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Accreditation Grant Principles 1999

Principles as amended, taking into account amendments up to Accreditation Grant Amendment Principles 2000 (No. 1)
Administered by: Health
Registered 08 Sep 2010
Start Date 22 Dec 2000
End Date 02 Jul 2002
Date of repeal 20 May 2011
Repealed by Accreditation Grant Principles 2011

Accreditation Grant Principles 1999

made under subsection 96-1 (1) of the

This compilation was prepared on 9 January 2001
taking into account amendments up to Accreditation Grant Amendment Principles 2000 (No. 1)

Prepared by the Office of Legislative Drafting,
Attorney-General’s Department, Canberra


Contents

Page

Part 1                 Preliminary

                      1.1  Name of Principles [see Note 1]                                                               6

                      1.2  Commencement                                                                                     6

                      1.3  Definitions                                                                                              6

                      1.4  Commencing residential care service                                                        8

                      1.5  Decisions made by accreditation body                                                      9

                      1.6  Revocation of Accreditation Grant Principles 1998                                      9

Part 2                 Accreditation of residential care services

Division 1             Purpose of Part (Act, s 80-1)

                      2.1  Purpose of Part 2                                                                                  10

Division 2             Procedures for accreditation

                      2.2  Application of Division 2                                                                         11

                      2.3  Summary of procedures for seeking accreditation                                     11

                      2.4  Application for accreditation                                                                   11

                      2.5  Making application                                                                                11

                      2.6  Payment of application fees                                                                   12

                      2.7  Circumstances in which a reduced fee is payable                                     13

                      2.8  Circumstances in which no fee is payable                                               13

Division 3             Procedures for assessment of applications

Subdivision 1             Commencing residential care service

                      2.9  Application of Subdivision 1                                                                    13

                    2.10  Making the accreditation decision                                                           14

                    2.11  Decision to accredit residential care service                                             14

                    2.12  Telling applicant about decision to accredit                                              14

                    2.13  Varying arrangements for support contacts                                              15

                    2.14  Decision not to accredit                                                                         15

Subdivision 2             Desk audit

                    2.15  Application of Subdivision 2                                                                    16

                    2.16  Assessment team must carry out desk audit                                           17

                    2.17  Carrying out desk audit                                                                          17

                    2.18  Contents of desk audit report                                                                  17

                    2.19  Accreditation body must decide whether or not to proceed                        18

Subdivision 3             Site audit

                    2.20  Application of Subdivision 3                                                                    19

                    2.21  Assessment team must carry out site audit                                             19

                    2.22  Applicant must tell persons receiving care (and their representatives) about site audit  19

                    2.23  Carrying out site audit                                                                            19

                    2.24  Assessment team to have meetings during site audit                               20

                    2.25  Assessment team must give report to accreditation body                          20

Subdivision 4             The accreditation decision

                    2.26  Application of Subdivision 4                                                                    21

                    2.27  Making the accreditation decision                                                           21

                    2.28  Decision to accredit residential care service                                             22

                    2.29  Telling applicant about decision to accredit                                              22

                    2.30  Varying arrangements for support contacts                                              23

                    2.31  Decision not to accredit                                                                         23

Subdivision 5             After the accreditation decision

                    2.32  Applicant may apply for reconsideration of period for which service to be accredited     24

                    2.33  Applicant may apply for reconsideration of decision not to accredit            25

                    2.34  Requirements of a valid application for reconsideration                              25

                    2.35  Content of an improvement outline                                                          25

                    2.36  Further desk audit or site audit                                                               25

                    2.37  Matters to be included on reconsideration                                                26

                    2.38  Decision on reconsideration                                                                   26

                    2.39  Telling applicant about decision to accredit                                              26

                    2.40  Decision not to accredit                                                                         27

Division 4             Assessment teams

                    2.41  Audit to be carried out by assessment teams                                          28

                    2.42  Assessment team                                                                                 28

                    2.43  Applicant may nominate a member of assessment team                          29

                    2.44  Accreditation body may refuse to include nominee                                   29

                    2.45  Eligibility for assessment team                                                               30

                    2.46  Accreditation body may give authorisation to assessment team                30

Part 3                 Continuous improvement

Division 1             Purpose and application of Part 3

                      3.1  Purpose and application (Act, s 80-1)                                                      32

Division 2             Continuous improvement of residential care services before 1 January 2001

Subdivision 1             Residential care services that are not accredited

                      3.2  Service’s obligations of compliance and continuous improvement               33

                      3.3  Support contacts                                                                                   33

                      3.4  Review audit of residential care services                                                  34

                      3.5  Procedure for review audit of residential care services                               34

                      3.6  Review audit report                                                                                35

                      3.7  Accreditation body must tell Secretary and provider about the report          35

                      3.8  Sanctions recommended if improvements are not satisfactory                   36

Subdivision 2             Residential care services that are accredited

                      3.9  Accredited provider’s obligations of compliance and continuous improvement 37

                    3.10  Plan for continuous improvement                                                            37

                    3.11  Support contacts                                                                                   37

                    3.12  Review audit of accredited residential care services                                  37

                    3.13  Procedure for review audit of accredited residential care services               38

                    3.14  Review audit report                                                                                39

                    3.15  Decision about review audit                                                                    39

                    3.16  Decision not to revoke accreditation                                                        40

                    3.17  Sanctions may be recommended if improvements are not satisfactory       41

Division 3             Continuous improvement of residential care services on and after 1 January 2001

                    3.18  Accredited provider’s obligations of compliance and continuous improvement 42

                    3.19  Plan for continuous improvement                                                            42

                    3.20  Support contacts                                                                                   42

                    3.21  Review audit of accredited residential care services                                  42

                    3.22  Procedure for review audit of accredited residential care services               43

                    3.23  Review audit report                                                                                44

                    3.24  Decision about review audit                                                                    44

                    3.25  Decision not to revoke accreditation                                                        45

                    3.26  Sanctions may be recommended if improvements are not satisfactory       46

Part 4                 Dealing with non-compliance

Division 1             Application of Part 4

                      4.1  Application                                                                                           47

Division 2             Non-compliance before 1 January 2001

                      4.2  Evidence of serious risk to residents                                                       47

                      4.3  Evidence of non-compliance with Act                                                      48

Division 3             Non-compliance on or after 1 January 2001

                      4.4  Evidence of serious risk to residents                                                       48

                      4.5  Evidence of non-compliance with Act                                                      49

                      4.6  Consequences of failure to comply with Accreditation Standards               49

                      4.7  Sanctions recommended if improvements are not satisfactory                   50

Part 5                 Conditions of accreditation grants

                      5.1  Purpose of Part 5 (Act, s 80-2)                                                               51

                      5.2  Information requested by the Minister                                                      51

                      5.3  Information requested by Secretary                                                         51

Part 6                 Promoting quality care in residential care services

                      6.1  Promoting and encouraging quality care                                                  52

                      6.2  Fees for materials                                                                                 52

                      6.3  Fees for seminars or conferences                                                           52

Part 7                 Reviewable decisions

                      7.1  What is a reviewable decision                                                                53

                      7.2  Procedure for review                                                                              53

                      7.3  Support contacts with service during review period                                    53

Part 8                 Registration of quality assessors

                      8.1  Appointment of registrar                                                                         54

                      8.2  Registration of quality assessors                                                            54

                      8.3  Criteria for continued inclusion on register                                                55

                      8.4  Person may apply for review of decision to remove from register                55

                      8.5  Accreditation body must review decision                                                 55

                      8.6  Decision on application                                                                          56

Part 9                 Other matters

                      9.1  Publication of original decisions                                                              57

                      9.2  Publication after request to reconsider decision                                        57

                      9.3  Publication after application to review decision                                         58

                      9.4  Audit report to be made available                                                            58

Notes                                                                                                                               59

 

 

 


Note:   Part 5.4 of the Aged Care Act 1997

Part 5.4 of the Aged Care Act 1997 is about making accreditation grants.

The Aged Care Standards and Accreditation Agency is the body corporate paid an accreditation grant under the accreditation grant agreement for the purpose of accreditation of residential care services in accordance with these Principles, and for other purposes set out in these Principles.  The functions of the Agency include:

     (a)     managing the accreditation process using the Accreditation Standards; and

     (b)     promoting high quality care, and helping industry to improve service quality, by identifying best practices and providing information, education and training to industry; and

     (c)     assessing, and strategically managing, services working towards accreditation; and

     (d)     liaising with the Department of Health and Aged Care about services that do not comply with the standards applicable to them (the Residential Care Standards or the Accreditation Standards, as appropriate).

These Principles set out the procedures to be followed, and the matters to be taken into account, by the Agency for accreditation of residential care services, the Agency’s responsibilities for services that have received accreditation, and conditions to which the accreditation grant is subject.

Part 1                 Preliminary

  

1.1           Name of Principles [see Note 1]

                These Principles are the Accreditation Grant Principles 1999.

1.2           Commencement

                These Principles commence on gazettal.

1.3           Definitions

                In these Principles:

Accountability Principles means the Accountability Principles 1998 made under section 96-1 of the Act.

accreditation grant agreement means an agreement under which an accreditation grant is payable.

Note   Accreditation grant agreements are authorised by subs 80-1 (1) of the Act.

Accreditation Standards means the Accreditation Standards in Schedule 2 of the Quality of Care Principles 1997.

accredited provider means an approved provider of a residential care service in respect of which:

                (a)    the approved provider has an allocation of places; and

               (b)    either:

                          (i)    the approved provider has been given a certificate of accreditation, under subsection 2.12 (3), paragraph 2.29 (3) (b) or subsection 2.39 (3); or

                         (ii)    there is in force a determination under section 42-5 of the Act.

accredited residential care service means a residential care service:

                (a)    that is accredited under these Principles; or

               (b)    in respect of which there is in force a determination under section 42-5 of the Act.

Act means the Aged Care Act 1997.

Allocation Principles means the Allocation Principles 1997 made under section 96-1 of the Act.

applicant means an approved provider that applies for accreditation of a residential care service on behalf of the residential care service.

assessment team means a team created under section 2.42.

commencing residential care service has the meaning given in section 1.4.

desk audit means the procedure described in Subdivision 2 of Division 3 of Part 2.

desk audit report means a report mentioned in section 2.17.

executive summary means a summary of the main findings of a report.

existing residential care service means a residential care service that, when an application for accreditation of the service is made, is already providing residential care.

Note   See s 2.4 and 2.5 for information about making an application.

improvement outline means a document described in paragraph 2.34 (2) (b) and section 2.35.

key personnel, for an approved provider, has the same meaning as in subsection 9-1 (2) of the Act.

plan for continuous improvement is a written plan that explains how a residential care service will continue to improve its compliance with the Residential Care Standards or the Accreditation Standards.

quality assessor means a person registered as a quality assessor by the registrar.

Note   The registrar is explained in Pt 8.

quality management system, for a residential care service, means the organisational structure, procedure and processes used by the service to implement the Accreditation Standards.

register means a register of quality assessors kept by the registrar.

Note   See the note to s 8.1.

registrar means the person or body appointed as registrar under subsection 8.1 (1).

registration period means the period mentioned in section 8.2.

representative, for a person receiving care, or who has received care, through a residential care service, includes an advocate, carer, legal guardian or relative.

residential care service includes a commencing residential care service.

Residential Care Standards means the Residential Care Standards in Schedule 3 to the Quality of Care Principles 1997.

Residential Care Subsidy Principles means the Residential Care Subsidy Principles 1997 made under section 96-1 of the Act.

review means review by the Administrative Appeals Tribunal.

reviewable decision has the meaning given by section 7.1.

