Aged Care Quality Bulletin #28 – April 2021 | Aged Care Quality and Safety Commission

Commissioner’s message

As we move into the cooler months and the COVID-19 pandemic is still a reality, ongoing vigilance by providers in relation to infection prevention and control (IPC) measures is key. This is the case, even as the vaccination program continues to be rolled out Australia-wide. Under the Aged Care Quality Standards, all providers have an explicit obligation to have infection control and prevention programs in place for the purposes of preventing and responding to infectious diseases, including COVID-19 and influenza.

In this edition, we provide advice on updated Standards guidance to reflect onsite IPC lead requirements in residential aged care services. We also share findings from our visitor access survey, which is a reminder to ensure that consumers are well-supported to enjoy regular engagement with family and friends at this time. In addition, information is provided on lessons learned about fit-for-purpose leadership in a pandemic from Victorian providers who experienced an outbreak.

The Serious Incident Response Scheme (SIRS) has now been in effect for almost one month and we’re continuing our communication and education efforts to help residential aged care providers better understand the new scheme and their responsibilities. Earlier this month we released fact sheets on each of the 8 types of reportable incidents that providers must record in their incident management system and report to the Commission via the My Aged Care Provider Portal. These resources provide comprehensive guidance on each incident type, possible signs of those incidents having occurred, how you can respond to them, as well as some examples of what would constitute a reportable incident in that category. These fact sheets are all available on our SIRS resources webpage. I encourage all residential aged care services to bookmark and visit this page.

Another important reporting obligation for all Commonwealth-subsidised residential aged care service providers is the National Aged Care Mandatory Quality Indicator Program (QI Program). As you’re no doubt aware, reporting quarterly on 3 quality indicators under the QI Program became compulsory on 1 July 2019. Importantly, the program is about to be updated and expanded. From 1 July 2021, 2 additional quality indicators are being introduced. See below for details of the program and new reporting requirements.

Antimicrobial stewardship is another clinically-related topic that deserves attention, and in this edition, we share our current work on this.

To assist approved providers of residential care, we also provide information about our planned prudential campaign in May 2021 to help providers better understand permitted uses of refundable accommodation deposits, with particular reference to loans.

Infection prevention and control still a key focus

All aged care providers have an explicit obligation under Aged Care Quality Standards 3 and 8 to have infection prevention and control (IPC) programs in place so that they are well placed to reduce the risk of, and respond to, infectious diseases including COVID-19 and influenza. Of course, these programs will vary depending on the nature of care and services provided.

All residential services should now have a dedicated, onsite clinical IPC lead. Embedding an IPC lead in each service is intended to build enduring capability in this vital area of practice. IPC leads must be based at their nominated facility to provide advice and oversight as part of ongoing, day-to-day operations, and champion continuous improvement in IPC across the service.

The Commission expects that, in accordance with the Quality Standards, each residential aged care provider will develop and implement an effective IPC program.

To support providers, the Commission has updated the ‘Guidance and resources for providers to support the Aged Care Quality Standards’ to reflect the IPC lead requirements, including those for specific infection control training for residential aged care providers.

As part of its risk-based approach, the Commission will continue to assess IPC practices as part of its normal program of monitoring activities, including site visits and other contacts.

Visitor access survey report findings

Visitor access also continues to be an important focus in our COVID-normal operating environment. The Commission conducted a visitor access survey of residential aged care services between 16 December 2020 and 19 January 2021. The survey revealed a number of areas that services should focus on to improve outcomes for residents, their families/representatives and staff in a COVID-normal world.

The full survey report is now available on our website and presents a summary of the findings, the detailed results of each survey question and key messages for providers.

The survey found that the vast majority of services had appropriate visitor access processes in place, and were focused on ensuring visitor access, and the health and wellbeing of residents in aged care facilities. Services did this while actively monitoring and complying with their local public health directions. This is a positive finding given the survey response period was over the December/January period, which is traditionally one of the busiest periods of the year. At that time, Australia also had several active COVID-19 outbreaks with public health directions in some states/territories changing over the course of a week.

However, while a majority of services indicated a willingness to manage visitor access safely, there was a greater reluctance to allow residents to leave the service and return without restrictions. Further, while a high proportion of services allowed in-person visits, many were not enabling remote visits or facilitating contact between residents and families/ representatives during periods when public health directions mandated lockdowns.

