8 tips for your next accreditation visit

A guide to audit readiness to make your next accreditation stress free.

Assessing compliance with the Quality Standards, the NQIP, SIRS, and monitoring the quality of care and services is an important function of the Aged Care Safety and Quality Commission (ACQSC).

Assessment contacts enable the Commission to conduct regular monitoring of services. The Commission is able to conduct an assessment at any time, either through a planned or unannounced visit. The assessment may be onsite, remote or both. 

A clinical management system provides an efficient way for providers to record and report on much of the information required during an assessment with the ACQSC. 

As a clinical management system provider with over 20 years' experience in the aged care space, we would like to share with you our eight tips for your next accreditation visit!


Tip 1: Aim to be audit ready 24/7 

Aged care services are essentially required to be audit ready 24/7. 

Whilst this may sound daunting, the first step to this is ensuring that the necessary clinical information is being captured accurately within your clinical management system. This comes down to organisational process as well as staff training in the correct usage of the system. 

Once you have the confidence that all of your clinical records are being recorded in your clinical management system, the next step to audit readiness is ensuring that staff are able to locate and provide the necessary information to the Assessment team shortly after their arrival. 

Instilling staff with confidence in accessing this information with ease will significantly reduce audit anxiety. 


Tip 2: Upskill multiple key staff

Upskill multiple 'persons in charge'. 

The 'person in charge' who is responsible for managing the service on that day or during that shift may change throughout the day.

It is essential to ensure all key staff are confident in accessing clinical records and producing any reports requested by the Assessment team. This will guarantee that you are audit ready even if an unannounced visit is to occur outside of hours. 


Tip 3: Conduct regular self assessments 

Self-assessment is critical to identify any gaps in your clinical documentation and staff knowledge (where training may be required).

Schedule and conduct routine self-assessments throughout the year by utilising the set of standard 'risk-based' questions that the Commission will use when commencing their performance assessments.

Any gaps identified can then form part of your continuous improvement planning.

This assists to further boost staff confidence in the integrity of the data contained within the clinical management system, as well as their ability to extract this data upon request.


Tip 4: Use a documents checklist

Ensure that staff are familiar with the list of documents that may be requested by the Assessment team upon arrival at the facility. 

Ensure that staff are:

  • Familiar with where these documents are located
  • Able to access these documents within the clinical management system (or elsewhere) with ease

Download our checklist of regularly requested documents to keep at hand!


Tip 5: Be prepared to evidence NQIP 

Evidence of compliance with the National Mandatory Aged Care Quality Indicator Program (NQIP) may form part of your assessment contact.

Ensure that staff are able to demonstrate how data for each of the quality indicators is being recorded so that this data can be reported on at the end of each quarter.

This process is made even easier if your clinical management system has the functionality to assist you with NQIP!


Tip 6: Don't overlook leisure and lifestyle

In addition to your clinical documentation, it will be helpful to ensure that your Leisure and Lifestyle documentation for each resident is accurate and appropriate. 

This may include information regarding the resident's social, emotional, spiritual, cultural and leisure care needs and preferences.

You should also be able to evidence their participation in related leisure activities. 


Tip 7: Conduct a complaints audit

Whilst they may not be captured within your clinical management system, resident complaints are a good source of information to identify areas for improvement.

The Assessment team may collect information to assess the service's performance against the Standards based on interviews and observations, as well as documentation. 

Any documented resident complaints may well be discussed during interviews with residents, and therefore are a good place to start when considering areas to focus on for continuous improvement planning. 


Tip 8: Reach out for help!

We are here to help!

If you are an AutumnCare client, you have access to support from our Clinical team during a site visit. Our team can walk you through which reports you will need to produce to provide the information being asked for, as well as how to produce these reports. The team can support you either by phone or via email. 


AutumnCare is an aged care software provider based in Western Australia. We specialise in the management of clinical data through industry best practice forms. Get in touch with us today if you'd like to find out more about how we can help you.

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