Note   This definition is not the same as the definition of reviewable decision in the Act, which applies to different circumstances.

review audit means the processes described in section 3.5, 3.13 or 3.22.

review audit report means a report mentioned in section 3.5, 3.13 or 3.22.

review period has the meaning given by section 7.3.

site audit means the process described in Subdivision 3 of Division 3 of Part 2.

site audit report means a report mentioned in section 2.25.

supplementary review audit report means a report mentioned in section 3.7.

support contact means a contact, between the accreditation body and a residential care service for 1 or more of the following purposes:

                (a)    to supervise the residential care service’s process of continuous improvement;

               (b)    to identify whether there is a need for a review audit;

                (c)    to give the approved provider additional information or training.

Note   See s 3.3.

1.4           Commencing residential care service

         (1)   For these Principles, a commencing residential care service is a residential care service for which the following circumstances exist:

                (a)    an approved provider has been allocated places, under Division 14 of the Act, in relation to the service;

               (b)    residential aged care has not previously been provided in respect of those places.

         (2)   A commencing residential care service does not include any other accredited residential care service on behalf of which an application is being made for accreditation for an additional period.

Example

A change in the approved provider to which places are allocated for a residential care service, or a change in the location of a service, does not, by itself, make a residential care service a commencing residential care service.

 

Note: Definitions

A number of expressions used in these principles are defined in the Aged Care Act 1997, including:

·          accreditation body

·          accreditation day

·           accreditation grant

·           application period

·           approved provider

·          care

·          certified

·          place

·          residential care

·          residential care service.

1.5           Decisions made by accreditation body

         (1)   A decision made by either of the following persons is taken to be a decision by the accreditation body:

                (a)    the general manager of the accreditation body;

               (b)    an officer of the accreditation body authorised by the general manager to make the decision.

         (2)   If these principles require that the accreditation body be satisfied about a matter, it is sufficient if either of the following persons is satisfied about the matter:

                (a)    the general manager of the accreditation body;

               (b)    an officer of the accreditation body authorised by the general manager to deal with the matter.

1.6           Revocation of Accreditation Grant Principles 1998

                The Accreditation Grant Principles 1998, gazetted on 22 July 1998 (Gazette GN 29) are revoked.


 


Part 2                 Accreditation of residential care services

 

Background information

Subsection 42-4 (1) of the Act provides that, on or after the accreditation day, a residential care service meets its accreditation requirement if it is accredited by the accreditation body, or there is a current determination, under section 42-5 of the Act, that it is taken to meet its accreditation requirement.

Subsection 42-4 (2) of the Act provides that the accreditation day is 1 January 2001 if no day is specified in the Residential Care Subsidy Principles. No day has been specified.

Subsection 42-4 (4) of the Act provides that the application period starts on 1 January 2000 if no day is specified in the Residential Care Subsidy Principles. No day has been specified.

Subsection 42-4 (4) also provides that the application period finishes at the end of the day before the accreditation day.

Part 2 of these Principles is about the accreditation of residential care services before and after the accreditation day. It deals with how the accreditation body will exercise its function of administering the accreditation process, and describes how residential care services must go about applying for accreditation, and the criteria they must satisfy to be successful. It also deals with the fees services must pay to the accreditation body.

 


Division 1              Purpose of Part (Act, s 80-1)

2.1           Purpose of Part 2

         (1)   This Part sets out the functions of an accreditation body during the application period, as it receives and considers applications, and makes decisions.

         (2)   This Part also sets out the obligations of the accreditation body to monitor the progress of services as they work towards accreditation.

         (3)   This Part also sets out arrangements for reconsideration or review of a decision made by the accreditation body.

Division 2              Procedures for accreditation

 

Background information: application of Residential Care Standards and Accreditation Standards

Before 1 January 2001 (the accreditation day), a residential care service must comply with the Residential Care Standards. However, to become accredited, and after accreditation, the service must comply with the Accreditation Standards.

On and after 1 January 2001, the Residential Care Standards no longer apply to any residential care service. All residential care services must be accredited against, and monitored for, their compliance with the Accreditation Standards.

 

2.2           Application of Division 2

                This Division applies to:

                (a)    a commencing or existing residential care service that wishes to be accredited; and

               (b)    an accredited residential care service that wishes to be accredited for a further period.

2.3           Summary of procedures for seeking accreditation

                The first stages of obtaining accreditation are:

                (a)    a residential care service must apply for accreditation through its approved provider; and

               (b)    the service to which the application relates must be assessed.

2.4           Application for accreditation

         (1)   An approved provider may apply, in writing, to the accreditation body for accreditation of a residential care service.

         (2)   The accreditation body must tell the applicant that the service to which the application relates will be assessed as part of the accreditation process.

2.5           Making application

         (1)   To be a valid application, the application must:

                (a)    be made by the approved provider on behalf of the service; and

               (b)    be made in the form decided by the accreditation body; and

                (c)    be accompanied by the appropriate fee under sections 2.6, 2.7 and 2.8; and

               (d)    include an undertaking by the applicant to ensure that the service will undertake continuous improvement, measured against the Accreditation Standards, if it is accredited.

         (2)   The accreditation body must not accept an application unless it is a valid application.

         (3)   The application may be accompanied by documents that relate to the service’s quality management system.

2.6           Payment of application fees

         (1)   This section does not apply to an application made on behalf of:

                (a)    a residential care service in respect of which an approved provider has been allocated fewer than 20 residential care places; or

               (b)    a residential care service in respect of which an approved provider has been allocated at least 20, but fewer than 26, residential care places.

         (2)   If an application is made before 1 November 1999, on behalf of a residential care service that is not a commencing residential care service, the fee for the application is the sum of:

                (a)    $2,550; and

               (b)    the lesser of:

                          (i)    $95 for each residential care place allocated to the service; and

                         (ii)    $9,500.

         (3)   The fee worked out under subsection (2) is payable by the applicant as follows:

                (a)    half of the fee is payable when the application is made;

               (b)    half of the fee is payable before the accreditation body gives the applicant a certificate of accreditation for the service to which the application relates.

Note 1   If a decision is made not to accredit the residential care service to which the application relates, the second half of the fee is not payable.

Note 2   Subsections 2.14 (6) and 2.31 (6) provide for the accreditation body to decide to accredit a residential care service after revoking a decision not to accredit the service to which the applicant relates.

         (4)   If the application is made before 1 November 1999, on behalf of a commencing residential care service, the application must be accompanied by a fee that is 20% of the fee that would have been payable if subsection (2) applied to the service.

         (5)   If the application is made on or after 1 November 1999, on behalf of a residential care service that is not a commencing residential care service, the application must be accompanied by a fee that is the sum of:

                (a)    $3,050; and

               (b)    the lesser of:

                          (i)    $95 for each residential care place allocated to the service; and

                         (ii)    $9,500.

         (6)   If the application is made on or after 1 November 1999, on behalf of a commencing residential care service, the application must be accompanied by a fee that is 20% of the fee that would have been payable if subsection (5) applied to the service.

2.7           Circumstances in which a reduced fee is payable

         (1)   An application made on behalf of a commencing residential care service, in respect of which an approved provider has been allocated 20 residential care places, must be accompanied by a fee of $300.

         (2)   An application made on behalf of a residential care service that is not a commencing residential care service, and in respect of which an approved provider has been allocated 20 residential care places, must be accompanied by a fee of $1,500.

         (3)   An application made on behalf of a commencing residential care service in respect of which an approved provider has been allocated more than 20, but fewer than 26, residential care places must be accompanied by a fee that is 20% of the sum of:

                (a)    $1,500; and

               (b)    $500 for each additional place above the 20 places.

         (4)   An application made on behalf of a residential care service that is not a commencing residential care service, and in respect of which an approved provider has been allocated more than 20, but fewer than 26, residential care places, must be accompanied by a fee that is the sum of:

                (a)    $1,500; and

               (b)    $500 for each additional place above the 20 places.

2.8           Circumstances in which no fee is payable

                There is no fee payable for an application made on behalf of a residential care service in respect of which an approved provider has been allocated fewer than 20 residential care places.

Division 3              Procedures for assessment of applications

Subdivision 1              Commencing residential care service

 

Background information

An application on behalf of a commencing residential care service is assessed mainly on the basis of the information given by the applicant. The system of desk audits and site audits described in Subdivisions 2 and 3 does not apply to a commencing residential care service, where persons are not yet receiving care from the service to which the application relates.

 

2.9           Application of Subdivision 1

                This Subdivision applies to an application made on behalf of a commencing residential care service.

2.10        Making the accreditation decision

         (1)   The accreditation body must make a decision on the application within 14 days after receiving it.

         (2)   However, if the applicant has not paid all or part of the application fee mentioned in section 2.5, the accreditation body must make a decision on the application within 14 days after it has received all of the fee.

         (3)   In deciding whether to accredit the residential care service, the accreditation body must take into account:

                (a)    the contents of the application; and

               (b)    information (if any) received from the Secretary; and

                (c)    the applicant’s undertaking that the service will undertake continuous improvement, measured against the Accreditation Standards, if it is accredited.

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

2.11        Decision to accredit residential care service

         (1)   If the accreditation body decides to accredit the residential care service, the accreditation body must decide:

                (a)    the period for which the service is to be accredited; and

               (b)    whether there are any matters in respect of which improvements must be made to improve its compliance with the Accreditation Standards; and

                (c)    the form and frequency of support contacts with the service.

         (2)   The accreditation body must record its decision about the matters mentioned in subsection (1).

         (3)   The period for which the service is to be accredited must be 12 months.

2.12        Telling applicant about decision to accredit

         (1)   If the accreditation body decides to accredit the residential care service, the accreditation body must, within 28 days, tell the applicant, in writing, of the decision.

         (2)   If the accreditation body decides to accredit the service, the accreditation body must also tell the applicant, in writing, about:

                (a)    the period for which the service is to be accredited; and

               (b)    any matters decided by the accreditation body for paragraph 2.11 (1) (b); and

                (c)    the arrangements for support contacts with the service by the accreditation body under Part 3, including how those arrangements may be varied for section 2.13; and

               (d)    the circumstances in which the accreditation may be reviewed under section 3.12; and

                (e)    the arrangements for further accreditation after the accreditation period ends; and

                (f)    the date by which the approved provider that has an allocation of places in respect of the service should apply for further accreditation.

         (3)   If the accreditation body decides to accredit the residential care service, the accreditation body must also give the applicant a certificate of accreditation for the service.

         (4)   The certificate must set out the period for which the service is to be accredited.

2.13        Varying arrangements for support contacts

                The accreditation body may, in writing, vary arrangements for support contacts with the residential care service by the accreditation body.

2.14        Decision not to accredit

         (1)   If the accreditation body decides not to accredit the residential care service, the accreditation body must:

                (a)    decide that the decision is to have effect from:

                          (i)    the end of the period mentioned in subsection 2.33 (1); or

                         (ii)    a later date; and

               (b)    decide the form and frequency of support contacts with the service.

Note   Although the accreditation body decides when its decision is to have effect, the decision is subject to subs (4) and (5).

         (2)   The accreditation body must also, within 28 days after making the decision, tell the applicant and the Secretary, in writing, about the decision.

         (3)   The accreditation body must also give the applicant:

                (a)    an explanation of the effect of subsections (4) and (5); and

               (b)    written reasons for the decision, including a recommendation about the matters in respect of which improvements would be necessary to demonstrate compliance with the Accreditation Standards; and

                (c)    information about the arrangements for support contacts with the service under Part 3; and

               (d)    information about how to submit an improvement outline and when this must be done; and

                (e)    information about how to apply for reconsideration by the accreditation body of the decision; and

                (f)    information about arrangements for support contacts with the service under Part 3 if the decision is to be reconsidered.

Note   See para 2.34 (2) (b) and s 2.35 for information about improvement outlines.

