ACQSC 24/7 RN Exemption Monitoring Visit

We would like to share with you the focus areas and insights on a recent new process conducted by the Aged Care Quality and Safety Commission (ACQSC) at an aged care provider we network with. The purpose of this monitoring visit was to assess the compliance with the 24/7 Registered Nurse (RN) exemption and to ensure the ongoing provision of quality and safe care. Here is a summary of the key requests made during the visit and insights gained from the visit.

Our client received two weeks notice for the one day ACQSC visit, with the exact nature not defined at the time of notification. The ACQSC clarified on arrival that this was a monitoring visit specifically related to the 24/7 RN exemption.

Key Focus Areas During the Visit

  • Verification of 24/7 RN Exemption: The ACQSC assessed whether the 24/7 RN exemption received from the Home was accurately implemented as per the submission.
  • Assessment of Quality and Safety: The visit aimed to ensure the ongoing provision of quality and safe care by consulting with staff and residents.
  • Examinations: The ACQSC examined clinical care, the Serious Incident Response Scheme (SIRS) incidents, complaint handling and emergency response and escalation procedures.
  • Risk-based Questions: Specific risk-based questions were tailored to issues related to the 24/7 RN exemption.
  • Document Review: The assessors requested various documents, including handover sheets, risk registers, incident reports, clinical governance framework, staff records, minutes, job ads and more related to the examined areas.
  • Roster Project: The ACQSC showed keen interest in a roster project and requested detailed information on its rationale and rollout.
  • Monitoring and Verification: The assessors were interested in the continuous monitoring and validation of information entered into the roster portal.

Insights Gained from the Visit

  • Safe and Effective Care: The Home was able to demonstrate that it provided safe and effective care during the visit.
  • Stakeholder Discussions: The assessors inquired about residents' and workforce discussions related to the 24/7 RN exemption.
  • Suggestions for Improvement: The ACQSC suggested having a range of examples of clinical deterioration and escalation prepared for future discussions.
  • Collaboration and Engagement: The collaborative approach within the Home was noted as a positive aspect of the visit, particularly in engaging with external experts.
  • No Formal Report: The ACQSC stated that no formal report would be provided. Instead, the findings were documented for future reference.
  • Future Contacts: The next contact with the ACQSC could be either face-to-face or desktop-based, depending on their evolving process.
  • Compliance with Exemption: The assessment confirmed that the provider had implemented the 24/7 RN exemption as submitted in their application.

How can CSS assist?

Critical Success Solutions (CSS) can work with you and your workforce to ensure that they are ready for assessor visits including answers to their questions such as:

  • How many and what shifts has there been where there was no RN rostered on?
  • What changes have been made since the Exemption Form was submitted?
  • What happens when there is no RN on site and someone deteriorates?
  • What documentation is available to guide the workforce when no RN is on site?
  • How was the 24/7 RN exemption discussed with workforce and residents?
  • Were any residents concerned about the exemption?
  • For competencies that carers need to undertake, do they have a choice NOT to undertake the competency or is it policy?

CSS can also review policies such as wound and clinical governance policies and your Clinical Governance Framework in readiness for any ACQSC visits.

Contact Critical Success Solutions to assist you with your actions and to tailor support to your needs.

Contact: Alex Pirozzi, Business Manager

Email: or
Mobile: 0448 672 118 or Office: 02 90520292

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