Title Page
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Organisation name
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Date of Gap Analysis
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Prepared by
Executive Summary
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Summary of findings (complete before you finalise the survey)
Section 1 - Incidents That Must Be Covered
(1) Does the incident management system cover incidents that consist of acts, omissions, events and circumstances that:
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a) occur in connection with providing supports or services to a person with disability.
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b) have, or could have, caused harm to the person with disability.
(2) Does the incident management system cover incidents that consist of acts by a person with a disability that:
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a) occur in connection with providing supports or services to the person with disability.
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b) have caused serious harm, or a risk of serious harm, to another person.
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(3) Does the incident management system cover reportable incidents that are alleged to have occurred in connection with providing supports or services to a person with disability?
Section 2 - Incident Management System Procedures
(1) Does the incident management system include procedures for identifying, managing and resolving incidents, including procedures that specify the following:
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a) how incidents are identified, recorded and reported.
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b) to whom incidents must be reported.
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c) the person who is responsible for reporting incidents that are reportable incidents to the Commissioner.
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d) how support and assistance will be provided to persons with disability affected by an incident (including information about access to advocates such as independent advocates), to ensure their health, safety and wellbeing.
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e) how persons with disability affected by an incident will be involved in the management and resolution of the incident.
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f) when an investigation is required to establish the causes of a particular incident, its effect and any operational issues that may have contributed to the incident occurring, and the nature of that investigation.
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g) when corrective action is required and the nature of that action.
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(2) Do the incident investigation procedures outline how the investigation may vary, depending on the seriousness of the incident?
(3) Does the incident management system (incident investigation procedure or process) require that all incidents be assessed in relation to the following (including the views of persons with disability affected by the incident):
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a) whether the incident could have been prevented.
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b) how well the incident was managed and resolved.
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c) what, if any, remedial action needs to be undertaken to prevent further similar incidents from occurring, or to minimise their impact.
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d) whether other persons or bodies need to be notified of the incident.
(4) If the incident management system has formal procedures, do they outline how the assessment of the incident (per Item 3) will occur:
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a) whether the incident could have been prevented.
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b) how well the incident was managed and resolved.
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c) what, if any, remedial action needs to be undertaken to prevent further similar incidents from occurring, or to minimise their impact.
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d) whether other persons or bodies need to be notified of the incident.
(5) Does the incident management procedures ensure (have documented) that the incident will be notified and managed in accordance with Part 3 of the Act, namely:
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a) Incidents meeting the classification of reportable incidents must be reported to the Commission (Subsection 73Z(5)). This includes incidents that are alleged to have occurred.
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b) Key personnel of the NDIS Providers duty to take all reasonable incidents occurring in connection with the provision of supports or services are reported to the Commissioner.
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c) There is a person specified to report reportable incidents to the Commissioner.
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d) All people employed or otherwise engaged with the provider (i.e. contractors) have a duty to report a reportable incident that has occurred in connection with the provision of supports or services and must notify a member of the key personnel, a supervisor or manager or the person specified by the Provider who is responsible to notify the Commissioner.
(6) Do the incident management procedures ensure (have documented) that the incident will be notified and managed in accordance with Part 3 of the act and reported within 24 hours if it involves any of the following?
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a) the death of a person with a disability.
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b) the serious injury of a person with a disability (requiring medical attention, even if not admitted to hospital).
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c) the abuse or neglect of a person with disability.
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d) the unlawful sexual or physical contact with, or assault of a person with a disability.
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e) sexual misconduct committed against, or in the presence of a person with disability, including grooming of the person for sexual activity.
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(7) Does the incident management policy and/or procedure include a process for reviewing the incident management system to ensure its effectiveness?
Section 3 - Incident Management and Procedural Fairness
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(1) Does the incident management system ensure that people are afforded procedural fairness when an incident is dealt with by the provider.
Section 4 - Documentation, Record Keeping and Statistics
(1) Is the incident management system:
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a) documented.
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b) copied and shared with participants, employees and contractors, family members, carers, independent advocates, significant others.
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c) understood by the people listed above, and assistance provided if these people do not understand.