For the health and wellbeing of residents, it is vital that they have an opportunity for ongoing connection with their families/representatives, even when physical contact is restricted. Services are encouraged to reflect on these survey findings and the rights of residents as articulated through the Charter of Aged Care Rights.

Moving to ‘command and control’ leadership during an outbreak

During outbreaks and other emergency situations, it is essential to have effective leadership and clearly defined roles for all staff involved in a service.

The Commission interviewed providers who experienced COVID-19 outbreaks in 2020 and found that an important lesson learned was to use a ‘command and control’ style of leadership.

Providers found having a single point of command resulted in:

faster decision making
clearer directions
staff being able to focus more intently on their role
actions being carried out quickly.

Providers also shared that having staff members with diverse skills, such as infection control and clinical expertise, helped greatly with outbreak management.

The Commission recommends that all aged care providers read the ‘“We saw the best in people”: Lessons learned…’ report, which is available on our website. The report reflects the experiences of 34 providers who experienced a COVID-19 outbreak in at least one of their Victorian residential aged care services in the latter part of 2020. All providers of aged care services across Australia are encouraged to improve emergency readiness and maintain vigilance in a COVID-normal environment.

Serious Incident Response Scheme (SIRS) update

The SIRS has now been in operation for almost a month and it is apparent that residential aged care providers are working hard to implement and fine-tune their approach to fulfilling their new obligations under the scheme. We have been reviewing initial reporting data, as well as feedback received from the sector, to identify areas for improvement in both the reporting process and the supporting resources available to the sector.

Key issues identified in the first weeks of operation include:

notification of incidents that do not fall within any of the 8 types of reportable incidents, in terms of the incident and resulting/possible injury or harm. For example, a resident with osteoporosis had a fall due to a collapsed hip and was taken to hospital. As the fall was not due to an action or inaction by care staff, this incident would not be required to be reported to the Commission under the SIRS. However, if the fall was due to a care staff member handling the consumer roughly or ignoring their need for physical support, this would be a reportable incident. However, it is equally important to note that under the SIRS, all providers have a responsibility to maintain an incident management system and are expected to keep a record of (and take any necessary action arising from) each incident that occurs in the service, regardless of whether it is a reportable incident.
incorrect classification of reportable incidents as Priority 1. Reportable incidents that should be classified as Priority 2 incidents do not need to be reported to the Commission until 1 October 2021. These incidents are currently ‘out of scope’. Providers are encouraged to review the distinction between the 2 priority classifications to ensure accurate reporting.
unnecessary/incorrect reporting of unexpected deaths. Subsection 15NA(8) of the Quality of Care Principles 2014 expands on the meaning of unexpected death of a consumer to provide that this includes death in circumstances where reasonable steps were not taken by the provider to prevent the death or the death is the result of care or services provided by the provider or a failure by the provider to provide care and services.

In response to these issues and other constructive feedback received, the Commission is continuing to refine and update the advice and information available to the sector over the coming weeks.

For more information on the SIRS, visit the Commission’s dedicated SIRS webpage.

Our current work on antimicrobial stewardship

In the last edition of the Quality Bulletin, we provided information about antimicrobial medications (which include antibiotics, antivirals and antifungals) and how effective infection prevention and control (IPC) measures and antimicrobial stewardship (AMS) interventions improve infectious disease outcomes and help to address the problem of antimicrobial resistance. In this edition, we’re outlining the Commission’s current work on AMS.

The Commission is currently focusing on the issue of AMS as it relates to:

clinical best practice
consumer focus, involvement and information
clinical governance in residential aged care services.

The 3 most common reasons for antimicrobial use in residential aged care are:

urinary tract infections or for long-term prophylaxis (to prevent such infections)
skin infections
respiratory tract infections.

Inappropriate antimicrobial use includes:

using an antimicrobial with insufficient or inappropriate clinical indication
prolonged use beyond the course duration recommended in guidelines
prolonged prophylaxis for conditions that are not recommended by guidelines.

