Critical Success Solutions (CSS) regularly bring to our clients and our network a listing of themes and evidence that was not in place leading to ‘Not Met’ requirement/s and subsequently ‘Not Met’ standard finding/s. We have liaised with our network, clients and consultants on the ground to find out what has been different with Commission Reviews. The following is a summary of what we have found during the last quarter.
Themes and Differences
- Increasing number of audits with external agents assessing, including interstate assessors from Victoria, Queensland, SA and KPMG, PWC etc. There are many new and inexperienced assessors visiting the sites. Providers are indicating that they having not just two or three assessors, but many more and they are staying for more time than usual – up to five days. There is high level of concern regarding the lack of knowledge shown by these new assessors. One provider indicated that the assessor walked in with a list of questions and if they did not answer as per the answer that was deemed correct on their sheet, they said “No that’s not right, try again.” The assessors demonstrated poor industry knowledge – for example, “What is NQIP and what expansion?” “What is ACCPA?” “What is IDDSI?”
- We have heard that assessors are currently undertaking education in relation to the new standards (due for release in July 2024) resulting in a number of the pilot organisations having detailed reviews during the trial period.
- There is a strong focus on the new reforms and with questions asked about how providers are preparing/implementing changes. New providers (new since December 2022) are already being reviewed against the reform requirements. This has resulted in the reviews being very prescriptive and detailed including a strong emphasis on governance structures, QCAB and CAB, key personnel suitability, etc.
- Entry meeting duration is up to two and a half hours. The questions are much broader than what is on the Commission website. Providers are noting that the first half of the first day of the review consists of entry meeting and the tour. Other risk profiling questions being investigated include: key personnel changes/ appointments and training/ induction, organisational structure changes, quality management system changes, environmental changes, training in key legislative changes for workforce, workforce issues/ morale?
- SIRS – the assessors are debating the decision making on SIRS matters and are wholly basing decisions on the SIRS decision making tool. They request to see RCA investigations regarding SIRS incidents and also other documentation to establish the correlation between SIRS, AHPRA, Code of Conduct and Charter of Rights.
- Organisational governance – there seem to be inconsistencies in approach by assessors especially in relation to organisational governance. For example, a few sites will be reviewed from one organisation and some will be called not met due to policies not reflective of legislative changes while others are compliant. Similarly, a review of board governance documentation might be met at one site and not met by another.
- Clinical governance emphasis in both home care and residential – rigorous review of escalation frameworks and clinical governance frameworks. Also, the determination that HIHP risks are not being managed appropriately. Many home care providers cannot provide documentation on clinical governance and have no RN oversight. Many reviews found that there is poor knowledge of clinical governance from board members, executive, local Leadership Teams and RNs.
- There is a strong focus on clinical issues including:
- Pain management reviews and effective measurements not being completed.
- Require timely follow-up to weight loss.
- BGLs being missed and appropriate follow-up of out-of-range BGLs not being reviewed in a timely manner or not at all.
- Directives for anticoagulant management not in place.
- Behaviour management poor – no BSPs, restrictive practice authorisations not in place or reviewed in required timeframes and issues with timely referrals to external agencies. There is not the appropriate understanding of RPSDM especially in light of the NSW interim hierarchy decision making tool not being used – resulting in a number of SIRS for inappropriate use of restrictive practices being placed on the Home or service. There are Psychotropic Registers that are inaccurate or incomplete on many reviews. Also a poor understanding about environmental restrictive practices and the appropriate assessment.
- Issues with end-of-life procedures – the workforce lack understanding of EOL, death reviews not completed, poor pain management, etc.
- Poor risk management – including approach to dignity of risk processes with lack of education conducted with the workforce (including contractors) and lack of mitigation of risks.
- Lack of analysis in relation to clinical data collection. The audits are completed and no analysis or review of issues are being followed up.
- Initial admission assessments not being completed by providers who have had a large number of admissions and respite consumers being admitted over a short period of time.
- Fixing things on the day of the review – again inconsistencies in the approach by assessors where some will allow for items to be fixed on the day while others will not.
- Real focus on the feedback from consumers and families – if the consumer says the food is cold, they do not investigate further and call this not met in the food requirement, just from a couple of areas of feedback, no checking of meal temperatures or review of other documentation. If a relative raises an issue and it cannot be justified with evidence, this seems to be an automatic not met.
- Standard 5 equipment management and cleaning – there needs to be specific instructions on how to clean equipment.
- Workforce sentiment – the assessors focus on workforce sentiment and workforce numbers. Any negative comments by the workforce are definitely amplified.
- Executive presence – they have really liked having the executive there to discuss issues directly and follow-up on issues directly with them.
- Paper based requests – many new assessors are generally not proficient with electronic management systems and want everything printed.
- IPC and IPC lead involvement – strong emphasis on reviewing the IPC hours allocated to the IPC lead, what reporting is conducted by the IPC lead, what education has been undertaken after the original course? Outbreak management plan up to date?
- NDIS – some assessors are asking questions regarding NDIS and if providers have met the requirements of the audits (where relevant). One assessor argued that NDIS check does not replace police check and you need to have both.
- Contractor management – a couple of assessors have rigorously gone through in detail what each contractor has stored on their file and what they have completed in relation to the requirements including education, resume, reference checks etc.
- Education – assessors have a focus now for both residential and home care on how information is being delivered. If the delivery method is online, questioning how the transfer of knowledge is being validated and applied in practice. One assessor went and watched a worker undertake a wound dressing. The assessor also reviewed wound management policies and procedures, education documentation including competency assessments, etc.
- Brokerage agreements – for home care are being reviewed and how the Care and Services Plans are communicated where the approved provider has brokered care and services delivery.
- Rostering for both home and residential care and workforce surge planning for home care.
- Complaints – not being closed out effectively with a focus on clinical care and governance.
If you would like support navigating the new requirements and standards, please email Alex@cssconsulting.com.au (Business Manager) or our office on firstname.lastname@example.org and we will discuss your requirements and tailor assistance.