APPROVED PROVIDERS under the AGED CARE ACT 1997 NOTIFICATION OF CHANGES TO KEY PERSONNEL FORM This form is to be used to notify the Department of Social Services of adding a Key Personnel. Send the completed form(s) to the Department of Social Services at the following address: Approved Provider Programs Section Prudential and Approved Provider Regulation Branch Aged Care Quality and Compliance Group Department of Social Services MDP 509 Sirius Building PO Box 7576 CANBERRA MAIL CENTRE ACT 2610 Your obligation to notify the Department Division 9 of the Aged Care Act 1997 (the Act) sets out the obligations that arise from being approved under section 8-1 of the Act. One of these obligations is to notify the Department of a change in any of the Approved Provider s Key Personnel within 28 days after the change occurs. Approved Providers have a responsibility under Part 4.3 of the Act to comply with this obligation. Failure to comply with a responsibility can result in a sanction being imposed under Part 4.4 of the Act. Giving false or misleading information is a serious offence. Key Personnel are defined in subsection 8-3A of the Act as: (a) a member of the group of persons who is responsible for the executive decisions of the entity at that time; (b) any other person who has authority or responsibility for (or significant influence over) planning, directing or controlling the activities of the entity at that time; (c) if, at that time, the entity conducts an aged care service: (i) any person who is responsible for the nursing services provided by the service; and (ii) any person who is responsible for the day-to-day operations of the service; whether or not the person is employed by the entity; (d) if, at that time, the entity proposes to conduct an aged care service: (i) any person who is likely to be responsible for the nursing services to be provided by the service; and (ii) any person who is likely to be responsible for the day-to-day operations of the service; whether or not the person is employed by the entity. If an Approved Provider enters into an agreement with a management company to deliver care services on their behalf, the Directors / Board members of the management company should be This form is an approved form for the purpose of the Aged Care Act 1997 Page 1
treated as Key Personnel in respect of the applicant. Selected persons employed by the management company will also be defined as Key Personnel, for example, a Director of Nursing. Approved Providers should ensure that any agreement with a management company engaged to deliver care services on their behalf includes clauses requiring the management company (and its Key Personnel): to comply with the same responsibilities under the Aged Care Act 1997 as apply to the Approved Provider; and to give the Approved Provider (and its Key Personnel) reasonable access at any time to the premises at which the services are provided. Any agreement with a management company to deliver care services on behalf of an Approved Provider does not remove or lessen any of the Approved Provider s responsibilities and obligations under the Aged Care Act 1997. Please ensure you are aware of your obligations as an Approved Provider. The advice set out in this form is not a substitute for your own consideration of the relevant provisions of the Act and the Principles under the Act. New Key Personnel If you appoint new Key Personnel, each new Key Personnel must complete Part A of this form. As well as requiring this information under paragraph 9-1(1)(b) of the Act it is requested under section 9-2 of the Act and is relevant to the Department s consideration of your organisation s ongoing suitability to be a provider of aged care. Each new Key Personnel must be given a copy of these instructions together with Part A of the form. The Department will consider the impact of a new Key Personnel on the suitability of the Approved Provider, taking into account the matters listed in section 8-3 of the Act and in Division 2 of Part 2 of the Approved Provider Principles 1997. Other changes to the Approved Provider Under section 9-1 of the Act, any change of circumstances that materially affects your suitability to be a provider of aged care must be notified in writing within 28 days after the change occurs, to: Approved Provider Programs Section Prudential and Approved Provider Regulation Branch Aged Care Quality and Compliance Group Department of Social Services MDP 509 Sirius Building PO Box 7576 CANBERRA MAIL CENTRE ACT 2610 Please also advise the Department in writing if any of the name or address details of the Approved Provider or its services change. This form is an approved form for the purpose of the Aged Care Act 1997 Page 2
Adding a New Key Personnel Please ensure that you have read a copy of the instructions for tification of Changes to Key Personnel at the front of this form. Full LEGAL name of Approved Provider: Lutheran Church of Australia Victorian District Approved Provider s ABN: 44 055 123 692 Service type*: RACS CACP Flexible Service ID*: Service name*: *If position is specific to one service. Personal particulars Name: Title: Given Name(s): Family Name: Former name(s): Title: Given Name(s): Family Name: Date of birth: Proposed Key Personnel role (please indicate if this role is associated with a management company): Executive Decision Maker Position in organisation: Council Member Start date: Address Business Street number and name: 755 Station Street Suburb/Town: Box Hill State/Territory: VIC Postcode: 3128 Address Personal Street number and name: Suburb/Town: State/Territory: Postcode: 1. Experience in aged care or related services (Aged Care Act 1997, 8-3) In the last 10 years, have you had experience in any of the following roles in this or other organisation(s) which provide residential or community care services to aged persons, persons with a disability or care in other supported environments, for example in organisations such as nursing homes or hostels, retirement villages, sheltered housing, day care centres, HACC programs: a company director or Board member? a person with responsibility for the provision of nursing care services, whether on a paid or unpaid basis? This form is an approved form for the purpose of the Aged Care Act 1997 Page 3
a person responsible for the day-to-day operations of the service, whether on a paid or unpaid basis? a person involved in the day-to-day operations of the service, whether on a paid or unpaid basis? a Key Personnel, as defined in Section 8-3A of the Aged Care Act 1997? If you ticked YES to any of the above boxes, give details of each organisation and service. Attach additional sheets if necessary. Service name: Street number and name: Suburb/Town: State/Territory: Postcode: Type of care offered at service: Position held at service/responsibilities: Period of involvement: to 2. Suitability to conduct an aged care service - Relevant skills and experience (Aged Care Act 1997, 8-3) Please include a statement under each heading that is relevant to your skills and experience. a) Compliance with regulated standards of care in a health or community service field: b) Financial management of a business c) Experience in staff management d) Any other relevant experience, including experience in evaluating or improving the quality of a business or service This form is an approved form for the purpose of the Aged Care Act 1997 Page 4
