audit, exit interview, statement of major findings |
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| Within 56 days after the accreditation body tells the applicant
about its decision to continue with the application by day 119 |
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| The assessment team must give a written report to the
accreditation body within 14 days after the site audit is finished by day 133 |
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| Within 28 days after receiving the site audit report,
unless a later time has been agreed to with the applicant by day 161 |
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| Inform applicant of decision to accredit (in writing) |
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| Within 14 days of making the decision by day 175 |
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| Agency to inform applicant and the Secretary about decision
not to accredit (in writing) |
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| Within 28 days after making the decision by day 189 |
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| Applicant request for reconsideration of period of accreditation |
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| Within 7 days of being told about a decision to accredit by day 182 |
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| Agency reconsideration decision of period of accreditation |
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| Within 7 days of receiving the request for reconsideration by day 189 |
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| Applicant request for reconsideration of decision not to accredit |
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| Within 14 days of being told about the decision not to accredit by day 203 |
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| Agency reconsideration decision of decision not to accredit |
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| Within 56 days after receiving the request for reconsideration by day 259 |
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| The publication must take place within 28 days after
the end of the period in which a request for reconsideration or review of the decision
may be made (eg by day 210 for a decision to accredit) |
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Assessment team
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Agency
(authorised decision-maker)
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Department of Health
and Ageing (Delegate to the Secretary)
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| Finds non-compliance in one or more of the expected outcomes
of the Accreditation Standards during an accreditation audit,
or a review audit. |
Makes a decision about whether or not there is non-compliance,
and if so refers information plus a recommendation regarding
sanctions to the Secretary, DHA, under s4.5 of the Accreditation
Grant Principles (AGPs) |
Makes an independent decision about compliance and whether
or not to take sanctions action and if so what type of action. |
| Finds that there is serious risk to the health, safety or wellbeing
of a person receiving care, during an accreditation audit or
a review audit. |
Makes a decision about whether or not there is evidence of
a serious risk, and if so refers information plus a recommendation
regarding sanctions to the Secretary, DHA, under s4.4 of the
AGPs. |
Makes an independent decision about whether or not immediate
and severe risk exists and whether or not to impose sanctions. |
| Finds that there is serious risk to the health, safety or wellbeing
of a person receiving care, during a support contact. |
Makes a decision about whether or not there is evidence of
a serious risk, and if so refers information plus a recommendation
regarding sanctions to the Secretary, DHA, under s4.6 of the
AGPs. |
Makes an independent decision about whether or not immediate
and severe risk exists and whether or not to impose sanctions. |
| Finds non-compliance in one or more of the expected outcomes
of the Accreditation Standards during a support contact. |
Makes a decision about whether or not there is non-compliance,
and if so establishes a timetable for improvements under s4.6(4)
of the AGPs. |
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| Finds non-compliance in one or more of the expected outcomes
of the Accreditation Standards during a support contact, at the
end of a timetable established under s4.6(4) of the AGPs. |
Makes a decision about whether or not there is non-compliance,
and if so refers to the Secretary DHA, information plus a recommendation
that sanctions be imposed, as required under s4.7 of the AGPs. |
Makes an independent decision about compliance and whether
or not to take sanctions action and if so what type of action. |
| Finds non-compliance in one or more of the expected outcomes
of the Accreditation Standards at the end of a timetable established
under s3.25 of the AGPs (following a review audit, where the
decision was not to revoke). |
Makes a decision about whether or not there is non-compliance,
and if so refers to the Secretary DHA, information plus a recommendation
about whether or not sanctions should be imposed, as required
under s3.26 of the AGPs. |
Makes an independent decision about compliance and whether
or not to take sanctions action and if so what type of action. |
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