         (4)   The decision not to accredit the residential care service has effect as follows:

                (a)    the decision does not have effect during the period mentioned in subsection 2.33 (1);

               (b)    if the applicant does not apply for reconsideration within the period mentioned in subsection 2.33 (1), the decision has effect at the time decided under paragraph (1) (a);

                (c)    if the applicant applies for reconsideration, the decision does not have effect, and the decision on reconsideration has effect instead.

Note   If the applicant applies for reconsideration, the decision on reconsideration has effect, by force of s 2.38, when the decision on reconsideration is made.

         (5)   Despite subsection (4), the accreditation body may revoke the decision not to accredit the residential care service:

                (a)    during the period mentioned in subsection 2.33 (1); or

               (b)    before the date (if any) decided under subparagraph (1) (a) (ii).

Example

The accreditation body must state a date from which the decision not to accredit has effect. This gives services an opportunity to give the accreditation body an improvement outline, and to demonstrate its compliance with the Accreditation Standards. If adequate performance is demonstrated, then the accreditation body may revoke its decision.

         (6)   If the accreditation body decides to revoke its decision, the accreditation body must:

                (a)    decide to accredit the service to which the application relates; and

               (b)    decide the period for which the service is to be accredited; and

                (c)    decide whether there are any matters in respect of which improvements must be made to improve the service’s performances against the Accreditation Standards; and

               (d)    decide the form and frequency of support contacts with the service; and

                (e)    comply with subsections 2.29 (1), (2) and (3); and

                (f)    tell the Secretary and the applicant, in writing, that the notice has been revoked.

Subdivision 2              Desk audit

 

Background information

It will be possible, in certain circumstances, for an assessment team to decide to carry out a site audit of an existing residential care service immediately after carrying out a desk audit, and without giving the accreditation body a desk audit report: see subsection 2.17 (5) and section 2.46.

 

2.15        Application of Subdivision 2

                This Subdivision does not apply to an application made on behalf of a commencing residential care service.

Note   Arrangements for a commencing residential care service are in Subdiv 1.

2.16        Assessment team must carry out desk audit

         (1)   An assessment team must carry out a desk audit in relation to the application.

Note   Division 4 describes the creation and composition of assessment teams.

         (2)   The desk audit must be completed within 49 days after the accreditation body receives the application.

2.17        Carrying out desk audit

         (1)   In carrying out the desk audit, the assessment team may:

                (a)    review any documents, given by the applicant, that relate to the residential care service’s quality management system; and

               (b)    determine whether the documents indicate that the service complies with the Accreditation Standards.

Note   Section 2.46 allows the accreditation body to authorise an assessment team to proceed directly to a site audit without giving the accreditation body a desk audit report. For example, the accreditation body may give an authorisation to an assessment team that is created to assess a residential care service in a remote area. In these circumstances, it may be more efficient to carry out desk and site audits without submitting a desk audit report. If the assessment team created to carry out a desk audit is given an authorisation, it must comply with the authorisation: see subs (5).

         (2)   In carrying out the desk audit, the assessment team must consider information that the Secretary gives the accreditation body about the service.

         (3)   For subsection (2), the Secretary may give the accreditation body information received from:

                (a)    persons who receive, or who have received, care from the service to which the application relates; and

               (b)    representatives of persons mentioned in paragraph (a).

         (4)   The assessment team must give a written report about the desk audit to the accreditation body (the desk audit report).

         (5)   However, if the assessment team has been given an authorisation under section 2.46, it must:

                (a)    carry out a site audit without giving a desk audit report to the accreditation body; and

               (b)    tell the applicant about which alternative, mentioned in that section, will be taken by the team.

2.18        Contents of desk audit report

         (1)   The desk audit report must include an executive summary.

         (2)   The report must recommend that the accreditation body:

                (a)    continue with the application; or

               (b)    refuse the application.

         (3)   If the recommendation is to refuse the application, the report must also include a recommendation about matters in respect of which the service could improve its compliance with the Accreditation Standards.

2.19        Accreditation body must decide whether or not to proceed

         (1)   If the accreditation body has been given a desk audit report, it must consider the recommendation in the report.

Note   Section 2.46 allows the accreditation body to authorise an assessment team to proceed directly to a site audit without giving the accreditation body a desk audit report. For example, the accreditation body may give an authorisation to an assessment team that is created to assess a residential care service in a remote area. In these circumstances, it may be more efficient to carry out desk and site audits without submitting a desk audit report. If the assessment team created to carry out a desk audit is given an authorisation, it must comply with the authorisation: see subs 2.17 (5).

         (2)   The accreditation body must, within 7 days after receiving the desk audit report, decide to:

                (a)    continue with the application; or

               (b)    refuse the application.

         (3)   If the accreditation body decides to continue with the application it must:

                (a)    tell the applicant about the decision, in writing, within 7 days after making the decision; and

               (b)    consult with the applicant about when the assessment team will start the site audit; and

                (c)    after a date has been agreed for paragraph (b), direct the assessment team to start the site audit.

         (4)   If the accreditation body decides to continue with the application, an assessment team must carry out a site audit of the applicant.

Note   See Subdiv 3 for a description of site audits.

         (5)   If the accreditation body refuses the application, it must decide the form and frequency of support contacts with the service.

         (6)   If the accreditation body refuses the application, it must also, within 7 days of deciding:

                (a)    tell the applicant, in writing, the reasons for the decision, including any matters in respect of which improvements are necessary to allow the assessment team to recommend that the accreditation body continue with the application; and

               (b)    give the applicant a copy of the desk audit report; and

                (c)    give the applicant information about the arrangements for support contacts with the service under Part 3; and

               (d)    give the applicant information about how to apply for reconsideration or review of the decision, and about arrangements for support contacts with the service under Part 3.

Subdivision 3              Site audit

 

Background information

It will be possible, in certain circumstances, for an assessment team to carry out a site audit of an existing residential care service immediately after carrying out a desk audit, and without giving the accreditation body a desk audit report: see subsection 2.17 (5) and section 2.46.

 

2.20        Application of Subdivision 3

                This Subdivision does not apply to an application made on behalf of a commencing residential care service.

Note   Arrangements for a commencing residential care service are in Subdiv 1.

2.21        Assessment team must carry out site audit

                An assessment team must complete a site audit within 56 days after the accreditation body tells the applicant about its decision to continue with the application.

Note   An assessment team must carry out a site audit if the accreditation body makes a decision to continue with an application after a desk audit: see subs 2.19 (2) and (3), which also deal with the accreditation body’s obligation to tell the applicant about its decision.

2.22        Applicant must tell persons receiving care (and their representatives) about site audit

                The applicant must, within 3 days after being told when the site audit will start, tell the persons receiving care from the residential care service (and their representatives):

                (a)    that a site audit of the service will be carried out, and when it will start; and

               (b)    that they will have an opportunity to talk to members of the assessment team.

2.23        Carrying out site audit

         (1)   The assessment team must, during the site audit, visit the premises of the residential care service to which the application relates.

         (2)   In carrying out the audit, the team:

                (a)    must act consistently with any provisions of the Accountability Principles applying to the audit; and

               (b)    must assess the quality of care provided by the applicant against the Accreditation Standards; and

                (c)    must consider any information about the quality of care given to it by persons who are receiving, or who have received, care through the applicant (or by their representatives); and

               (d)    must not disclose or communicate to the applicant, or to key personnel of the applicant, information identifying persons, mentioned in paragraph (c), who have given information to the team.

Note   The Accountability Principles will set out various aspects of the access that a person may have to a residential care service in carrying out functions under these Principles.

         (3)   For paragraph (2) (c), the team must consider the information whether it was given to the team by:

                (a)    the person receiving care, or who has received care; or

               (b)    the person’s representative; or

                (c)    the Secretary.

2.24        Assessment team to have meetings during site audit

         (1)   The assessment team must meet with the applicant (or key personnel of the applicant) on a daily basis, during the site audit, to discuss the audit process.

         (2)   The team must also meet with at least 10% of the persons receiving care through the service (or the representatives of the persons) during the site audit to discuss the audit.

         (3)   Also, if a person receiving care through the service (or his or her representative) asks to meet with the team during the site audit, the applicant must allow the team to meet privately with the person.

         (4)   The team must also:

                (a)    meet with the applicant, or key personnel of the applicant, at the end of the site audit to discuss the assessment; and

               (b)    at this meeting, give the applicant or key personnel a written report of matters that the team believes are the major findings of the site audit.

         (5)   The applicant or key personnel may, within 14 days of the meeting mentioned in paragraph (4) (a), give the accreditation body, and the assessment team, a written response to the report given for paragraph (4) (b).

2.25        Assessment team must give report to accreditation body

         (1)   Within 14 days after the site audit is finished, the assessment team must give a written report about the audit to the accreditation body (the site audit report).

         (2)   The site audit report must include:

                (a)    an executive summary; and

               (b)    a recommendation about accreditation of the residential care service, and about the period of accreditation; and

                (c)    the reasons for the recommendations.

         (3)   If the report recommends accreditation of the residential care service, the site audit report must also include:

                (a)    a statement about the service’s compliance with the Accreditation Standards; and

               (b)    a recommendation about support contacts with the service after accreditation.

         (4)   If the report recommends not to accredit the residential care service, the site audit report must also include a recommendation about matters in respect of which improvements would be necessary to justify a recommendation to accredit the service.

Subdivision 4              The accreditation decision

2.26        Application of Subdivision 4

                This Subdivision does not apply to an application made on behalf of a commencing residential care service.

Note   Arrangements for a commencing residential care service are in Subdiv 1.

2.27        Making the accreditation decision

         (1)   The accreditation body must, within 28 days after receiving the site audit report, decide:

                (a)    to accredit the service; or

               (b)    not to accredit the service.

         (2)   However, if the accreditation body and the applicant agree, within 28 days after receiving the site audit report, on a later time for making the decision, the accreditation body must make a decision on the application by the agreed time.

         (3)   In deciding whether to accredit the residential care service, the accreditation body must take into account:

                (a)    the desk audit report (if any); and

               (b)    the site audit report; and

                (c)    information (if any) received from the Secretary about matters that must be considered, under Division 38 of the Act, for certification of the service; and

               (d)    other information (if any) received from the Secretary; and

                (e)    information (if any) received from the applicant in response to the report of the site audit mentioned in paragraph 2.24 (4) (b); and

                (f)    whether it is satisfied that the residential care service will undertake continuous improvement, measured against the Accreditation Standards, if it is accredited.

Note   Section 2.46 allows the accreditation body to authorise an assessment team to proceed directly to a site audit without giving the accreditation body a desk audit report. For example, the accreditation body may give an authorisation to an assessment team that is created to assess a residential care service in a remote area. In these circumstances, it may be more efficient to carry out desk and site audits without submitting a desk audit report. If the assessment team created to carry out a desk audit is given an authorisation, it must comply with the authorisation: see subs 2.17 (5).

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

Example for paragraph (3) (c)

Under paragraph 38-3 (1) (a) of the Act, the Secretary must have regard to the standard of the buildings and equipment that are being used by the residential care service in providing residential care.

2.28        Decision to accredit residential care service

         (1)   If the accreditation body decides to accredit a residential care service, the accreditation body must decide:

                (a)    the period for which the service is to be accredited; and

               (b)    whether there are any matters in respect of which improvements must be made to improve its compliance with the Accreditation Standards; and

                (c)    the form and frequency of support contacts with the service.

         (2)   The accreditation body must record its decision about the matters mentioned in subsection (1).

2.29        Telling applicant about decision to accredit

         (1)   Within 14 days after making a decision in relation to the application, the accreditation body must tell the applicant, in writing, of the decision.