(2) Does the incident management system include the following information recorded as a minimum for each incident that occurs:
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a) a description of the incident, including the impact on, or harm caused to, any person with disability affected by the incident.
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b) whether the incident is a reportable incident.
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c) if known - the time, date and place at which the incident occurred.
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d) if Question c) does not apply - the time and date the incident was first identified.
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e) the names and contact details of the persons involved in the incident.
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f) the names and contact details of any witnesses to the incident.
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g) details of the assessment undertaken in accordance with the requirements of subsection 10(3) (See Section 2, Question 3 of this audit).
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h) the actions taken in response to the incident, including actions taken to support or assist persons with disability affected by the incident.
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i) any consultations undertaken with the persons with disability affected by the incident.
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j) whether persons with disability affected by the incident have been provided with any reports or findings regarding the incident.
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k) if an investigation is undertaken by the provider in relation to the incident - the details and outcomes of the investigation.
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l) the name and contact details of the person making the record of the incident.
(3) Does the incident management system include the following information recorded as a minimum in relation to each reportable incident that is alleged to have occured:
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a) a description of the alleged incident.
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b) if known - the time, date and place at which the incident is alleged to have occurred.
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c) the names and contact details of the persons involved in the alleged incident.
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d) the names and contact details of any witnesses to the alleged incident.
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e) details of the assessment undertaken in accordance with the requirements of subsection 10(3) (See Section 2, Question 3 of this Audit).
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f) the actions taken in response to the alleged incident, including actions taken to support or assist persons with disability affected by the incident.
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g) any consultations undertaken with the persons with disability affected by the alleged incident.
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h) whether persons with disability affected by the incident have been provided with any reports or findings regarding the alleged incident.
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i) if an investigation is undertaken by the provider in relation to the alleged incident - the details and outcomes of the investigation.
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j) the name and contact details of the person making the record of the alleged incident.
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(4) Does the incident management policy include the requirement that all records relating to incident reporting, review, investigation, consultation and action taken (including reportable incidents) are to be kept for 7 years or more depending on other relevant Commonwealth and State or Territory laws?
(5) Does the incident management policy allow you to collect statistical and other information relating to incidents so that you can:
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a) review issues raised by the occurrence of incidents.
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b) identify and address systemic issues.
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c) report information relating to complaints to the Commissioner, if requested to do so by the Commissioner.
Section 5 - Roles, Responsibilities, Compliance and Training of Workers
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(1) Does the incident management system set out the roles and responsibilities of any persons employed or otherwise engaged by the registered NDIS provider in identifying, managing and resolving incidents and in preventing incidents from occurring?
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(2) Does the incident management system describe how each person employed or otherwise engaged by the registered NDIS provider comply with the incident management system?
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(3) Does the incident management system include requirements relating to the provision of training to any persons employed or otherwise engaged by the registered NDIS provider in the use of, and compliance with , the incident management system?
Section 6 - Reportable Incidents / Specific Requirements
(1) Does your incident management system include a definition of reportable incidents as per subsection 73(Z) (4) of the Act as follows:
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a) the death of a person with disability.
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b) serious injury of a person with disability
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c) abuse or neglect of a person with disability
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d) unlawful sexual or physical contact with, or assault of, a person with disability
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e) sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity
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f) the use of a restrictive practice in relation to a person with disability, other than where the use is in accordance with an authorisation (however described) of a State or Territory in relation to the person.
(2) Does the incident management policy and/or procedure note the following:
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a) regarding reportable incident reporting requirements.<br><br>Note that if an act is unlawful physical contact with a person with a disability it is not a reportable incident if the contact with and impact on the person with a disability is negligible.
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b) The use of a restrictive practice in relation to a person with disability where the use is in accordance with an authorisation (however described) of a State or Territory is a reportable incident if the use is not in accordance with a behaviour support plan for the person with disability.<br>The use of a restrictive practice in relation to a person with disability where the use is in accordance with an authorisation (however described) of a State or Territory is not a reportable incident if:<br>(a) the use is in accordance with a behaviour support plan for the person with disability; and<br>(b) the State or Territory in which the restrictive practice is used does not have authorisation process in relation to the useof the restrictive practice.
