Is your incident reporting process compliant?

Do you have a clear definition of what constitutes a reportable serious incident?

Your organisation should have documented criteria that align with the eight reportable incident types defined in the Aged Care Act 2024.

Are all staff trained to identify and report potential SIRS incidents?

Training should cover all staff — clinical, care, administrative, and ancillary — not just clinical leads. The 24-hour clock starts when any staff member becomes aware.

Do you distinguish between Priority 1 and Priority 2 incidents?

Priority 1 reportable incidents include physical or psychological injury or discomfort requiring medical or psychological treatment, reasonable grounds for reporting to police, unlawful sexual contact or inappropriate sexual conduct, unexpected death and unexplained absence. Notify the Commission within 24 hours of provider awareness. Priority 2 incidents must be notified within 30 calendar days.

Is there a process for identifying unreasonable use of force, unlawful sexual contact, psychological abuse, unexpected death, stealing or financial coercion, neglect, inappropriate restrictive practices, unexplained absence from care?

Each incident type has specific characteristics. Staff should be able to recognise all eight categories, not just the most obvious ones like physical harm.

Can staff apply all current Priority 1 criteria?

Use rule 165A-25, including its treatment, police, sexual conduct, unexpected death and unexplained absence criteria. Assess the incident facts and record the decision.

Do you have a process to notify ACQSC within 24 hours of becoming aware?

The notification must be submitted to the Aged Care Quality and Safety Commission within 24 hours. This is calendar hours, not business hours.

Is there an after-hours notification process for incidents that occur outside business hours?

A Priority 1 incident at 11pm on a Saturday still requires notification within 24 hours. Your process must cover weekends, public holidays, and night shifts.

Do you track the exact time of awareness to calculate the 24-hour deadline?

The clock starts when any staff member becomes aware of the incident, not when a manager is informed. Accurate time tracking is essential for demonstrating compliance.

Can you identify Priority 2 incidents?

Priority 2 incidents are reportable serious incidents that do not meet the threshold for Priority 1 — they do not involve immediate danger, death, or serious injury but are still reportable under SIRS.

Do you have a process to notify ACQSC within 30 calendar days?

The 30 calendar day deadline requires careful tracking. Late notifications are a compliance failure that may trigger regulatory attention.

Do you track the 30 calendar day deadline accurately?

The 30-day deadline is counted in calendar days (not business days). Accurate tracking and automated reminders help ensure notifications are submitted on time.

Do you assign an independent investigator for each reportable incident?

The investigator should be independent of the incident — not the person who was involved, their direct supervisor, or anyone with a conflict of interest.

Is there a structured investigation methodology?

Investigations should follow a documented methodology: gather facts, interview witnesses, review documentation, identify contributing factors, and determine root causes.

Do you document findings, root causes, and contributing factors?

Investigation reports must capture what happened, why it happened, what systemic factors contributed, and what needs to change to prevent recurrence.

Are affected individuals (care recipients, families) notified appropriately?

Open disclosure principles apply. Affected care recipients and their families should be informed of the incident, what action has been taken, and what changes are being made.

Do you apply natural justice principles during investigations?

Staff members who are the subject of an investigation have the right to know the allegations, respond to them, and have their response considered before findings are made.

Do investigation findings result in documented remediation actions?

Every investigation that identifies a gap, failure, or contributing factor should produce specific, actionable remediation steps — not vague commitments to improve.

Are remediation actions assigned to specific responsible persons with due dates?

Each action should have a named owner and a target completion date. Unassigned actions or open-ended timelines indicate a weak remediation process.

Do you track completion of remediation actions?

Actions should be tracked to completion with evidence of implementation. Overdue actions should trigger escalation alerts to management.

Are systemic issues identified and addressed?

Individual incidents may reveal systemic patterns — staffing gaps, training deficiencies, environmental hazards, or policy failures. Remediation should address root causes, not just symptoms.

Do you maintain a register of all incidents (reportable and non-reportable)?

A comprehensive incident register captures all incidents, not just those that meet the SIRS reporting threshold. This supports trend analysis and pattern identification.

Are all ACQSC notifications documented with timestamps?

Every notification to the ACQSC should be recorded with the date and time of submission, the notification reference number, and the content of the notification.

Is there an append-only audit trail of all incident-related actions?

Every action taken — from initial report through investigation, notification, and remediation — should be logged in an append-only audit trail with timestamps and user identification.

Can you produce a complete incident history for ACQSC on request?

During an assessment contact, ACQSC assessors may request your full incident history. You should be able to produce this within minutes, not days.

Do you maintain a restrictive practices register?

All uses of restrictive practices — physical restraint, chemical restraint, mechanical restraint, seclusion, and environmental restraint — must be recorded in a dedicated register.

Are behaviour support plans in place before any restrictive practice is used?

A current, reviewed behaviour support plan must be in place before any restrictive practice is applied. The plan should document alternative strategies attempted and the rationale for the restrictive practice.

Are restrictive practices reported through SIRS where required?

Inappropriate use of restrictive practices — or use without a behaviour support plan — is a reportable incident under SIRS and must be notified to the ACQSC.