         (2)   If the accreditation body decides to accredit a residential care service, the accreditation body must also tell the applicant, in writing, about:

                (a)    the period for which the service is to be accredited; and

               (b)    how to apply for reconsideration of that period in accordance with section 2.32; and

                (c)    any matters decided by the accreditation body for paragraph 2.28 (1) (b); and

               (d)    the arrangements for support contacts with the service by the accreditation body under Part 3, including how those arrangements may be varied for section 2.30; and

                (e)    the circumstances in which the accreditation may be reviewed under section 3.12; and

                (f)    the arrangements for a further period of accreditation after the accreditation period ends; and

                (g)    the date by which an application should be made for a further period of accreditation.

         (3)   If the accreditation body decides to accredit a residential care service, the accreditation body must also give the applicant:

                (a)    a copy of the site audit report; and

               (b)    a certificate of accreditation for the service.

         (4)   However, the accreditation body is not required to issue a certificate for paragraph (3) (b) if the fee mentioned in paragraph 2.6 (3) (b) has not been paid.

         (5)   A certificate for subsection (3) must set out the period for which the service is to be accredited.

2.30        Varying arrangements for support contacts

                The accreditation body may, in writing, vary arrangements for support contacts with the residential care service by the accreditation body.

2.31        Decision not to accredit

         (1)   If the accreditation body decides not to accredit the residential care service, the accreditation body must:

                (a)    decide that the decision is to have effect from:

                          (i)    the end of the period mentioned in subsection 2.33 (1); or

                         (ii)    a later date; and

               (b)    decide the form and frequency of support contacts with the service.

Note   Although the accreditation body decides when its decision is to have effect, the decision is subject to subs (4) and (5).

         (2)   The accreditation body must also, within 28 days after making the decision, tell the applicant and the Secretary, in writing, about the decision.

         (3)   The accreditation body must also give the applicant:

                (a)    an explanation of the effect of subsections (4) and (5); and

               (b)    written reasons for the decision, including a recommendation about the matters in respect of which improvements would be necessary to demonstrate compliance with the Accreditation Standards; and

                (c)    a copy of any information given to the accreditation body by the Secretary for the assessment of the applicant; and

               (d)    a copy of the site audit report; and

                (e)    information about the arrangements for support contacts with the service under Part 3; and

                (f)    information about how to submit an improvement outline and when this must be done; and

                (g)    information about how to apply for reconsideration by the accreditation body of the decision.

Note   See para 2.34 (2) (b) and s 2.35 for information about improvement outlines.

         (4)   The decision not to accredit the residential care service has effect as follows:

                (a)    the decision does not have effect during the period mentioned in subsection 2.33 (1);

               (b)    if the applicant does not apply for reconsideration within the period mentioned in subsection 2.33 (1), the decision has effect at the time decided under paragraph (1) (a);

                (c)    if the applicant applies for reconsideration, the decision does not have effect, and the decision on reconsideration has effect instead.

Note   If the applicant applies for reconsideration, the decision on reconsideration has effect, by force of s 2.38, when the decision on reconsideration is made.

         (5)   Despite subsection (4), the accreditation body may revoke the decision not to accredit the residential care service:

                (a)    during the period mentioned in subsection 2.33 (1); or

               (b)    before the date (if any) decided under subparagraph (1) (a) (ii).

         (6)   If the accreditation body decides to revoke its decision, the accreditation body must:

                (a)    decide to accredit the service to which the application relates; and

               (b)    decide the period for which the service is to be accredited; and

                (c)    decide whether there are any matters in respect of which improvements must be made to improve the service’s performances against the Accreditation Standards; and

               (d)    decide the form and frequency of support contacts with the service; and

                (e)    comply with subsections 2.29 (1), (2) and (3); and

                (f)    tell the Secretary and the applicant, in writing, that the notice has been revoked.

Example

The accreditation body must state a date from which the decision not to accredit has effect. This gives services an opportunity to give the accreditation body an improvement outline, and to demonstrate its compliance with the Accreditation Standards. If adequate performance is demonstrated, then the accreditation body may revoke its decision.

Subdivision 5              After the accreditation decision

 

Background information: application of

Residential Care Standards and Accreditation Standards

Before 1 January 2001 (the accreditation day), a residential care service must comply with the Residential Care Standards, unless it is accredited. However, to become accredited, and after accreditation, the service must comply with the Accreditation Standards.

On and after 1 January 2001, the Residential Care Standards no longer apply to any residential care service. All residential care services must be accredited against, and monitored for, their compliance with the Accreditation Standards.

 

2.32        Applicant may apply for reconsideration of period for which service to be accredited

         (1)   The applicant may, within 7 days after being told about a decision to accredit the residential care service, give to the accreditation body a written request to reconsider the period mentioned in paragraph 2.29 (2) (a).

         (2)   The accreditation body must, within 7 days of receiving a request:

                (a)    decide whether or not to vary the period; and

               (b)    tell the applicant, in writing, about its decision.

         (3)   If the decision is to vary the period, the accreditation body must also give the applicant a replacement certificate setting out the revised period for which the service is to be accredited.

2.33        Applicant may apply for reconsideration of decision not to accredit

         (1)   If the accreditation body decides not to accredit a residential care service, the applicant may, within 14 days after being told about the decision, apply to the accreditation body for reconsideration of the decision.

         (2)   However, subsection (1) does not authorise the applicant to apply for reconsideration of a decision that the accreditation body has already reconsidered as part of one application under section 2.4 for accreditation of the service.

2.34        Requirements of a valid application for reconsideration

         (1)   To be a valid application, the application must be made in the form decided by the accreditation body.

         (2)   An application may include either or both of the following:

                (a)    a statement of the grounds on which reconsideration is sought;

               (b)    an improvement outline.

         (3)   If an applicant applies for reconsideration, the accreditation body must continue to carry out support contacts with the service under Part 3 during the period starting when the accreditation body acted under subsection 2.14 (1) or paragraph 2.31 (1) (a) and ending when the decision on reconsideration takes effect.

2.35        Content of an improvement outline

                An improvement outline for paragraph 2.34 (2) (b) must:

                (a)    be in writing; and

               (b)    explain the steps that the service to which the application relates will take to demonstrate compliance with the Accreditation Standards; and

                (c)    include a date by which the steps will be completed.

2.36        Further desk audit or site audit

         (1)   This section applies to a residential care service except a commencing residential care service.

         (2)   If the accreditation body receives an improvement outline for the service, the accreditation body may appoint an assessment team to carry out a further desk audit or further site audit of the service.

         (3)   In carrying out the further audit, the team must:

                (a)    act consistently with any provisions of the Accountability Principles applying to the audit; and

               (b)    comply with Subdivision 2 or 3 when carrying out the audit.

Note   The Accountability Principles will set out various aspects of the access that a person may have to a residential care service in carrying out functions under these Principles.

2.37        Matters to be included on reconsideration

                If the accreditation body receives a valid application under section 2.33, the accreditation body must consider the following matters:

                (a)    the desk audit report (if any);

               (b)    the site audit report prepared for section 2.25 or 2.36;

                (c)    any improvement outline given to the accreditation body by the applicant;

               (d)    any grounds for reconsideration stated in the application for reconsideration.

2.38        Decision on reconsideration

         (1)   The accreditation body must, after considering an application for reconsideration, decide:

                (a)    to accredit the service; or

               (b)    not to accredit the service.

         (2)   The accreditation body must make its decision within 56 days after receiving the application.

         (3)   If, the accreditation body decides to accredit a residential care service, the accreditation body must decide:

                (a)    the period for which the service is to be accredited; and

               (b)    whether there are any matters in respect of which improvements must be made to improve its compliance with the Accreditation Standards; and

                (c)    the form and frequency of support contacts with the service.

         (4)   The accreditation body must record its decision about the matters mentioned in subsection (3).

         (5)   If the residential care service to which the decision relates is a commencing residential care service, the period for which the service is to be accredited must be 12 months.

2.39        Telling applicant about decision to accredit

         (1)   Within 14 days after making a decision on the application, the accreditation body must tell the applicant, in writing, of the decision.

         (2)   If the accreditation body decides to accredit a residential care service, the accreditation body must also tell the applicant, in writing, about:

                (a)    the period for which the service is to be accredited; and

               (b)    any matters decided by the accreditation body for paragraph 2.38 (3) (b); and

                (c)    the arrangements for support contacts with the service by the accreditation body under Part 3, including how those arrangements may be varied; and

               (d)    the circumstances in which the accreditation may be reviewed; and

                (e)    the arrangements for further accreditation after the accreditation period ends.

         (3)   If the accreditation body decides to accredit a residential care service, the accreditation body must also give the applicant a certificate of accreditation for the service.

         (4)   After the service is accredited, the accreditation body may, in writing, vary the arrangements for support contacts with the service by the accreditation body.

Note   To vary the arrangements for continuing supervision, the accreditation body must comply with s 2.30.

2.40        Decision not to accredit

         (1)   If, after considering an application for reconsideration, the accreditation body decides not to accredit the residential care service to which the application relates, the accreditation body must, within 14 days of making the decision:

                (a)    tell the applicant, in writing, about the decision; and

               (b)    tell the Secretary, in writing, about the decision.

         (2)   If the accreditation body decides not to accredit the service under subsection 2.38 (1), it must also decide the form and frequency of support contacts with the service.

         (3)   The accreditation body must give the applicant:

                (a)    notice of the date on which the refusal to accredit the service will take effect; and

               (b)    written reasons for the decision, including a recommendation about the matters in respect of which improvements would be necessary to demonstrate compliance with the Accreditation Standards; and

                (c)    information about the arrangements for support contacts with the service under Part 3; and

               (d)    information about how to submit an improvement outline and when this must be done; and

                (e)    information about how to apply to the Administrative Appeals Tribunal for review of the decision.

Note 1   See para 2.34 (2) (b) and s 2.35 for information about improvement outlines.

Note 2   See Pt 7 for information about review of decisions.

Division 4              Assessment teams

2.41        Audit to be carried out by assessment teams

         (1)   Desk audits and site audits of residential care services must be carried out by assessment teams.

         (2)   Review audits of residential care services must also be carried out by assessment teams.

         (3)   Assessment teams must be created by the accreditation body, and include only registered quality assessors.

2.42        Assessment team

         (1)   The quality assessors who carry out an audit are the assessment team.

Note   An assessment team will be created to assess each application for accreditation, and for each review audit that is undertaken.

         (2)   An assessment team, created for a purpose other than a review audit, may consist of 1 member.

Note   See para 3.13 (1) (a) and 3.22 (1) (a) for more information about the creation of an assessment team to undertake a review audit.

         (3)   Subsection (4) applies if the accreditation body:

                (a)    receives a valid application for accreditation of an existing residential care service; or

               (b)    appoints an assessment team for subsection 2.36 (3); or

                (c)    decides to conduct a review audit.

         (4)   The accreditation body must:

                (a)    decide the number of quality assessors who are to be the members of the assessment team; and

               (b)    create the team; and

                (c)    direct the team to carry out the duties required by the accreditation body.

Note   The assessment team that carries out a particular audit might not be the team that carries out other parts of an accreditation process.

         (5)   The accreditation body must tell the applicant who is in the assessment team for the audit within 28 days after receiving the application for accreditation.

Example

An example of circumstances in which the accreditation body may decide to create a team consisting of only 1 member is where the service is a small service located in a rural or remote area.

         (6)   If a member of an assessment team becomes unavailable during the audit, the accreditation body may replace the member.

         (7)   If the accreditation body acts under subsection (6), it must tell the applicant as soon as possible after acting.

         (8)   The accreditation body must disband an assessment team when the team has completed the duties given to it by the accreditation body.

