A review audit is an on-site assessment of the quality of care provided by an aged care home measured against the Accreditation Standards. Review audits are conducted by an assessment team of at least two registered aged care quality assessors and generally take from two to four days.
Review audits may be conducted with little or no notice (ie conducted as spot checks).
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The Agency may arrange a review audit if:
- it has reason to believe that the home may not be complying with the Accreditation Standards or other responsibilities under the Act, or
- there has been a change in provider or key personnel at the home, or
- there has been a transfer of allocated places, or
- there has been a change to the premises, or
- the home has not complied with the arrangements made for support contacts.
The Agency must conduct a review audit if requested to do so by the Department of Health and Ageing.
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Review audits are conducted on-site, involving observation of what is happening in the home, interviewing residents and their representatives, staff and management and other relevant people (eg visiting doctors, pharmacists), and reference to documents and records.
In conducting a review audit, the assessment team must consider:
- any comments made by the Secretary, Department of Health and Ageing
- any comments made by residents or past residents of the home on the quality of care
- any submission which the provider may make on behalf of the home.
On completion of the visit, the assessment team will meet with the key personnel on site and provide a Statement of major findings. The provider may respond to the Statement of major findings, in writing within seven days of the review audit.
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Within seven days of the review audit, the assessment team completes its Review audit report. The Review audit report is sent to the provider and is also provided to the Agency for a decision, with a recommendation about whether or not to revoke accreditation, or whether the period of the home’s accreditation should be varied.
Within 14 days after receiving the Review audit report, the Agency must make its decision and inform the provider.
Homes found to have met their obligation to comply with the Accreditation Standards and to undertake continuous improvement will continue to be accredited.
It is important to note that while assessment teams conduct review audits and make recommendations, it is the Agency that makes the decision about a review audit.
The Agency makes decisions on a case by case basis according to the individual circumstances of the home concerned. In making its decision, the Agency looks at whether there is any non-compliance in the home, any recent history of non-compliance, information from the Department of Health and Ageing and any written responses submitted by the provider to the Statement of major findings.
The decision the Agency makes may differ from the team’s recommendation because the decision maker must take into account all relevant facts, including any further information submitted to the Agency and may give different weight to the available information than the assessment team did.
The three decisions the Agency can make are:
- not to revoke the home’s accreditation
- to vary the accreditation expiry date
- to revoke the home’s accreditation.
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If the decision is not to revoke the home’s accreditation, then the accreditation expiry date will remain the same. A decision not to revoke may be made if there is non-compliance. However, where there are any findings of non-compliance, the Agency will ask the provider to agree to a Timetable for improvement, and will assist the home to address areas of non-compliance by conducting support contacts.
If, at the end of the timetable, the home has any non-compliance the Agency must tell the Department of Health and Ageing and the provider about whether or not sanctions should be imposed on the provider.
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Where a home fails to comply with the Accreditation Standards, the Agency may decide to vary the accreditation expiry date. The variation would usually be to shorten the period of accreditation. The Agency will advise the provider in writing of the decision and the reasons for the decision, and the new accreditation expiry date.
If there are any findings of non-compliance the Agency will set a Timetable for improvement. The Agency will assist the home to achieve the Timetable for improvement by conducting support contacts.
Failure to remedy non-compliance within the timetable set will result in the Agency recommending to the Department of Health and Ageing that sanctions be imposed on the provider.
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Findings of significant non-compliance or serious risk to the health, wellbeing and safety of residents may lead to a decision to revoke the home’s accreditation. The Agency will tell the provider on what date the accreditation will expire. Commonwealth subsidies would cease on that date. The Agency will give the provider the reasons for revocation and an explanation of the areas in which improvements are needed in order that accreditation may continue. The Department of Health and Ageing will be given the same information.
The Agency also will tell the provider how to apply for reconsideration and review of the decision and about the supervision of the home during the review period.
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The provider may appeal against any decision the Agency makes regarding the home’s accreditation. For details about reconsiderations and appeals about decisions, refer to Reconsiderations and appeals.
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Review audit decisions and reports are published on the Agency’s website. The most recent report for a home is published under “current reports” and old reports are available in the archive section of the website.
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