Other causes of inappropriate antimicrobial use can relate to:

failure to recognise serious infection and institute correct antibiotics in a timely manner
use of the wrong antimicrobial agent or wrong dose for the clinical setting
failure to attend to results of microbiological testing to guide ongoing choice of antimicrobial
failure to consider the potential side effects or harm in individuals
failure to consider drug absorption and metabolism, for example, in gastrointestinal, renal or liver disorders
failure to document or consider allergy status, including the nature and severity of allergy.

The Commission is currently reviewing AMS resources and fact sheets that will be suitable for residential aged care settings with the assistance of Dr Lyn-li Lim (an infectious diseases and AMS physician), the Australian Commission for Safety and Quality in Health Care and the National Centre of Antimicrobial Stewardship/VICNISS.

Other resources

A fact sheet developed by the Australian Commission on Safety and Quality in Health Care will enable you to review the systems and practices in your service in relation to urinary tract infection and asymptomatic bacteriuria.
The Aged Care National Antimicrobial Prescribing Survey (NAPS) is an audit tool that supports the monitoring of the prevalence of infections, antimicrobial use and antimicrobial resistance in residential aged care services and multi-purpose services. All Australian aged care homes and multi-purpose services are eligible, and encouraged, to participate in this survey. There are benefits to providers in participating. For more information, read this information sheet on the NAPS website.

Expanded quality indicator reporting obligations from 1 July

As we outlined in our November 2020 edition, the National Aged Care Mandatory Quality Indicator Program (QI Program) is being updated and expanded to include new quality indicators from 1 July 2021.

This is an important reporting process in the residential aged care sector which is still maturing, with approved providers and services being expected to use these indicators to oversee and assess aspects of quality of care which may affect consumers’ health and wellbeing. In short, the QI Program supports you to measure, monitor, compare and improve the quality of your services. You can then identify trends in your performance over time and compare yourselves against national averages. Ultimately, this leads to better quality of care and quality of life for consumers, and the program’s expansion will enhance this even further.

The quality indicators that apply for residential aged care providers from 1 July 2021 include:

pressure injuries
physical restraint
unplanned weight loss
falls and major injury (new)
medication management (new) including polypharmacy and anti-psychotics.

We’re reminding all approved providers of residential aged care services that your quality indicator collection and reporting requirements will change over the coming months:

Until 30 June, collect information against the 3 current indicators, then report your April–June 2021 quarter information in the My Aged Care Provider Portal by 21 July.
From 1 July, start collecting information against each of the 5 updated and expanded indicators. You’ll then need to report your July–September 2021 quarter information in the My Aged Care Provider Portal by 21 October.

To help you prepare for your new reporting obligations, the quality indicator data elements summary which outlines the data elements for implementation from 1 July, is now available on the Department of Health website.

More information about the QI Program is also available on the department’s website, and additional guidance materials about the expanded program (including Part A of the QI Program Manual, quick reference guides, data recording templates and instructions, and frequently asked questions) will be released in the lead-up to 1 July.

If you have any questions about the expansion of the QI Program, contact the My Aged Care service provider and assessor helpline on 1800 836 799.

Prudential campaign – permitted uses of refundable accommodation deposits

Residential aged care approved providers holding refundable accommodation deposits (RADs) must comply with the Prudential Standards and only use these deposits as permitted under the Aged Care Act 1997 (the Act) and the Fees and Payments Principles 2014 (the Principles).

Approved providers must implement and maintain governance arrangements that ensure RADs are used only as permitted and refunded to care recipients correctly.

For example, providers can use RADs to make loans if:

it is not made to an individual
it is made on commercial terms
a written agreement is in place
the money loaned will only be used for the following:
- capital expenditure (as specified in the Principles)
- investments in financial products (as specified in the Act)
- refunding RADs, bond balances or entry contributions
- repaying debt accrued for the of capital expenditure or for refunding bond balances.

An analysis of prudential information indicates that some providers are using RADs to make loans, however, our data does not specify the purpose of the loan. In light of this, the Commission will run a targeted campaign to help providers better understand how they can use RADs and comply with the Governance Standard.

The campaign will be conducted in May 2021 and will involve a site visit to selected approved providers based on Commission data. The campaign will determine whether providers are compliant with their statutory obligations for loan agreements using RADs, including that they are managed in accordance with the Governance Standard. If the review identifies non-compliance, the Commission may consider regulatory action.