2.43        Applicant may nominate a member of assessment team

         (1)   Before the accreditation body creates an assessment team for an applicant, the accreditation body must ask the applicant to nominate not more than 3 quality assessors as potential members of the team.

         (2)   However, the accreditation body is not required to ask an applicant to nominate quality assessors if the accreditation body:

                (a)    has decided, under paragraph 2.42 (4) (a), that the assessment team will only have 1 member; or

               (b)    is creating an assessment team to undertake a further site audit for the purposes of:

                          (i)    section 2.36; or

                         (ii)    Subdivision 2 of Division 2 of Part 3; or

                         (iii)    Division 3 of Part 3; or

                (c)    is creating an assessment team to undertake a review audit.

         (3)   The applicant is not required to nominate a member.

         (4)   If the applicant nominates 1 or more quality assessors who are eligible for inclusion in the team under subsections 2.45 (1), (2), (3) and (4) in response to a request under subsection (1):

                (a)    the accreditation body must include 1 of the nominees; and

               (b)    the accreditation body may include other nominees; and

                (c)    the accreditation body is not required to include a specific nominee, or a specific number of nominees, whether or not the applicant has asked it to do so.

         (5)   A quality assessor nominated by the applicant must be:

                (a)    a registered quality assessor; and

               (b)    eligible for inclusion in the team under subsections 2.45 (1), (2), (3) and (4).

         (6)   If the accreditation body acts under subsection 2.42 (6), the accreditation body is not required to replace a member with a quality assessor nominated by the applicant, unless the member to be replaced was an assessor nominated by the applicant.

2.44        Accreditation body may refuse to include nominee

         (1)   The accreditation body may refuse to include in an assessment team a quality assessor nominated by the applicant if the assessor is not eligible for inclusion in the team under subsection 2.45 (1), (2), (3) or (4).

         (2)   If the accreditation body acts under subsection (1), it must tell the applicant about its decision.

         (3)   The applicant may, within 7 days after being told about the decision, ask the accreditation body, in writing, to reconsider the decision.

         (4)   The applicant may only make 1 request under subsection (3).

Example

An applicant may nominate 3 quality assessors for inclusion in the assessment team. If none of them is included, and the applicant wants the accreditation body to reconsider all 3 nominees, the applicant may only make 1 application for reconsideration.

         (5)   If the accreditation body receives a request under subsection (3), it:

                (a)    may, within 7 days of receiving the request, vary its decision under subsection (1); and

               (b)    must tell the applicant, in writing, about its decision.

2.45        Eligibility for assessment team

         (1)   Each member of an assessment team must be a registered quality assessor.

         (2)   The accreditation body must not include a quality assessor in the team for an audit unless the assessor is available to complete the audit.

         (3)   The accreditation body must not include a quality assessor in the team if the assessor helped the applicant implement a quality management system for a residential care service, or for a residential care service operated by key personnel of the applicant, in the 3 years before the team is created.

         (4)   The accreditation body must not include a quality assessor in the team if the assessor has a pecuniary or other interest that could conflict with a proper audit of the applicant.

         (5)   The applicant may, in writing, within 14 days after being told under subsection 2.42 (5) who is in the team, object to a quality assessor in the team because the assessor is not eligible for inclusion in the team under subsection (1), (2), (3) or (4).

         (6)   If an applicant makes an objection for subsection (5), the accreditation body must decide to:

                (a)    accept the objection and create a new assessment team; or

               (b)    reject the objection.

         (7)   The accreditation body must tell the applicant, in writing, about its decision, within 7 days of receiving the objection.

Note   Section 2.46 allows the accreditation body to authorise an assessment team to proceed directly to a site audit without giving the accreditation body a desk audit report. For example, the accreditation body may give an authorisation to an assessment team that is created to assess a residential care service in a remote area. In these circumstances, it may be more efficient to carry out desk and site audits without submitting a desk audit report.

2.46        Accreditation body may give authorisation to assessment team

         (1)   The accreditation body may, in writing, authorise an assessment team to carry out a site audit without giving the accreditation body a desk audit report under section 2.17.

         (2)   If the accreditation body gives an authorisation for subsection (1), it must give a copy of the authorisation to the applicant.


 


Part 3                 Continuous improvement

 

Background information

Subsection 42-4 (1) of the Act provides that, on or after 1 January 2001 (the accreditation day), a residential care service meets its accreditation requirement if it is accredited by the accreditation body, or there is a current determination under section 42-5 of the Act that it is taken to meet its accreditation requirement.

Subsection 42-4 (2) of the Act provides that the accreditation day is 1 January 2001 if no day is specified in the Residential Care Subsidy Principles. No day has been specified.

Before the accreditation day, a residential care service must comply with the Residential Care Standards, unless it is accredited. However, to become accredited, and after accreditation, the service must comply with the Accreditation Standards.

On and after 1 January 2001, the Residential Care Standards no longer apply to any residential care service. All residential care services must be accredited according to their compliance with the Accreditation Standards. After accreditation, the services will be monitored according to their compliance with the Accreditation Standards only.

Also, under section 2.5 of these principles, a service on behalf of which an application is made must undertake to engage in continuous improvement after accreditation, to better deliver services in accordance with the Accreditation Standards.

 


Division 1              Purpose and application of Part 3

3.1           Purpose and application (Act, s 80-1)

         (1)   This Part sets out the on-going responsibilities of the accreditation body, accredited providers and residential care services:

                (a)    to help accredited residential care services meet their responsibility of continuous improvement, by education and training, and monitoring services’ performance by support contacts; and

               (b)    to help other services meet the requirements for accreditation.

         (2)   Subdivision 1 of Division 2:

                (a)    applies to a residential care service that is operating before 1 January 2001, but is not accredited; and

               (b)    ceases to apply immediately before 1 January 2001.

         (3)   Subdivision 2 of Division 2:

                (a)    applies to an accredited residential care service that is operating before 1 January 2001; and

               (b)    ceases to apply immediately before 1 January 2001.

         (4)   Division 3 applies to an accredited residential care service on and after 1 January 2001.

Division 2              Continuous improvement of residential care services before 1 January 2001

Subdivision 1              Residential care services that are not accredited

 

Background information

This Subdivision applies to residential care services, operating before 1 January 2001, that are not yet accredited, but that are working towards accreditation.

These services must comply with the Residential Care Standards. In addition, they must undertake a process of continuous improvement towards accreditation on the basis of complying with the Accreditation Standards. This is because accreditation will only be given to services that can demonstrate compliance with the Accreditation Standards.

This Subdivision sets out the obligations, before 1 January 2001, of a service that is seeking to achieve, and demonstrate, compliance with the Accreditation Standards. It also sets out the role that the accreditation body will play in monitoring the progress of the service, and helping it to comply with the Residential Care Standards and Accreditation Standards.

 

3.2           Service’s obligations of compliance and continuous improvement

         (1)   An approved provider that has an allocation of places in respect of a residential care service must:

                (a)    comply with the Residential Care Standards, and its other responsibilities under the Act; and

               (b)    undertake a process of continuous improvement.

         (2)   This Division explains how continuous improvement will be monitored by the accreditation body, and how the accreditation body will help accredited providers to meet the obligations of accreditation.

3.3           Support contacts

         (1)   The accreditation body may carry out regular supervision of a residential care service to ensure compliance with the Residential Care Standards and other responsibilities under the Act.

         (2)   Supervision by the accreditation body is carried out through support contacts, and with the assistance of the approved provider that has an allocation of places in respect of the service.

         (3)   The accreditation body may carry out a support contact in a way that it decides is appropriate for the residential care service.

         (4)   Within 14 days after each support contact, the accreditation body must confirm or vary the arrangements for future support contacts.

3.4           Review audit of residential care services

         (1)   The accreditation body may arrange for a review audit if it believes, on reasonable grounds, that there may not be compliance with the Residential Care Standards, or other responsibilities under the Act.

         (2)   The accreditation body may arrange for a review audit if there has been a change to the service about which, under section 9-1 of the Act, the accredited provider must tell the Secretary.

         (3)   The accreditation body may arrange for a review audit if, under section 16-1 of the Act, there has been a transfer of allocated places.

         (4)   The accreditation body may arrange for a review audit if there has been a change to the premises of the service.

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

3.5           Procedure for review audit of residential care services

         (1)   In carrying out the review audit, the assessment team:

                (a)    must consist of at least 2 quality assessors who meet the requirements of subsections 2.45 (1), (2), (3) and (4); and

               (b)    must act consistently with any provisions of the Accountability Principles applying to the audit; and

                (c)    must assess the quality of care provided by the residential care service against the Residential Care Standards; and

               (d)    must consider any comments made by the Secretary, or by persons receiving care, or who have received care, through the service (or their representatives) on the quality of care; and

                (e)    must consider any submissions made, on behalf of the service, by the approved provider that has an allocation of places in respect of the service; and

                (f)    must carry out the review audit on the service’s premises.

Note 1   Subsections 2.45 (1), (2), (3) and (4) describe the criteria that a quality assessor must meet to be included in an assessment team. However, an assessment team created to undertake a review audit will not include an assessor nominated by the service: see subs 2.43 (2). Also, subs 2.45 (5), (6) and (7) do not apply to assessment teams created for review audits.

Note 2   The Accountability Principles will set out various aspects of the access that a person may have to a residential care service in carrying out functions under these Principles.

         (2)   In carrying out the review audit, the assessment team must not disclose or communicate to the service, or to key personnel, information identifying persons, mentioned in paragraph (1) (d), who have given information to the team.

         (3)   The team must, within 7 days after completing the review audit, give a written report about the review audit (the review audit report) to the accreditation body and the approved provider that has an allocation of places in respect of the service.

         (4)   The accreditation body must ensure that the review audit report is completed, and given to the Secretary, within 21 days after the review audit starts.

         (5)   The procedures in Divisions 2 and 3 of Part 2 do not apply to an audit carried out under this Part.

3.6           Review audit report

         (1)   The review audit report mentioned in section 3.5 must include an executive summary.

         (2)   The report must also include:

                (a)    a recommendation about any matters in respect of which improvements would be necessary; and

               (b)    a recommendation about further support contacts with the service.

3.7           Accreditation body must tell Secretary and provider about the report

         (1)   Within 14 days after receiving the review audit report, the accreditation body must tell the Secretary, and the approved provider that has an allocation of places in respect of the residential care service, in writing, about the review audit report, including:

                (a)    written recommendations about the matters (if any) mentioned in subsection 3.6 (2); and

               (b)    information about the arrangements for support contacts with the service by the accreditation body under this Part; and

                (c)    the need to agree on a timetable to make improvements in these matters.

         (2)   The approved provider may, within 14 days of being told about the matters mentioned in subsection (1), give the accreditation body and the assessment team a written response.

         (3)   The accreditation body:

                (a)    must consider the approved provider’s response (if any); and

               (b)    may give the Secretary and the provider a supplementary review audit report.

         (4)   The accreditation body must, within 14 days after the end of the period mentioned in subsection (2), publish the review audit report and the supplementary review audit report (if any).

3.8           Sanctions recommended if improvements are not satisfactory

         (1)   This section applies if the accreditation body, and the approved provider that has an allocation of places in respect of the residential care service, have agreed on a timetable mentioned in paragraph 3.7 (1) (c).

         (2)   If, at the end of the timetable mentioned in subsection (1), the accreditation body is not satisfied that the level of care provided by the residential care service complies with the Residential Care Standards, the accreditation body must do the things mentioned in this section.

         (3)   Within 7 days after the end of the timetable, the accreditation body must give written notice that it is not satisfied to:

                (a)    the Secretary; and

               (b)    the approved provider that has an allocation of places in respect of the residential care service.