(3) Does the incident management system ensure and provide documented guidance to all persons responsible regarding their duty to report incidents, and that if they become aware that a reportable incident has occurred in connection with the provision of supports or services, they must notify one of the following parties of that fact as soon as possible:
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a) a member of the providers key personnel.
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b) a supervisor or manager of the person.
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c) the person specified as the notifier to the Commission for reportable matters.
(4) Does the incident management procedures outline the following information, which must be provided within 24 hours of reportable incidents:
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a) the name and contact details of the registered NDIS provider.
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b) a description of the reportable incident.
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c) a description of the impact on, or harm to, the person with disability (except for a reportable incident involving death).
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d) the immediate actions taken in response to the reportable incident, including actions taken to ensure the health, safety and wellbeing of persons with disability affected by the incident and whether the incident has been reported to police or any other body.
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e) the name and contact details of the person making the notification.
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f) if known - the time, date and place at which the reportable incident occurred.
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g) the names and contact details of the persons involved in the reportable incident.
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h) any other information required by the Commissioner.
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Be aware that if this information is not available within 24 hours, it must be provided within 5 business days. This includes names and contact details of any witnesses to the reportable incident, and any further actions proposed to be taken in response to the reportable incident.
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(5) Does the incident management procedure include the obligations for all other reportable incidents that do not meet the definitions provided in Question 1 are to be reported within 5 business days with the same information supplied as per Question 4?
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(6) Does the incident management procedure note that the registered NDIS provider is not required to provide certain information outlined in Part 3, Paragraph 20(2)(b), (c), (f) or (g), 20(4)(a) or 21(3)(b), (c), (d) or (e) of the Act if obtaining this information will prejudice the conduct of a criminal investigation or expose a person with a disability to a risk of harm?
Section 7 - Quality Indicator Requirements
(1) Provider Governance and Operational Management
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Outcome: Each participant is safeguarded by the provider’s incident management system, ensuring that incidents are acknowledged, respond to, well-managed and learned from.
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Indicator 1: An incident management system is maintained that is relevant and proportionate to the scope and complexity of supports delivered and the size and scale of the organisation. The system complies with the requirements under the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.<br>
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Indicator 2: Each participant is provided with information on incident management, including how incidents involving the participant have been managed.
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Indicator 3: Demonstrated continuous improvement in incident management by regular review of incident management policies and procedures, review of the causes, handling and outcomes of incidents, seeking of participant and worker views, and incorporation of feedback throughout the provider’s organisation.
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Indicator 4: All workers are aware of, trained in, and comply with the required procedures in relation to incident management.<br>
(2) Implementing Behaviour Support Plans Module - Reportable Incidents involving the Use of a Restrictive Practice
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Outcome: Each participant that is subject to an emergency or unauthorised use of a restrictive practice has the use of that practice reported and reviewed.
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1. The participant’s immediate referral to, and assessment by a medical practitioner (where appropriate) is supported following an incident.
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2. Collaboration is undertaken with mainstream service providers, such as police and/or other emergency services, mental health and emergency department, treating medical practitioners and other allied health clinicians, in responding to the unauthorised use of a restrictive practice. <br>
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3. The Commissioner is notified of all reportable incidents involving the use of an unauthorised restrictive practice in accordance with the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.
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Where an unauthorised restrictive practice has been used, the workers and management of providers implementing behaviour support plans engage in debriefing to identify areas for improvement and to inform further action. The outcomes of the debriefing are documented.
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Based on the review of incidents, the supports to the participant are adjusted, and where appropriate, the engagement of a specialist behaviour support provider is facilitated to develop or review the participant’s behaviour support plan or interim behaviour support plan, if required, in accordance with the National Disability Insurance Scheme (Restrictive Practices and Behaviour Support) Rules 2018.
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Authorisation processes (however described) are initiated as required by their jurisdiction.
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The participant, and with the participant’s consent, their support network and other stakeholders as appropriate, are included in the review of incidents.<br>
Observations and suggestions for improvement
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Observations