3. Revocation or refusal of licence or sanctions a) To your knowledge, in the last 10 years has a Commonwealth, State, Territory or Local Government agency revoked or refused to grant a licence or similar instrument in respect of the operations of a hostel, nursing home, other residential care service or community service in which you were in a position equivalent to a Key Personnel as defined in section 8-3A of the Aged Care Act 1997? (Go to Q 3 b) Type of licence: Date of refusal or revocation: Reason for refusal or revocation: b) To your knowledge, during this period were any sanctions imposed under the Aged Care Act 1997 in respect of the operations of a hostel, nursing home, other residential care service or community service in which you were in a position equivalent to a Key Personnel as defined in section 8-3A of the Aged Care Act 1997? (Go to Q 4) Nature of sanction(s): Period of sanction(s): to If the space provided is not sufficient and/or if you answer YES to either of these questions, please attach additional sheets describing your involvement at the time and the subsequent outcome(s). 4. Convictions and current prosecutions Have you been convicted of or are you currently being prosecuted for: offences under any part of, the Aged Care Act 1997, the Crimes Act 1914, or any other legislation? any offence involving obtaining money, property or a benefit by any untrue or misleading representation? an indictable offence against a law of the Commonwealth or a State or Territory or against an equivalent law of a foreign country? If YES to any of the above questions please provide details: Jurisdiction (Commonwealth, State, Territory, foreign country): Relevant Statute(s): Alleged Offence(s): Nature of conviction: Date(s) of trial: Dates(s) of conviction: Name of Court(s): te: Different Commonwealth, State and Territory laws relating to spent convictions mean that you may not have to disclose convictions that have been recorded against you for certain offences. These laws typically apply to convictions recorded more than 10 years ago and which did not involve long periods of imprisonment. If you do not know whether a conviction is spent, you should seek independent advice as to whether such a law applies in your situation. This form is an approved form for the purpose of the Aged Care Act 1997 Page 5
5. Bankruptcy and Receivership a) Are you an insolvent under administration? b) Have you ever been an insolvent under administration? c) Have you been associated in a management capacity equivalent to a Key Personnel as defined in section 8-3A of the Aged Care Act 1997 with a corporation that is or has been under the control of an administrator, receiver/manager or liquidator? If YES to any of the above questions, please provide details. Attach additional sheets if necessary. Jurisdiction: (Commonwealth, State, Territory): Give details (e.g. bankruptcy, insolvent under administration, company under receivership): Commencement Date: End Date: If you answer YES to c) above, please attach additional sheets describing your involvement at the time and the subsequent outcome(s). 6. Commonwealth, State, Territory or Local Government financial and/or statutory obligations To your knowledge, in the last 10 years has a Commonwealth, State, Territory or Local Government agency, taken or commenced, any action against an organisation in which you are, or were at the time, in a position equivalent to that of a Key Personnel under section 8-3A of the Aged Care Act 1997 in respect of financial and/or statutory obligations (for example actions relating to occupational health and safety, the environment, payroll or income tax, employee wages and entitlements, superannuation payments, etc)? Type(s) of action: Date(s) of action: Reason(s) for action: If you answer YES to this question, please attach additional sheets describing your involvement at the time and the subsequent outcome(s). This form is an approved form for the purpose of the Aged Care Act 1997 Page 6
Key Personnel Declaration I declare that the information I have given in this tification of Changes to Key Personnel form is correct and complete. I declare that, to the best of my knowledge and belief, I am not a disqualified individual as defined by section 10A-1(1) of the Aged Care Act 1997. I consent to the Secretary to the Department of Social Services obtaining information and documents from the agencies as listed below, to the extent that such information or documents are relevant to the assessment of my suitability as a Key Personnel. I consent to the Secretary to the Department of Social Services releasing my name and date of birth and details of previous employment to the agencies listed below to assist them to identify information or documents relevant to the assessment of my suitability as a Key Personnel. List of agencies: Department of Social Services, in respect of any previous or current involvement of mine in Commonwealth-funded aged care; Aged Care Standards and Accreditation Agency, in respect of the accreditation status of services during any previous or current involvement of mine in Commonwealth-funded aged care; Australian Securities and Investments Commission; Insolvency and Trustee Services Australia (ITSA); Organisations that provide information on: company directorships; charges against companies; company and individual credit/debit information; and company and individual court records; and State and Federal Government Departments and statutory authorities in respect of any previous or current involvement of mine in organisations providing residential or community care services to aged persons, persons with a disability or care in other supported environments. Name of person signing: Signed: Date: Giving false or misleading information is a serious offence. DECLARATION BY APPROVED PROVIDER For any new Key Personnel named in this Part, I declare that the Approved Provider has taken all reasonable steps specified in section 22.3B of the Sanctions Principles in accordance with section 63 of the Aged Care Act 1997 to ensure that the person is not a disqualified individual. Name of person signing: Dinu Stamatescu Position: District Administrator Signed: Date: te: This declaration should only be signed by those persons who are legally empowered to give assurances and enter into contracts and commitments on behalf of the Approved Provider. This form is an approved form for the purpose of the Aged Care Act 1997 Page 7