         (4)   As soon as practicable, give to the Secretary, and to the approved provider, notice of any other information, given to it during the review audit, about the level of care provided by the service.

         (5)   The accreditation body must also give to the Secretary and to the approved provider specific information about, and evidence of, the way in which the level of care is not satisfactory.

         (6)   The accreditation body must also:

                (a)    give the Secretary a recommendation about whether or not sanctions under the Act should be imposed on the approved provider; and

               (b)    give the approved provider a copy of the recommendation mentioned in paragraph (a).

Subdivision 2              Residential care services that are accredited

 

Background information

This Subdivision applies to residential care services that are accredited before 1 January 2001.

These services must comply with the Accreditation Standards only. They must also demonstrate continuous improvement, measured against these Standards: see section 2.5.

This Subdivision sets out the continuous improvement obligations, before 1 January 2001, of an accredited residential care service. It also sets out the role that the accreditation body will play in helping it to meet the obligation of continuous improvement.

 

3.9           Accredited provider’s obligations of compliance and continuous improvement

         (1)   An accredited provider must:

                (a)    ensure that the residential care service complies with the Accreditation Standards and its other responsibilities under the Act; and

               (b)    undertake a process of continuous improvement, measured against the Accreditation Standards.

         (2)   This Division explains how continuous improvement will be monitored by the accreditation body, and how the accreditation body will help accredited providers to meet the obligations of accreditation.

3.10        Plan for continuous improvement

         (1)   An accredited provider must give the accreditation body a plan for continuous improvement by the residential care service for which the provider holds a certificate of accreditation.

         (2)   The plan must include an explanation of how the service will address any matters identified by the assessment team, during a site audit, in respect of which the service could improve its performance.

         (3)   The plan must be in a form approved by the accreditation body.

3.11        Support contacts

         (1)   The accreditation body may carry out regular supervision of an accredited residential care service to ensure compliance with the Accreditation Standards and other responsibilities under the Act.

         (2)   Supervision by the accreditation body must be carried out through support contacts, and with the assistance of the accredited provider, during which the accreditation body will:

                (a)    monitor compliance with the Accreditation Standards and compliance with the Act; and

               (b)    assist the service to undertake its continuous improvement process.

Note   The frequency and form of support contacts will be set out in the decision to accredit the service: see subs 2.29 (2).

         (3)   Within 14 days after each support contact, the accreditation body must confirm or vary the arrangements for future support contacts.

3.12        Review audit of accredited residential care services

         (1)   The accreditation body may arrange for a review audit if it believes, on reasonable grounds, that there may not be compliance with the Accreditation Standards or other responsibilities under the Act.

         (2)   The accreditation body may arrange for a review audit if there has been a change to the service about which, under section 9-1 of the Act, the accredited provider must tell the Secretary.

         (3)   The accreditation body may arrange for a review audit if, under section 16-1 of the Act, there has been a transfer of allocated places.

         (4)   The accreditation body may arrange for a review audit if there has been a change to the premises of the service.

         (5)   The accreditation body may arrange for a review audit if the service has not complied with the arrangements made for support contacts, as required by the accreditation decision made for section 2.11, 2.28 or 2.38.

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

3.13        Procedure for review audit of accredited residential care services

         (1)   In carrying out the review audit, the assessment team:

                (a)    must consist of at least 2 quality assessors who meet the requirements of subsections 2.45 (1), (2), (3) and (4); and

               (b)    must act consistently with any provisions of the Accountability Principles applying to the audit; and

                (c)    must assess the quality of care provided by the residential care service against the Accreditation Standards; and

               (d)    must consider any comments made by the Secretary on the quality of care; and

                (e)    must consider any comments made by persons receiving care, or who have received care, through the service (or their representatives) on the quality of care; and

                (f)    must consider any submissions made by the accredited provider on behalf of the service; and

                (g)    must carry out the review audit on the service’s premises.

Note 1   Subsections 2.45 (1), (2), (3) and (4) describe the criteria that a quality assessor must meet to be included in an assessment team. However, an assessment team created to undertake a review audit will not include an assessor nominated by the service: see subs 2.43 (2). Also, subs 2.45 (5), (6) and (7) do not apply to an assessment team created for a review audit.

Note 2   The Accountability Principles will set out various aspects of the access that a person may have to a residential care service in carrying out functions under these Principles.

         (2)   In carrying out the review audit, the assessment team must not disclose or communicate to the service, or to key personnel, information identifying persons, mentioned in paragraph (1) (e), who have given information to the team.

         (3)   The team must also:

                (a)    meet with the approved provider, or key personnel of the approved provider, at the end of the review audit to discuss the assessment; and

               (b)    at this meeting, give the approved provider or key personnel a written report of matters that the team believes are the major findings of the review audit.

         (4)   The approved provider or key personnel may, within 7 days of the meeting mentioned in paragraph (3) (a), give the accreditation body and the assessment team a written response to the report given for paragraph (3) (b).

         (5)   The team must, within 7 days after completing the review audit, give a written report about the review audit (the review audit report) to the accreditation body and the accredited provider.

         (6)   The procedures in Divisions 2 and 3 of Part 2 do not apply to an audit carried out under this Part.

3.14        Review audit report

         (1)   The review audit report mentioned in section 3.13 must include:

                (a)    an executive summary; and

               (b)    a recommendation about whether the residential care service’s accreditation should be revoked, and the reasons for the recommendation.

         (2)   If the assessment team gives a recommendation to revoke the accreditation of the service, the report must include a recommendation about the matters in respect of which improvements would be necessary to justify a recommendation to accredit the service if it were to apply for accreditation in the future.

         (3)   If the assessment team gives a recommendation not to revoke the accreditation of the service, the report must include recommendations about:

                (a)    whether the period of accreditation should be varied; and

               (b)    further support contacts with the service.

3.15        Decision about review audit

         (1)   The accreditation body may decide:

                (a)    to vary the period of accreditation; or

               (b)    to revoke the accreditation of the service; or

                (c)    not to revoke the accreditation.

         (2)   In making its decision, the accreditation body must take into account:

                (a)    the review audit report; and

               (b)    any information given to the accreditation body by persons receiving care, or who have received care, through the residential care service (or their representatives); and

                (c)    any information given to the accreditation body by the Secretary; and

               (d)    information (if any) received from the approved provider in response to the report of findings of the review audit mentioned in section 3.13.

         (3)   Within 14 days after receiving the review audit report, the accreditation body must:

                (a)    tell the accredited provider, in writing, about the decision; and

               (b)    if the decision is to revoke the accreditation of the service — tell the Secretary, in writing, about the decision.

         (4)   If the accreditation body decides to vary the period of accreditation, the accreditation body must give the accredited provider written reasons for the variation.

         (5)   If the accreditation body decides to revoke the accreditation of the service, the accreditation body must:

                (a)    give the accredited provider written reasons for the revocation, including a recommendation about matters in respect of which improvements would be necessary to recommend continuation of the service’s accreditation; and

               (b)    tell the accredited provider when the decision takes effect; and

                (c)    give the accredited provider information about how to apply for reconsideration and review of the decision, and about arrangements for the supervision of the service under this Part during the review period.

         (6)   The accredited provider may, within 14 days of being told about the decision to revoke the accreditation of the service, ask the accreditation body, in writing, to reconsider its decision to revoke the service’s accreditation.

         (7)   The reconsideration procedure in Subdivision 5 of Division 3 of Part 2 applies to reconsideration of a decision to revoke the accreditation of the service as if:

                (a)    references in Subdivision 5 to a decision not to accredit a service were references to a decision to revoke accreditation; and

               (b)    references in Subdivision 5 to a decision, on reconsideration, to accredit a service were references to a decision, on reconsideration, not to revoke accreditation; and

                (c)    references in Subdivision 5 to a decision, on reconsideration, not to accredit a service were references to a decision, on reconsideration, to confirm the revocation of accreditation; and

               (d)    references in Subdivision 5 to an applicant were references to an accredited provider who makes a request under subsection (5).

3.16        Decision not to revoke accreditation

         (1)   If the accreditation body decides not to revoke the accreditation of the residential care service, the accreditation body must decide:

                (a)    whether there are any matters in respect of which improvements must be made to ensure that the service complies with its responsibilities for continuous improvement; and

               (b)    the need to agree on a timetable to make improvements in these matters; and

                (c)    the form and frequency of support contacts with the service by the accreditation body under this Part.

         (2)   The accreditation body must tell the accredited provider about the decision mentioned in subsection (1).

         (3)   The accredited provider may, in writing, ask the accreditation body to reconsider its decision within 14 days of being told about the decision.

         (4)   If the accreditation body receives a request under subsection (3), it must decide whether to confirm its decision, and give the accredited provider its decision:

                (a)    in writing; and

               (b)    within 14 days of receiving the request.

3.17        Sanctions may be recommended if improvements are not satisfactory

         (1)   If, at the end of a timetable agreed on for section 3.16, the accreditation body is not satisfied that the level of care provided by the residential care service complies with the Accreditation Standards, the accreditation body must:

                (a)    tell the Secretary, in writing, that it is not satisfied; and

               (b)    give a copy of the review audit report, and any other relevant documents, to the Secretary, and the approved provider, as soon as practicable.

         (2)   The accreditation body must also give the Secretary and the approved provider specific information about, and evidence of, the way in which the level of care is not satisfactory.

         (3)   The accreditation body must also give to the Secretary a recommendation about whether or not sanctions under the Act should be imposed on the approved provider.

Division 3              Continuous improvement of residential care services on and after 1 January 2001

 

Background information

This Division applies to residential care services that are accredited on and after 1 January 2001.

These services must comply with the Accreditation Standards. They must also demonstrate continuous improvement, measured against these Standards: see section 2.5.

This Division sets out the continuous improvement obligations, on and after 1 January 2001, of an accredited residential care service. It also sets out the role that the accreditation body will play in helping it to meet the obligation of continuous improvement.

 

3.18        Accredited provider’s obligations of compliance and continuous improvement

         (1)   An accredited provider must:

                (a)    ensure that the residential care service complies with the Accreditation Standards and its other responsibilities under the Act; and

               (b)    undertake a process of continuous improvement, measured against the Accreditation Standards.

         (2)   This Division explains how continuous improvement will be monitored by the accreditation body, and how the accreditation body will help accredited providers to meet the obligations of accreditation.

3.19        Plan for continuous improvement

         (1)   An accredited provider must give the accreditation body a plan for continuous improvement by the residential care service for which the provider holds a certificate of accreditation.

         (2)   The plan for continuous improvement must include an explanation of how the service will address any matters identified by the assessment team, during a site audit, in respect of which the service could improve its performance.

         (3)   The plan for continuous improvement must be in a form approved by the accreditation body.

3.20        Support contacts

         (1)   The accreditation body must carry out regular supervision of an accredited residential care service to ensure compliance with the Accreditation Standards and other responsibilities under the Act.

         (2)   Supervision by the accreditation body must be carried out through support contacts, during which the accreditation body will:

                (a)    monitor compliance with the Accreditation Standards and compliance with the Act; and

               (b)    assist the service to undertake its continuous improvement process.

Note   The frequency and form of support contacts will be set out in the decision to accredit the service: see subs 2.12 (2) and 2.29 (2).

         (3)   Within 14 days after each support contact, the accreditation body must confirm or vary the arrangements for future support contacts.

3.21        Review audit of accredited residential care services

         (1)   The accreditation body may arrange for a review audit if it believes, on reasonable grounds, that there may not be compliance with the Accreditation Standards or other responsibilities under the Act.

         (2)   The accreditation body may arrange for a review audit if there has been a change to the service about which, under section 9-1 of the Act, the accredited provider must tell the Secretary.

         (3)   The accreditation body may arrange for a review audit if, under section 16-1 of the Act, there has been a transfer of allocated places.

         (4)   The accreditation body may arrange for a review audit if there has been a change to the premises of the service.

         (5)   The accreditation body may arrange for a review audit if the service has not complied with the arrangements made for support contacts, as required by the accreditation decision made for section 2.11, 2.28 or 2.38.

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

3.22        Procedure for review audit of accredited residential care services

         (1)   In carrying out the review audit, the assessment team must:

                (a)    consist of at least 2 quality assessors who meet the requirements of subsections 2.45 (1), (2), (3) and (4); and

               (b)    act consistently with any provisions of the Accountability Principles applying to the audit; and

                (c)    assess the quality of care provided by the residential care service against the Accreditation Standards; and

               (d)    must consider any comments made by the Secretary on the quality of care; and

                (e)    must consider any comments made by persons receiving care, or who have received care, through the service (or their representatives) on the quality of care; and

                (f)    consider any submissions made by the accredited provider on behalf of the service; and

                (g)    carry out the review audit on the service’s premises.

Note 1   Subsections 2.45 (1), (2), (3) and (4) describe the criteria that a quality assessor must meet to be included in an assessment team. However, an assessment team created to undertake a review audit will not include an assessor nominated by the service: see subs 2.43 (2). Also, subs 2.45 (5), (6) and (7) do not apply to an assessment team created for a review audit.

Note 2   The Accountability Principles will set out various aspects of the access that a person may have to a residential care service in carrying out functions under these Principles.

         (2)   In carrying out the review audit, the assessment team must not disclose or communicate to the service, or to key personnel of the service, information identifying persons, mentioned in paragraph (1) (e), who have given information to the team.

         (3)   The team must also:

                (a)    meet with the approved provider, or key personnel of the approved provider, at the end of the review audit to discuss the assessment; and

               (b)    at this meeting, give the approved provider or key personnel a written report of matters that the team believes are the major findings of the review audit.

         (4)   The approved provider or key personnel may, within 7 days of the meeting mentioned in paragraph (3) (a), give the accreditation body and the assessment team a written response to the report given for paragraph (3) (b).

         (5)   The team must, within 7 days after completing the review audit, give a written report about the review audit (the review audit report) to the accreditation body and the accredited provider.

         (6)   The procedures in Divisions 2 and 3 of Part 2 do not apply to an audit carried out under this Part.

3.23        Review audit report

         (1)   The review audit report mentioned in section 3.22 must include:

                (a)    a recommendation:

                          (i)    not to revoke the residential care service’s accreditation; or

                         (ii)    to revoke the service’s accreditation; and

               (b)    the reasons for the recommendation.

         (2)   If the assessment team gives a recommendation to revoke the service’s accreditation, the report must also include a recommendation about the matters in respect of which improvements would be necessary to justify a recommendation to accredit the service if it were to apply for accreditation in the future.

         (3)   If the assessment team gives a recommendation not to revoke the accreditation of the service, the report must include recommendations about:

                (a)    whether the period of accreditation should be varied; and

               (b)    further support contacts with the service.

3.24        Decision about review audit

         (1)   The accreditation body may decide:

                (a)    to vary the period of accreditation; or

               (b)    to revoke the accreditation of the service; or

                (c)    not to revoke the accreditation.

Note   It is open to the accreditation body to make no change to the existing arrangements.

         (2)   In making its decision, the accreditation body must take into account:

                (a)    the review audit report; and

               (b)    any information given to the accreditation body by persons receiving care, or who have received care, through the residential care service (or their representatives); and

                (c)    any information given to the accreditation body by the Secretary; and

               (d)    information (if any) received from the approved provider in response to the report of findings of the review audit mentioned in section 3.22.

         (3)   Within 14 days after receiving the review audit report, the accreditation body must:

                (a)    tell the approved provider, in writing, about the decision; and

               (b)    if the decision is to revoke the accreditation of the service — tell the Secretary, in writing, about the decision.

         (4)   If the accreditation body decides to vary the period of accreditation, the accreditation body must give the accredited provider written reasons for the variation.

         (5)   If the accreditation body decides to revoke the service’s accreditation, the accreditation body must:

                (a)    give the accredited provider written reasons for the revocation, including a recommendation about matters in respect of which improvements would be necessary to recommend continuation of the service’s accreditation; and

               (b)    tell the accredited provider when the decision takes effect; and

                (c)    give the accredited provider information about how to apply for reconsideration and review of the decision, and about arrangements for the supervision of the service under this Part during the review period.

         (6)   The accredited provider may, within 14 days of being told about the decision, ask the accreditation body, in writing, to reconsider its decision to revoke the service’s accreditation.

         (7)   The reconsideration procedure in Subdivision 5 of Division 3 of Part 2 applies to reconsideration of a decision to revoke the accreditation of the service as if:

                (a)    references in Subdivision 5 to a decision not to accredit a service were references to a decision to revoke accreditation; and

               (b)    references in Subdivision 5 to a decision, on reconsideration, to accredit a service were references to a decision, on reconsideration, not to revoke accreditation; and

                (c)    references in Subdivision 5 to a decision, on reconsideration, not to accredit a service were references to a decision, on reconsideration, to confirm the revocation of accreditation; and

               (d)    references in Subdivision 5 to an applicant were references to an accredited provider who makes a request under subsection (5).

3.25        Decision not to revoke accreditation

         (1)   If the accreditation body decides not to revoke the residential care service’s accreditation, the accreditation body must decide:

                (a)    whether there are any matters in respect of which improvements must be made to ensure that the service complies with its responsibilities for continuous improvement; and

               (b)    the need to agree on a timetable to make improvements in these matters; and

                (c)    the form and frequency of support contacts with the service by the accreditation body under this Part.

         (2)   The accreditation body must tell the accredited provider about the decision mentioned in subsection (1).

         (3)   The accredited provider may, in writing, within 14 days after being told about a decision under subsection (1), ask the accreditation body to reconsider the decision.

         (4)   If the accreditation body receives a request under subsection (3), it must decide whether to confirm its decision and give the accredited provider its decision about the request:

                (a)    in writing; and

               (b)    within 14 days of receiving the request.

3.26        Sanctions may be recommended if improvements are not satisfactory

         (1)   If, at the end of a timetable agreed on for section 3.25, the accreditation body is not satisfied that the level of care provided by the residential care service complies with the Accreditation Standards, the accreditation body must:

                (a)    tell the Secretary, in writing, that it is not satisfied; and

               (b)    give a copy of the review audit report, and any other relevant documents, to the Secretary, and the approved provider, as soon as practicable.

         (2)   The accreditation body must also give the Secretary and the approved provider specific information about, and evidence of, the way in which the level of care is not satisfactory.

         (3)   The accreditation body must also give to the Secretary a recommendation about whether or not sanctions under the Act should be imposed on the approved provider.


 

Part 4                 Dealing with non-compliance

Division 1              Application of Part 4

4.1           Application

         (1)   Division 2 applies in respect of residential care services before 1 January 2001.

         (2)   Division 3 applies in respect of accredited residential care services on and after 1 January 2001.

Division 2              Non-compliance before 1 January 2001

 

Background information

This Division applies to residential care services before 1 January 2001.

These services must comply with the Residential Care Standards. In addition, these services must be working towards accreditation in accordance with the Accreditation Standards. This is because accreditation will only be given to services that can demonstrate compliance with the Accreditation Standards.

This Division sets out the consequences of non-compliance before 1 January 2001.

 

4.2           Evidence of serious risk to residents

         (1)   If a desk audit, site audit or review audit of a residential care service finds evidence of a serious risk to the health, safety or wellbeing of a person receiving care, the accreditation body must, as soon as it becomes aware of the evidence:

                (a)    tell the Secretary, in writing, about it; and

               (b)    give a copy of the report, and other relevant documents, to the Secretary, and the approved provider that operates the service, as soon as practicable.

         (2)   A report for paragraph (1) (b) must include:

                (a)    specific information about the reason for the risk, and evidence of the risk; and

               (b)    recommendations to the Secretary about whether or not sanctions under the Act should be imposed on the approved provider; and

                (c)    a statement of any standards or outcomes that have not been complied with; and

               (d)    any improvement outline that the accreditation body considers appropriate in the circumstances.

4.3           Evidence of non-compliance with Act

         (1)   If a desk audit, site audit or review audit of a residential care service finds evidence of a failure of an approved provider to comply with 1 or more of the approved provider’s responsibilities under Part 4.1, 4.2 or 4.3 of the Act, the accreditation body must, as soon as it becomes aware of the evidence:

                (a)    tell the Secretary, in writing, about it; and

               (b)    give a copy of the report to the Secretary, and the approved provider, as soon as practicable.

         (2)   A report for paragraph (1) (b) must include:

                (a)    specific information about, and evidence of, the risk; and

               (b)    recommendations to the Secretary about whether or not sanctions under the Act should be imposed on the approved provider.

Division 3              Non-compliance on or after 1 January 2001

 

Background information

This Division applies to residential care services that are accredited on and after 1 January 2001.

These services must comply with the Accreditation Standards only. They must also demonstrate continuous improvement, measured against these Standards: see section 2.5 and Part 3.

This Division sets out the consequences of non-compliance on and after 1 January 2001.

 

4.4           Evidence of serious risk to residents

         (1)   If a desk audit, site audit or review audit of a residential care service finds evidence of a serious risk to the health, safety or wellbeing of a person receiving care, the accreditation body must, as soon as it becomes aware of the evidence:

                (a)    tell the Secretary, in writing, about it; and

               (b)    give a copy of the report, and other relevant documents, to the Secretary, and the approved provider that operates the service, as soon as practicable.

         (2)   A report for paragraph (1) (b) must include:

                (a)    specific information about the reason for the risk, and evidence of the risk; and

               (b)    recommendations to the Secretary about whether or not sanctions under the Act should be imposed on the approved provider; and

                (c)    a statement of any standards or outcomes that have not been complied with; and

               (d)    any improvement outline that the accreditation body considers appropriate in the circumstances.

4.5           Evidence of non-compliance with Act

         (1)   If a desk audit, site audit or review audit of a residential care service finds evidence of a failure of an approved provider to comply with 1 or more of the approved provider’s responsibilities under Part 4.1, 4.2 or 4.3 of the Act, the accreditation body must, as soon as it becomes aware of the evidence:

                (a)    tell the Secretary, in writing, about it; and

               (b)    give a copy of the report to the Secretary, and the approved provider, as soon as practicable.

         (2)   A report for paragraph (1) (b) must include:

                (a)    specific information about, and evidence of, the risk; and

               (b)    recommendations to the Secretary about whether or not sanctions under the Act should be imposed on the approved provider.

4.6           Consequences of failure to comply with Accreditation Standards

         (1)   If, in performing its functions, the accreditation body identifies a failure by a residential care service to comply with the Accreditation Standards, the accreditation body must decide whether the failure has placed, or may place, the safety, health or wellbeing of persons receiving care through the service at serious risk.

         (2)   If the accreditation body decides that the failure has placed, or may place, the safety, health or wellbeing of persons receiving care through the service at serious risk, the accreditation body must immediately tell the Secretary and the approved provider that operates the service, in writing, about the failure and any other concerns of the accreditation body.

         (3)   For subsection (2), the accreditation body must also give the Secretary:

                (a)    specific information about, and evidence of, the risk; and

               (b)    recommendations about whether or not sanctions under the Act should be imposed on the approved provider.

         (4)   However, if the accreditation body decides that the failure has not placed, and will not place, the safety, health or wellbeing of persons receiving care through the service at serious risk, the accreditation body must tell the approved provider, in writing, about:

                (a)    matters in respect of which improvements must be made by the service to ensure that it complies with the Accreditation  Standards; and

               (b)    the timetable to make improvements; and

                (c)    the program of support contacts by an assessment team to assess progress made by the service in making improvements.

4.7           Sanctions recommended if improvements are not satisfactory

                If, at the end of the timetable, the accreditation body is not satisfied that the level of care provided by the residential care service complies with the Accreditation Standards, the accreditation body must:

                (a)    give the Secretary and the approved provider specific information about, and evidence of, matters in respect of which the level of care does not comply with the Accreditation Standards; and

               (b)    recommend to the Secretary that sanctions under the Act be imposed on the approved provider that operates the service.


 

Part 5                 Conditions of accreditation grants

  

5.1           Purpose of Part 5 (Act, s 80-2)

                This Part sets out a condition to which an accreditation grant is subject.

Note   The grant is subject to other conditions: see Act, s 80-2.

5.2           Information requested by the Minister

                If asked by the Minister, the accreditation body must give the Minister information about any aspect of the accreditation body’s operations.

5.3           Information requested by Secretary

                If the Secretary asks the accreditation body for protected information for the purposes of the Act, the accreditation body must give the information to the Secretary.


 

Part 6                 Promoting quality care in residential care services

  

6.1           Promoting and encouraging quality care

         (1)   The accreditation body must promote and encourage quality care in residential care services.

         (2)   The accreditation body may, as part of that function:

                (a)    provide information, education, training and support for residential care services; and

               (b)    identify and encourage best practice for residential care services.

6.2           Fees for materials

         (1)   If the accreditation body provides a service for this Part, it may charge fees relating to the cost of providing manuals, documents and other items it supplies.

         (2)   The fee for each manual or document is the lesser of:

                (a)    the cost of obtaining and supplying the manual or document; and

               (b)    $75.

         (3)   The fee for any other item (including a videotape) is the lesser of:

                (a)    the cost of obtaining and supplying the item; and

               (b)    $55.

6.3           Fees for seminars or conferences

         (1)   If the accreditation body provides a service for this Part, it may charge fees relating to the cost of arranging or presenting seminars or conferences.

         (2)   Subsection (1) does not prevent the accreditation body from charging a fee under section 6.2 for providing manuals, documents and services in the course of the seminar or conference.

         (3)   The fee is the lesser of:

                (a)    the cost of arranging and presenting the seminar or conference, less any cost that is covered by a fee charged under section 6.2; and

               (b)    $400 per day for a person attending the seminar or conference.

         (4)   Subsection (3) does not require the accreditation body to charge a fee, or the same fee, for every person attending a seminar or conference.


 

Part 7                 Reviewable decisions

  

7.1           What is a reviewable decision

                Each of the following decisions of the accreditation body is a reviewable decision:

 

Item

Decision

Section under which decision is made

2

Variation of period for which residential care service is to be accredited

2.32

3

Refusal of an application on reconsideration

2.38

4

Refusal to include an applicant’s nominated assessor in an assessment team

2.44

5

Refusal to accept an applicant’s objection to a quality assessor

2.45

6

Revocation of an accreditation

3.15 and 3.24

7

Variation of a period of accreditation

3.15 and 3.24

8

Refusal of an application to review registrar’s decision to remove from register

8.6

7.2           Procedure for review

                Application may be made to the Administrative Appeals Tribunal for review of a reviewable decision.

7.3           Support contacts with service during review period

                If a residential care service applies for reconsideration or review of a reviewable decision, the accreditation body must continue to carry out support contacts with the service under Part 3 from the day the accreditation body tells the service about its decision to the day when the decision on reconsideration or review takes effect (the review period).


 

Part 8                 Registration of quality assessors

  

8.1           Appointment of registrar

         (1)   The accreditation body must appoint, in writing, a person or body as a registrar to perform the following functions:

                (a)    to keep a register of quality assessors;

               (b)    to register persons as quality assessors.

         (2)   The registrar may keep the register in written or electronic form.

         (3)   The accreditation body must ensure, as part of appointing the registrar, that the registrar will carry out the functions in this Part.

Note   As part of its functions under Part 5.4 of the Act, the accreditation body proposes to make arrangements for quality assessors to be registered by a registrar.

8.2           Registration of quality assessors

         (1)   The registrar must register a person as a quality assessor if the person has:

                (a)    given the registrar an application, in writing, describing the person’s experience and qualifications in quality assessment that is relevant to aged care; and

               (b)    successfully completed a course about aged care quality assessment that is approved by the accreditation body; and

                (c)    participated in an orientation programme delivered by the accreditation body and the registrar; and

               (d)    been interviewed, and recommended to the accreditation body, by the Aged Care Industry Panel; and

                (e)    fulfilled other registration requirements that have been:

                          (i)    agreed by the accreditation body and the Registrar; and

                         (ii)    published by the accreditation body.

         (2)   The registrar must register a person as a quality assessor for a period of 1 year (the registration period).

         (3)   The registrar must, before the end of a person’s registration period:

                (a)    consider whether that person has met the criteria set out in section 8.3; and

               (b)    if the registrar is satisfied that the person has met the criteria set out in section 8.3 — register the person as a quality assessor for a further registration period of 1 year.

         (4)   The registrar must, before the end of a person’s further registration period:

                (a)    consider whether that person has met the criteria set out in section 8.3; and

               (b)    if the registrar is satisfied that the person has met the criteria set out in section 8.3 — register the person as a quality assessor for a further registration period of 1 year.

         (5)   If the registrar is not satisfied that the person has met the criteria set out in section 8.3, the registrar may decide to remove a person’s name from the register.

         (6)   If the registrar makes a decision under subsection (3) or (4), the registrar must tell the person and the accreditation body, in writing, about the decision.

         (7)   If the registrar makes a decision under subsection (5), the registrar must tell the person and the accreditation body, in writing:

                (a)    about the decision; and

               (b)    about the reasons for the decision.

8.3           Criteria for continued inclusion on register

         (1)   The person must demonstrate compliance with:

                (a)    the criterion mentioned in subsection (2); and

               (b)    the criteria mentioned in subsection (3).

         (2)   The person must demonstrate, to the registrar’s satisfaction, that he or she has complied satisfactorily with the person’s obligations as a quality assessor.

         (3)   The person must also demonstrate that the person has, during each registration period:

                (a)    assessed at least 2 residential care services for accreditation by the accreditation body; and

               (b)    completed at least 15 hours of professional development, education and training that is relevant to aged care quality assessment.

8.4           Person may apply for review of decision to remove from register

         (1)   Within 14 days after being told about a decision under subsection 8.2 (5), the person may apply to the accreditation body for a review of the registrar’s decision.

         (2)   An application under subsection (1) must:

                (a)    be in writing; and

               (b)    address the criteria mentioned in section 8.3.

8.5           Accreditation body must review decision

         (1)   If accreditation body receives an application under subsection 8.4 (1), the accreditation body must review the registrar’s decision.

         (2)   In conducting a review for subsection (1), the accreditation body:

                (a)    must consider the person’s application; and

               (b)    must consider the registrar’s reasons for making the decision; and

                (c)    may ask the person, or the registrar, for further information.

8.6           Decision on application

         (1)   The accreditation body must decide whether to grant or refuse the person’s application within 28 days after receiving it.

         (2)   If the accreditation body decides to grant the person’s application, the accreditation body must order the registrar to register the person.

         (3)   The registrar must comply with an order made under subsection (2).


 

Part 9                 Other matters

  

9.1           Publication of original decisions

         (1)   This section applies to a decision made by the accreditation body under subsection 2.11 (1), 2.14 (1), 2.27 (1) or 2.38 (1), unless:

                (a)    the accreditation body has received a request to reconsider the decision; or

               (b)    an application has been made to the Administrative Appeals Tribunal for review of the decision.

         (2)   The accreditation body must publish:

                (a)    the decision; and

               (b)    the executive summary of any assessment team’s report in relation to the decision; and

                (c)    any improvement outline given to the accreditation body under paragraph 2.34 (2) (b).

         (3)   However, the accreditation body must not publish, or otherwise make available, a document that contains protected information for Part 6-2 of Chapter 6 of the Act unless the publication is authorised under that Part.

         (4)   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.

9.2           Publication after request to reconsider decision

         (1)   This section applies if the accreditation body receives a request to reconsider a decision:

                (a)    not to accredit a residential care service; or

               (b)    to revoke the accreditation of a service.

         (2)   As soon as practicable after making the decision on reconsideration, the accreditation body must publish a statement that the decision:

                (a)    has been made; and

               (b)    is reviewable.

         (3)   If no application is made to the Administrative Appeals Tribunal to review the decision, within the prescribed time mentioned in paragraph 29 (1) (d) of the Administrative Appeals Tribunal Act 1975, the accreditation body must publish the decision within 7 days after the end of the prescribed time.

Note   Paragraph 29 (1) (d) of the Administrative Appeals Tribunal Act 1975 provides that an application to the Tribunal for review of a decision must be lodged with the Tribunal within a prescribed time.

         (4)   However, the accreditation body must not publish, or otherwise make available, protected information for Part 6-2 of Chapter 6 of the Act unless the publication is authorised under that Part.

9.3           Publication after application to review decision

         (1)   This section applies if an application is made to the Administrative Appeals Tribunal to review a decision, by the accreditation body, made on reconsideration:

                (a)    not to accredit a residential care service; or

               (b)    to revoke the accreditation of a service.

         (2)   The accreditation body must publish a statement that:

                (a)    a decision has been made not to accredit the service, or to revoke the service’s accreditation; and

               (b)    the decision is being reviewed.

         (3)   The accreditation body must publish the decision within 7 days after the decision on review is made.

         (4)   However, the accreditation body must not publish, or otherwise make available, protected information for Part 6-2 of Chapter 6 of the Act unless the publication is authorised under that Part.

9.4           Audit report to be made available

         (1)   The accreditation body must give a copy of the following documents to anyone who asks for a copy:

                (a)    an assessment team’s full report;

               (b)    a decision made by the accreditation body;

                (c)    an improvement outline.

         (2)   However, the accreditation body must not publish, or otherwise make available, a part of a document mentioned in subsection (1) that contains protected information for Part 6-2 of Chapter 6 of the Act unless the publication is authorised under that Part.


Notes to the Accreditation Grant Principles 1999

Note 1

The Accreditation Grant Principles 1999 (in force under subsection 96-1 (1) of the Aged Care Act 1997) as shown in this compilation is amended as indicated in the Tables below.

For application, saving or transitional provisions see Table A.

Table of Instruments

Title

Date of notification
in Gazette

Date of
commencement

Application, saving or
transitional provisions

Accreditation Grant Principles 1999

15 Sept 1999 (see Gazette 1999, No. GN37)

15 Sept 1999

 

Accreditation Grant Amendment Principles 2000 (No. 1)

22 Dec 2000
(see Gazette 2000, No. S656)

22 Dec 2000

S. 4 [see Table A]

Table of Amendments

ad. = added or inserted      am. = amended      rep. = repealed      rs. = repealed and substituted

Provision affected

How affected

S. 1.3.......................................

am. 2000 No. 1

S. 2.13.....................................

rs. 2000 No. 1

S. 2.30.....................................

rs. 2000 No. 1

S. 5.3.......................................

ad. 2000 No. 1

S. 7.1......................................

am. 2000 No. 1

Table A

Accreditation Grant Amendment Principles 2000 (No. 1)

4       Transitional

                Sections 2.13, 2.30 and 7.1 of the Accreditation Grant Principles 1999, as in force immediately before the commencement of these Principles, continue to apply in relation to a variation of arrangements for support contacts made under subsection 2.13 (1) or 2.30 (1) of the Accreditation Grant Principles 1999 before the commencement of these Principles.